Characterization of postoperative acute pancreatitis (POAP) after distal pancreatectomy

Thirty-day prevalence and clinical impact of fluid collections at the resection margin after distal pancreatectomy: Follow-up of a multicentric randomized controlled trial

BACKGROUND

Postoperative fluid collections at the resection margin of the pancreatic stump are frequent after distal pancreatectomy, yet their clinical impact is unclear. The aim of this study was to assess the 30-day prevalence of postoperative fluid collections after distal pancreatectomy and the factors associated with a clinically relevant condition.

METHODS

Patients enrolled in a randomized controlled trial of parenchymal transection with either reinforced, triple-row staple, or ultrasonic dissector underwent routine magnetic resonance 30 days postoperatively. Postoperative fluid collection was defined as a cyst-like lesion of at least 1 cm at the pancreatic resection margin. Postoperative fluid collections requiring any therapy were defined as clinically relevant.

RESULTS

A total of 133 patients were analyzed; 69 were in the triple-row staple transection arm, and 64 were in the ultrasonic dissector transection arm. The overall 30-day prevalence of postoperative fluid collections was 68% (n = 90), without any significant difference between the two trial arms. Postoperative serum hyperamylasemia was more frequent in patients with postoperative fluid collections than those without (31% vs 7%, P = .001). Among the postoperative fluid collection population, an early postoperative pancreatic fistula (odds ratio 14.9, P = .002), post pancreatectomy acute pancreatitis (odds ratio 12.7, P = .036), and postoperative fluid collection size larger than 50 mm (odds ratio 6.6, P = .046) were independently associated with a clinically relevant postoperative fluid collection.

CONCLUSION

Postoperative fluid collections at the resection margin are common after distal pancreatectomy and can be predicted by early assessment of postoperative serum hyperamylasemia. A preceding pancreatectomy acute pancreatitis and/or postoperative pancreatic fistula and large collections (>50 mm) were associated with a clinically relevant postoperative fluid collection, representing targets for closer follow-up or earlier therapeutic interventions.

Textbook outcome after pancreatoduodenectomy and distal pancreatectomy with postoperative hyperamylasemia-a propensity score matching analysis

PURPOSE

Postoperative serum hyperamylasemia (POH) is a part of the new, increasingly highlighted, definition for postpancreatectomy pancreatitis (PPAP). This study aimed to analyze whether the biochemical changes of PPAP are differently associated with postoperative complications after distal pancreatectomy (DP) compared with pancreatoduodenectomy (PD). The textbook outcome (TO) was used as a summary measure to capture real-world data.

METHODS

The data were retrospectively extracted from a prospective clinical database. Patients with POH, defined as levels above our institution's upper limit of normal on postoperative day 1, after DP and the corresponding propensity score-matched cohort after PD were evaluated on postoperative complications by using logistic regression analyses.

RESULTS

We analyzed 723 patients who underwent PD and DP over a period of 9 years. After propensity score matching, 384 patients (192 patients in each group) remained. POH was observed in 78 (41.1%) and 74 (39.4%) after PD and DP correspondingly. There was a significant increase of postoperative complications in the PD group: Clavien-Dindo classification system ≥3 (P < .01 vs P = .71), clinically relevant postoperative pancreatic fistula (P < .001 vs P = .2), postpancreatectomy hemorrhage (P < .001 vs P = .11), and length of hospital stay (P < .001 vs P = .69) if POH occurred compared with in the DP group. TO was significantly unlikely in cases with POH after PD compared with DP (P > .001 vs P = .41). Furthermore, POH was found to be an independent predictor for missing TO after PD (odds ratio [OR], 0.29; 95% CI, 0.14-0.60; P < .001), whereas this was not observed in patients after DP (OR, 0.53; 95% CI, 0.21-1.33; P = .18).

CONCLUSION

As a part of the definition for PPAP, POH is a predictive indicator associated with postoperative complications after PD but not after DP.

