[Use of lanreotide in the prevention of pancreatic fistula after cephalic duodeno-pancreatectomy. Preliminary study]

Peng's binding pancreaticojejunostomy after pancreaticoduodenectomy: a French prospective study

BACKGROUND

Pancreatic fistula (PF) is the single most important complication after pancreaticoduodenectomy. Recently, a 0% rate of PF was reported using a binding pancreaticojejunostomy with intussusception of the pancreatic stump. The aim of this study was to assess the safety of this new binding pancreaticojejunostomy in condition most susceptible to PF, i.e. soft pancreas and non-dilated main pancreatic duct.

METHODS

Forty-five consecutive patients with soft pancreas and non-dilated main pancreatic duct underwent a binding pancreaticojejunostomy. Post-operative PF was defined according to the International Study Group of Pancreatic Fistula.

RESULTS

Four patients (8.9%) developed a PF. In one case, PF developed on post-operative day 3 due to a technical deficiency. In the three other cases, pancreatic fistula developed after the tenth post-operative day; all the patients had local and/or general co-morbidities before PF occurrence.

CONCLUSIONS

Binding pancreaticojejunostomy according to Peng is a safe and secure technique that improves the rate of pancreatic fistula, especially in case of soft texture of the pancreas remnant. However, a 0% rate seems to be hard to achieve because other abdominal and general complications are frequent and can lead to secondary leakage of the pancreatic anastomosis.

Complications after pancreaticoduodenectomy: the problem of current definitions

Pancreaticoduodenectomy nowadays represents a complex procedure and a challenge for the surgeon. Even though mortality is reported to be below 5% for experienced surgeons, morbidity is still around 30%-50%, often leading to prolongation of hospital stay, demanding postoperative investigations and procedures, and outpatient monitoring of the patients with complications. In the literature there is no agreement on the definitions of postoperative complications following pancreaticoduodenectomy, leading to a wide range of complication rates in different specialist units, particularly regarding the source of every complication, postoperative pancreatic fistula, and others such as delayed gastric emptying. Some authors have demonstrated that applying different definitions in homogeneous, single-center series, the incidence of a complication varied with statistical significance, implying the impossibility of correctly comparing different experiences. It seems essential to organize a Consensus Meeting among expert surgeons to prepare world-wide accepted definitions. The aim of this article is to review the current controversial definitions and to suggest a new clinical-based approach to the problem of the feasibility and reliability of the definitions themselves.

Postoperative pancreatic fistula: an international study group (ISGPF) definition

BACKGROUND

Postoperative pancreatic fistula (POPF) is still regarded as a major complication. The incidence of POPF varies greatly in different reports, depending on the definition applied at each surgical center. Our aim was to agree upon an objective and internationally accepted definition to allow comparison of different surgical experiences.

METHODS

An international panel of pancreatic surgeons, working in well-known, high-volume centers, reviewed the literature on the topic and worked together to develop a simple, objective, reliable, and easy-to-apply definition of POPF, graded primarily on clinical impact.

RESULTS

A POPF represents a failure of healing/sealing of a pancreatic-enteric anastomosis or a parenchymal leak not directly related to an anastomosis. An all-inclusive definition is a drain output of any measurable volume of fluid on or after postoperative day 3 with an amylase content greater than 3 times the serum amylase activity. Three different grades of POPF (grades A, B, C) are defined according to the clinical impact on the patient's hospital course.

CONCLUSIONS

The present definition and clinical grading of POPF should allow realistic comparisons of surgical experiences in the future when new techniques, new operations, or new pharmacologic agents that may impact surgical treatment of pancreatic disorders are addressed.

Evaluation of lanreotide effects on human exocrine pancreatic secretion after a single dose: preliminary study

BACKGROUND

Total parenteral nutrition and somatostatin or analogues represent a consolidated therapeutic approach for external fistulas, a frequent complication of major pancreatic surgery.

AIMS

To establish the effects of the somatostatin analogue lanreotide on exocrine pancreatic secretion.

METHODS

Eight patients, undergoing pancreaticoduodenectomy for malignancy, were enrolled in the trial. The volume and composition of pancreatic secretion were evaluated after one single subcutaneous injection of lanreotide 0.5 mg or placebo in a randomised, double-blind cross-over trial.

RESULTS

In the seven patients completing the study, the 24-h output volume was 208.6+/-41.3 and 253.9+/-72.4 ml after lanreotide and placebo, respectively. During the first 6 hours values were 48.1+/-14.7 and 77.6+/-21.4 ml (p=0. 02). No significant difference between treatments was detected in the qualitative composition of 24-h pancreatic secretion, although bicarbonate secretion remained lower after the active drug at all the observation intervals. Peak lanreotide levels were detected 15-30 min after drug injection. Clinical and laboratory tolerability was good.

CONCLUSIONS

Lanreotide induced a statistically significant reduction in the output volume with respect to placebo in the first 6 hours after administration, but not thereafter. The present results encourage a new study to be undertaken in a larger sample and with a multiple dosing scheme of treatment.

Somatostatin and octreotide in the prevention of postoperative pancreatic complications and the treatment of enterocutaneous pancreatic fistulas: a systematic review of randomized controlled trials

BACKGROUND

The aim of this study was to evaluate, through systematic review, the effectiveness of somatostatin and octreotide in the prevention of postoperative pancreatic complications and the treatment of established enterocutaneous pancreatic fistulas.

METHODS

Electronic databases, including Medline and EMBASE, were searched systematically by using keywords including 'somatostatin', 'octreotide', 'fistula' and 'randomiz(s)ed controlled trial'. In addition, citations of relevant primary and review articles were examined. Particular authors were contacted when necessary. Data on patient recruitment, intervention and outcome were extracted from the included trials and analysed.

RESULTS

Use of somatostatin or octreotide for the prevention of postpancreatectomy complications, including pancreatic fistulas, was identified in 14 randomized controlled trials, including one abstract and one conference proceeding, involving a total of 1686 patients. Use of somatostatin or octreotide for the treatment of established enterocutaneous pancreatic fistulas was identified in ten trials involving a total of 301 patients. Significant heterogeneity was found among the identified trials with regard to the definition of fistula, dosage of octreotide, starting time and duration of the treatment, among other factors.

CONCLUSION

There was major disagreement between the studies on whether use of the drugs in question is of value in preventing postoperative complications. This analysis suggests that, in units where the postoperative fistula rate following pancreaticoduodenectomy for neoplasia and other pancreatic conditions exceeds 10 per cent, somatostatin or octreotide administered before operation may significantly reduce the rate of major postoperative complications, particularly pancreatic fistulas. The identified evidence also suggests that there may be a limited role for such drugs in the treatment of established postoperative enterocutaneous pancreatic fistulas. A major conclusion is that further clarification of the roles of these drugs is still required through large, high-quality, randomized trials.

[Role of somatostatins in the preventin of pancreatic fistulae and the treatment of digestive fistulae]

Somatostatin and analogues exert an extraordinary range of inhibitory effects which eventually may have a variety of therapeutic applications. Treatment of intestinal and pancreatic fistula are the main targets in general and digestive surgery. The perioperative and prophylactic application of somatostatin or octreotide in patients who undergo major pancreatic surgery reduces the postoperative complication rate. This prevention seems indicated following Whipple procedure in patients with soft pancreatic tissue. The efficacy of somatostatin or analogues in the treatment of intestinal or pancreatic fistulae is still in debate. Fistula output frequently decreases but closure rate, healing time and complications rate are not reduced. The treatment and care of patients with high output fistulae may be simplified by somatostatin or analogues if a positive effect on output is obvious in the first days of treatment.