Post-pancreatectomy Acute Pancreatitis in Distal Pancreatectomies - a Rare Bird According to the New Definition

BACKGROUND

Post-pancreatectomy acute pancreatitis (PPAP) is a recently identified clinical condition characterized by sustained elevated serum amylase levels for at least 48 h post-operatively, consistent radiological findings, and relevant clinical features. The purpose of this study was to determine the frequency of PPAP after DP, to investigate the rate of major complications in patients with sustained or transiently elevated serum amylase activity, and to explore the usability of CT as a prerequisite for the diagnosis of PPAP.

METHODS

This retrospective single-center observational study included consecutive patients 18 years or older who underwent DP at Karolinska University Hospital between 2008 and 2020. The two serum amylase levels on post-operative days (POD) 1 and 2 were correlated with post-operative major complications by logistic regression analyses.

RESULTS

Of the 403 patients who underwent DP, 14% (n = 58) had sustained elevated serum amylase levels according to PPAP criteria, and 31% (n = 126) had transiently elevated serum amylase levels on either POD1 or POD2. Of the patients with sustained elevated levels, 45% (n = 26) developed major complications, but less than 2% (n = 1) showed imaging findings consistent with acute pancreatitis. Of the 126 patients who exhibited only transiently elevated serum amylase on either POD1 or POD2, 38% (n = 48) developed major complications. The frequency of PPAP was 0.25% (n = 1).

CONCLUSION

These findings indicate that PPAP after DP is rare and that computed tomography has limited usability for diagnosing PPAP. The findings also suggest that transiently elevated serum amylase may be an early indicator of acute pancreatitis, especially when peaked.

Pre-emptive resection for intraductal papillary mucinous neoplasia - Long-term outcome is similar between non-invasive and early invasive lesions in a tertiary single center

BACKGROUND

Pre-emptive resection for intraductal papillary mucinous neoplasm (IPMN) aims to reduce the risk before invasive transformation has taken place. Pancreatic resections are highly associated with major morbidity and mortality. Long-term overall survival (OS) after resection for invasive IPMN (inv-IPMN) in early stages is favorable. Comparison of long-term OS for resected non-invasive IPMN and early staged inv-IPMN is poorly delineated. This study aims to compare outcomes for resected non-invasive IPMN and T1-staged inv-IPMN.

METHODS

All patients ≥18 years of age resected for IPMN up to stage T1 at Karolinska University Hospital between 2008 and 2020 were included. Two-year OS were compared between groups by chi-squared test, and 5-year OS was estimated using Kaplan-Meier method. Covariates associated with death was assessed in multivariable Cox regression model.

RESULTS

We included 284 patients, 264 (93%) non-invasive IPMN and 20 (7%) T1-staged inv-IPMN. Dysplasia of low grade (LGD) and high grade, i.e., tumor in situ (Tis) were present in 190 (67%) and 75 (26%) patients respectively. The 2-year OS for the entire cohort was 96%, and there were no differences between non-invasive and inv-IPMN (96% vs 92%, p = 0.203), nor between IPMN with LGD and Tis-T1b-staged IPMN (96% vs 95%, p = 0.734).

CONCLUSION

Two thirds of the specimen from pre-emptive resections were of LGD and did not involve superior OS than in situ or early cancer. Due to high complication burden, efforts should be made to avoid resection when LGD is probable and rather identify more accurate predictors for surgery.

The Impact of Post-Pancreatectomy Acute Pancreatitis (PPAP) on Long-Term Outcomes after Pancreaticoduodenectomy: A Single-Center Propensity-Score-Matched Analysis According to the International Study Group of Pancreatic Surgery (ISGPS) Definition

Post-pancreatectomy acute pancreatitis (PPAP) is a potentially life-threating complication. Although multiple authors demonstrated PPAP as a predisposing feature for a more detrimental clinical course, no evidence is currently present on its potential impact on long-term outcomes. The aim of this study is to evaluate how PPAP onset may influence overall (OS) and disease-free survival (DSF) after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC). Patients who underwent PD for PDAC from 2006 to 2021 were enrolled. PPAP was defined according to the International Study Group of Pancreatic Surgery (ISGPS) definition. Propensity score matching (PSM) was performed in order to reduce potential selection biases. After PSM, 32 patients out of 231 PDs who developed PPAP (PPAP group) were matched to 32 patients who did not present PPAP (no-PPAP group). PPAP patients more frequently presented major post-operative complications (p = 0.02) and post-operative pancreatic fistula (POPF) (p = 0.003). Median follow-up was 26.2 months, with no difference between the two groups (p = 0.79). A comparable rate of local or distant metastases was noted in the two cohorts (p = 0.2). Five-year OS was comparable between the two populations (39.3% and 35.7% for the no-PPAP and PPAP populations, respectively; p = 0.53). Conversely, despite not being statistically significant, a worse 5-year DFS was evidenced in the case of PPAP (23.2%) as compared to the absence of PPAP (37.4%) (p = 0.51). With the limitations due to the small sample size, PPAP may potentially relate to worse long-term outcomes in terms of DFS. However, further studies with wider study populations are still needed in order to better clarify the prognostic role of PPAP.

Prediction of postoperative pancreatic fistula and pancreatitis after pancreatoduodenectomy or distal pancreatectomy: A review

BACKGROUND AND OBJECTIVE

Postoperative pancreatic fistula (POPF) is the leading cause of morbidity and early mortality in patients undergoing pancreatic resection. In addition, recent studies have identified postoperative acute pancreatitis (POAP) as an independent contributor to morbidity. Most perioperative mitigation strategies experimented for POPF have been shown to be in vain with no consensus on the best perioperative management. Clinical prediction models have been developed with the hope of identifying high POPF risk patients with the leading idea of finding subpopulations possibly benefiting from pre-existing or novel mitigation strategies. The aim of this review was to map out the existing prediction modeling studies to better understand the current stage of POPF prediction modeling, and the methodology behind them.

METHODS

A narrative review of the existing POPF prediction model studies was performed. Studies published before September 2022 were included.

RESULTS

While the number of POPF prediction models for pancreatoduodenectomy has increased, none of the currently existing models stand out from the crowd. For distal pancreatectomy, two unique POPF prediction models exist, but due to their freshness, no further external validation or adoption in clinics or research has been reported. There seems to be a lack of adherence to correct methodology or reporting guidelines in most of the studies, which has rendered external validity-if assessed-low. Few of the most recent studies have demonstrated preoperative assessment of pancreatic aspects from computed tomography (CT) scans to provide relatively strong predictors of POPF.

CONCLUSIONS

Main goal for the future would be to reach a consensus on the most important POPF predictors and prediction model. At their current state, few models have demonstrated adequate transportability and generalizability to be up to the task. Better understanding of POPF pathophysiology and the possible driving force of acute inflammation and POAP might be required before such a prediction model can be accessed.

Early and Sustained Elevation in Serum Pancreatic Amylase Activity: A Novel Predictor of Morbidity After Pancreatic Surgery

OBJECTIVE

To characterize early postoperative serum pancreatic amylase (spAMY) trends after pancreatic resections.

SUMMARY BACKGROUND DATA

A postoperative spAMY elevation is a common finding but uncertainties remain about its meaning and prognostic implications.

METHODS

Analysis of patients who consecutively underwent pancreatectomy from 2016 to 2019. spAMY activity was assessed from postoperative day (POD) 0 to 3. Different patterns of spAMY have been identified based on the spAMY standard range (10-52 U/l).

RESULTS

Three patterns were identified: (#1) spAMY values always < the lower limit of normal/within the reference range /a single increase in spAMY > upper limit of normal at any POD; (#2) Sustained increase in spAMY activity on POD 0 + 1; (#3) Sustained increase in spAMY activity including POD 1 + 2. Shifting through spAMY patterns was associated with increase morbidity (21% in #1 to 68% in #3 at POD 7; log rank < 0.001). Almost all severe complications (at least Clavien-Dindo ≥3) occurred in patients with pattern #3 (15% vs 3% vs 5% in #1 and #2 at POD 7, P = 0.006), without difference considering >3-times or >the spAMY normal limit ( P = 0.85). POPF (9% in #1 vs 48% in #3, P < 0.001) progressively increased across patterns. Pre-operative diabetes (OR 0.19), neoadjuvant therapy (OR 0.22), pancreatic texture (OR 8.8), duct size (OR 0.78), and final histology (OR 2.2) were independent predictors of pattern #3.

CONCLUSIONS

A sustained increase in spAMY activity including POD 1 + 2 (#3) represents an early postoperative predictor of overall and severe early morbidity. An early and dynamic evaluation of spAMY could crucially impact the subsequent clinical course with relevant prognostic implications.

Impact of spleen preservation on the incidence of postoperative pancreatic fistula after distal pancreatectomy: Is less more?

BACKGROUND

Postoperative pancreatic fistula (POPF) remains a major complication after distal pancreatectomy (DP) with a significant impact on patients' quality of life. There is limited evidence that preservation of the spleen reduces the risk of POPF. Therefore, we aimed to investigate the impact of splenectomy on perioperative outcome.

METHODS

Data from patients who underwent DP for malignant and benign disease at our institution between 2004 and 2021 were reviewed. Patients were grouped according to spleen preservation (SP-DP) and splenectomy (DPS). Intraoperative parameters and postoperative outcomes were compared between groups. Univariable and multivariable analyses were used to investigate factors that influence the occurrence of clinically relevant (cr)POPF.

RESULTS

A total of 199 patients were included, of whom 61 (30.7%) patients underwent SP-DP. Patients who underwent SP-DP had a significantly lower rate of crPOPF (p = 0.022), shorter hospital stay (p = 0.003), and less readmissions (p = 0.012). On multivariate analysis, obesity (OR 2.88, p = 0.021), benign lesions (OR 2.35, p = 0.018), postoperative acute pancreatitis (OR 2.53, p = 0.028), and splenectomy (OR 2.83, p = 0.011) were independent risk factors associated with the onset of crPOPF.

DISCUSSION

Preservation of the spleen reduces the risk of crPOPF in patients undergoing distal pancreatectomy for benign and malignant disease.

Drain fluid biomarkers for prediction and diagnosis of clinically relevant postoperative pancreatic fistula: A narrative review

Clinically relevant postoperative pancreatic fistula (CR-POPF) has continued to compromise patient recovery post-pancreatectomy despite decades of research seeking to improve risk prediction and diagnosis. The current diagnostic criteria for CR-POPF requires elevated drain fluid amylase to present alongside POPF-related complications including infection, haemorrhage and organ failure. These worrying sequelae necessitate earlier and easily obtainable biomarkers capable of reflecting evolving CR-POPF. Drain fluid has recently emerged as a promising source of biomarkers as it is derived from the pancreas and hence, capable of reflecting its postoperative condition. The present review aims to summarise the current knowledge of CR-POPF drain fluid biomarkers and identify gaps in the field to invigorate future research in this critical area of clinical need. These findings may provide robust diagnostic alternatives for CR-POPF and hence, to clarify their clinical utility require further reports detailing their diagnostic and/or predictive accuracy.

Progression from biochemical leak to pancreatic fistula after distal pancreatectomy. Don't cry over spilt amylase

BACKGROUND

Postoperative pancreatic fistula (POPF) is a frequent complication after distal pancreatectomy (DP), but its upgrading from biochemical leak (BL) still represents an unexplored phenomenon. This study aims at identifying risk factors of the clinical evolution from BL to grade-B POPF after DP.

METHODS

Patients who underwent DP between 2015 and 2019 and who developed either BL (n = 89,56%) or BL upgraded to late B fistula (LB) after postoperative day 5 (n = 71,44%) were included. Preoperative, surgical, postoperative predictors were compared between the two groups.

RESULTS

Patients with LB were significantly older (61 vs 56 years, P < 0.025) and received neoadjuvant chemotherapy more frequently (22.5% vs 8.5%,P = 0.017). Extended lymphadenectomy (52.8% vs 31.0%,P = 0.006), longer operative times (OT) (307 vs 250 min,P = 0.002), greater estimated blood loss (250 vs 150 ml, P = 0.021), and the appearance of purulent fluid in surgical drains (58.4% vs 21.1%; P < 0.001) were more frequently observed in LB group. Only purulent fluid in surgical drains and longer OT were confirmed as independent predictors of BL clinical progression.

CONCLUSIONS

Purulent fluid from surgical drains should be suspicious of BL upgrading. Frail patients undergoing longer interventions may represent key targets of mitigation strategies to minimize the magnitude of an incipient fistula and its increase in morbidity.

Hyperamylasemia grade versus drain fluid amylase: which better predicts pancreatectomy outcomes?

BACKGROUND

The clinical importance of postoperative hyperamylasemia (POHA) grade is unknown. Our objectives were to evaluate the association of POHA grade with clinically relevant postoperative pancreatic fistula (CR-POPF) and compare its prognostic utility against postoperative day 1 drain fluid amylase (DFA-1).

METHODS

Patients who underwent pancreatectomy from January 2019 through March 2020 were identified in the ACS NSQIP pancreatectomy-targeted dataset. POHA grade was assigned using post-operative serum amylase and clinical sequelae. The primary outcome was CR-POPF within 30 days. The association of POHA grade with CR-POPF was assessed using multivariable logistic regression, and c-statistics were used to compare POHA grade versus DFA-1.

RESULTS

POHA occurred in 520 patients at 98 hospitals, including 261 (50.2%) with grade A, 234 (45.0%) with grade B, and 25 (4.8%) with grade C POHA. CR-POPFs were increased among patients with grade B (66.2%, OR 9.28 [5.84-14.73]) and C (68.0%, OR 10.50 [3.77-29.26]) versus grade A POHA (19.2%). POHA-inclusive models better predicted CR-POPF than those with DFA-1 alone (p < 0.002) and models with both predictors outperformed POHA alone (p = 0.039).

CONCLUSION

POHA grade represents a measure of post-pancreatectomy outcomes that predicts CR-POPF and outperforms DFA-1 but must be aligned with new international definitions.

Risk Factors and Clinical Impacts of Post-Pancreatectomy Acute Pancreatitis After Pancreaticoduodenectomy: A Single-Center Retrospective Analysis of 298 Patients Based on the ISGPS Definition and Grading System

Background

The definition and grading system of post-pancreatectomy acute pancreatitis (PPAP) has recently been proposed by ISGPS. This study aimed to put this definition and classification into practice and investigate the potential risk factors and clinical impacts of PPAP.

Methods

Demographic and perioperative data of consecutive patients who underwent pancreaticoduodenectomy (PD) from January 2019 to July 2021 were collected and analyzed retrospectively. The diagnostic criteria of PPAP published by ISGPS, consisting of biochemical, radiologic, and clinical parameters, were adopted. The risk factors were analyzed by univariate and multivariate analyses.

Results

A total of 298 patients were enrolled in this study, and the total incidence of PPAP was 52.4% (150 patients). Stratified by clinical impacts of PPAP, the incidences of grades B and C PPAP were 48.9% and 3.5%, respectively. PPAP after PD was significantly associated with pancreatic fistula and other unfavorable complications. Soft pancreatic texture (OR 3.0) and CRP ≥ 180 mg/L (OR 3.6) were the independent predictors of PPAP, AUC 0.613. Stratified by the grade of PPAP, soft pancreatic texture (OR 2.7) and CRP ≥ 180 mg/L (OR 3.4) were the independent predictors of grade B PPAP, and soft pancreatic texture (OR 19.3), operation duration >360 min (OR 13.8), and the pancreatic anastomosis by using conventional duct to mucosa methods (OR 10.4) were the independent predictors of grade C PPAP. PPAP complicated with pancreatic fistula significantly increased the severe complications and mortality compared to only PPAP occurrence.

Conclusion

PPAP was not an uncommon complication after PD and was associated with unfavorable clinical outcomes, especially since it was complicated with pancreatic fistula. Soft pancreatic texture and CRP ≥ 180 mg/L were the independent predictors of PPAP. Higher-volume multicenter and prospective studies are strongly needed.

Postoperative acute pancreatitis after pancreatic resection in patients with pancreatic ductal adenocarcinoma

INTRODUCTION

Postoperative pancreatic fistula (POPF) is one of the major critical complications after pancreatic resection. Recently, postoperative acute pancreatitis (POAP), a new concept for a pancreatic-specific complication following pancreatic resection, has been advocated, and its association with POPF has been reported. The present study examined the clinical features of POAP and identified the associations of POAP with POPF and other postoperative morbidities in pancreatic ductal adenocarcinoma (PDAC) patients undergoing pancreatic resection.

METHODS

A total of 312 consecutive patients who underwent pancreatic resection for PDAC at our institution from 2013 to 2019 were enrolled in this study. POAP was defined as an elevated serum amylase level above the upper limit normal on postoperative day (POD) 0 or 1, based on Connor's definition. The severity of POPF was assessed by the International Study Group on Pancreatic Surgery definition.

RESULTS

A total of 184 patients (58.9%) had POAP. POAP occurred in 58.5% of subtotal stomach-preserving pancreatoduodenectomy patients and 60% of distal pancreatectomy combined with splenectomy patients. The presence of POAP was significantly associated with the development of clinically relevant POPF, higher rates of severe morbidity, and a prolonged hospital stay after pancreatic resection. A multivariate analysis showed that the presence of POAP and elevated C-reactive protein levels on POD 3 were independent predictors of clinically relevant POPF after subtotal stomach-preserving pancreatoduodenectomy.

CONCLUSIONS

POAP is associated with the development of POPF, higher rates of severe morbidity, and a prolonged hospital stay after pancreatic resection and is an independent risk factor for clinically relevant POPF after pancreatoduodenectomy. POAP represents an important indicator for planning treatment strategies to prevent serious complications, including POPF.

Postoperative serum hyperamylasemia (POH) predicts additional morbidity after pancreatoduodenectomy: It is not all about pancreatic fistula

BACKGROUND

The association between postoperative serum hyperamylasaemia (POH) and morbidity has been hypothesized but rarely explored once occurring with or without (POH-exclusive) a combined postoperative pancreatic fistula (POPF).

METHODS

Analysis of patients who consecutively underwent pancreaticoduodenectomy from 2016 to 2020. POH was defined as serum amylase activity greater than the institutional upper limit of normal (52 U/L), persisting within the first 48 hours postoperatively (postoperative day [POD] 1 and 2).

RESULTS

Among 852 patients, 15.8% developed POH-exclusive. Compared with patients without POH or POPF (64.3%), they showed a significantly higher postoperative burden (Clavien-Dindo ≥II: 52.6% vs 30.8%) with increased rates of bacteraemia (12.6% vs 6%), pleural effusion (13.3% vs 5.3%), postpancreatectomy haemorrhage (13.3% vs 7.5%), postpancreatectomy acute pancreatitis (PPAP) (10.3% vs 0%), and organ site infections (18.5% vs 10.9%; all P < .05). A total of 13.8% experienced POH with POPF leading to the worse outcome. The combined occurrence of POH with POPF led to a shorter median time to morbidity (3 PODs, 95% confidence interval [CI] 2.2-3.7 vs 6 PODs, 95% CI 4.2-8; P < .001) than patients experiencing POPF-exclusive (5.9%). In all, 46.6% of POH patients developed POPF. Body mass index (BMI) (odds ratio [OR] 1.1), male sex (OR 2.1), increased drain fluid amylase on POD 1 (OR 1.001), and increased C-reactive protein (OR 1.01) were independent risk factors for POPF once POH has occurred.

CONCLUSION

POH has relevant postoperative clinical implications, independently from POPF occurrence. Developing POH with POPF leads to an earlier onset of higher postoperative burdens. Once POH is diagnosed, risk factors for additional POPF could identify patients who may benefit from additional surveillance, specific drains protocols, and preventive strategies.

Postpancreatectomy Acute Pancreatitis (PPAP): Definition and Grading From the International Study Group for Pancreatic Surgery (ISGPS)

OBJECTIVE

The ISGPS aimed to develop a universally accepted definition for PPAP for standardized reporting and outcome comparison.

BACKGROUND

PPAP is an increasingly recognized complication after partial pancreatic resections, but its incidence and clinical impact, and even its existence are variable because an internationally accepted consensus definition and grading system are lacking.

METHODS

The ISGPS developed a consensus definition and grading of PPAP with its members after an evidence review and after a series of discussions and multiple revisions from April 2020 to May 2021.

RESULTS

We defined PPAP as an acute inflammatory condition of the pancreatic remnant beginning within the first 3 postoperative days after a partial pancreatic resection. The diagnosis requires (1) a sustained postoperative serum hyperamylasemia (POH) greater than the institutional upper limit of normal for at least the first 48 hours postoperatively, (2) associated with clinically relevant features, and (3) radiologic alterations consistent with PPAP. Three different PPAP grades were defined based on the clinical impact: (1) grade postoperative hyperamylasemia, biochemical changes only; (2) grade B, mild or moderate complications; and (3) grade C, severe life-threatening complications.

DISCUSSIONS

The present definition and grading scale of PPAP, based on biochemical, radiologic, and clinical criteria, are instrumental for a better understanding of PPAP and the spectrum of postoperative complications related to this emerging entity. The current terminology will serve as a reference point for standard assessment and lend itself to developing specific treatments and prevention strategies.

Modified Frailty Index to Assess Risk in Elderly Patients Undergoing Distal Pancreatectomy: A Retrospective Single-Center Study

Background

To compare the postoperative course of elderly patients (≥70 years) submitted to minimally invasive (MIDP) versus open distal pancreatectomy (ODP) and to evaluate if the modified Frailty Index (mFI) predicts the surgical course of elderly patients submitted to DP.

Methods

Data of patients aged ≥70 who underwent DP at a single institution between March 2011 and December 2019 were retrospectively retrieved. A 2:1 propensity score matching (PSM) was used to correct for differences in baseline characteristics. Then, postoperative complications were compared between the two groups (MIDP vs. ODP). Additionally, the entire cohort of DP elderly patients was stratified according to the mFI into three groups: non-frail (mFI = 0), mildly frail (mFI = 1/2), or severely frail (mFI = 3) and then compared.

Results

A total of 204 patients were analyzed. After PSM, 40 MIDP and 80 ODP patients were identified. The complications considered stratified homogenously between the two groups, with no statistically significant differences. The severity of the postoperative course increased as mFI did among the three groups regarding any complication (p = 0.022), abdominal collection (p = 0.014), pulmonary complication (p = 0.001), postoperative confusion (p = 0.047), Clavien-Dindo severity ≥3 events (p = 0.036), and length of stay (p = 0.018).

Conclusions

Elderly patients can be safely submitted to MIDP. The mFI identifies frail elderly patients more prone to develop surgical and non-surgical complications after DP.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-021-06436-2.

Early biochemical predictors of clinically relevant pancreatic fistula after distal pancreatectomy: a role for serum amylase and C-reactive protein

BACKGROUND

Recent evidence suggests that pancreatic inflammation plays a pivotal role in the occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy but few data are available for distal pancreatectomy (DP). The aim of this study was to evaluate the impact of early biochemical markers on the occurrence of CR-POPF after DP.

METHODS

Clinical and laboratory data for 432 consecutive DP patients were reviewed. Serum amylase was evaluated on postoperative day (POD) 1, and drain fluid amylase (DFA) and C-reactive protein (CRP) were evaluated on POD 2 and 3. Receiver operator characteristic (ROC) curves were performed for all biochemical markers and an area under the curve (AUC) was computed. Multivariable regression analyses to identify the factors associated with CR-POPF and severe postoperative morbidity (Clavien-Dindo grade ≥ 3) were performed.

RESULTS

At 90 days after surgery, CR-POPF occurred in 155 (36%) patients, severe complications in 66 (15%) patients. ROC curve analyses showed that DFA on POD2 had the largest AUC (0.753, p < 0.001), followed by serum amylase on POD 1 (0.651, p < 0.001), serum CRP on POD3 (0.644, p < 0.001), and CRP change between POD 2 and POD 3 (0.644, p < 0.001). Multivariable analysis identified male gender (OR 2.29, 95% CI 1.36-3.86; p = 0.002), DFA ≥ 1500 U/L on POD2 (OR 4.63, 95% CI 2.72-7.89; p < 0.001), serum amylase ≥ 100 U/L on POD 1 (OR 1.72, 95% CI 1.01-2.93; p = 0.046), and CRP increase by at least 25 mg/L on POD 3 compared to the previous day (OR 1.89, 95% CI 1.11-3.21; p = 0.019) as independent predictors of CR-POPF, yielding a valid regression model (AUC 0.765, 95% CI 0.714-0.816, p < 0.001).

CONCLUSIONS

Postoperative serum amylase and CRP trajectory represent useful early biochemical markers for CR-POPF in addition to DFA. Our findings suggest that these laboratory tests should be incorporated into clinical practice to aid postoperative patient and drain management.

The role of acinar content at pancreatic resection margin in the development of postoperative pancreatic fistula and acute pancreatitis after pancreaticoduodenectomy

BACKGROUND

A fatty infiltration of the pancreas has been traditionally regarded as the main histological risk factor for postoperative pancreatic fistula, whereas the role of the secreting acinar compartment has been poorly investigated. The aim of this study was to evaluate the role of acinar content at pancreatic resection margin in the development of clinically relevant postoperative pancreatic fistula and clinically relevant postoperative acute pancreatitis after pancreaticoduodenectomy.

METHODS

Data from 388 consecutive patients who underwent pancreaticoduodenectomy (2018-2019) were analyzed. Pancreatic section margins were histologically assessed for acinar, fibrosis, and fat content. Acinar content was categorized using median and third quartile as cut-offs. Univariate and multivariable analysis of possible predictors of clinically relevant postoperative pancreatic fistula and clinically relevant postoperative acute pancreatitis were performed.

RESULTS

Acinar content was <60% in 166 patients (42.8%), ≥60% and ≤80% in 156 patients (40.2%), and >80% in 66 patients (17.0%). The rate of clinically relevant postoperative pancreatic fistula and clinically relevant postoperative acute pancreatitis was significantly higher in patients with acinar content >80% (39.4% and 33.3%, respectively) as well as in those with acinar content ≥60% and ≤80% (36.5% and 35.3%, respectively), compared with patients with acinar content <60% (10.2% and 5.4%, respectively) (P < .001). Acinar content was identified as an independent predictor of clinically relevant postoperative pancreatic fistula (≥60% and ≤80%, odds ratio 2.51, P = .008; >80%, odds ratio 2.93, P = .010) and clinically relevant postoperative acute pancreatitis (≥60% and ≤80%, odds ratio 9.42, P < .001; >80%, odds ratio 10.16, P < .001).

CONCLUSION

An acinar content at pancreatic resection margin ≥60% is associated to an increased risk of clinically relevant postoperative pancreatic fistula and clinically relevant postoperative acute pancreatitis. Fat content was associated neither with clinically relevant postoperative pancreatic fistula nor with clinically relevant postoperative acute pancreatitis.