Risk factors of postoperative pancreatic fistula in patients after distal pancreatectomy: a systematic review and meta-analysis

The use of Arista AH as a local haemostatic agent in distal splenopancreatectomy: report of two cases

Bleeding is still one of the most feared intraoperative and postoperative complications that can lead to an increase in morbidity, mortality, length of hospital stay and costs. Nowadays, in addition to accurate surgical techniques, several local haemostatic agents are available and can be used in case of oozing bleeding. Herein, we report our experience with a ready-to-use polysaccharide powder in two patients undergoing distal splenopancreatectomy. Bleeding control was achieved in both cases. No patient showed postoperative bleeding, and no other complications were reported.

Prolonged pre-firing pancreatic compression with linear staplers in distal pancreatectomy: a valuable technique for post-operative pancreatic fistula prevention

PURPOSE

Post-operative pancreatic fistula (POPF) remains the main complication after distal pancreatectomy (DP). The aim of this study is to evaluate the potential benefit of different durations of progressive stapler closure on POPF rate and severity after DP.

METHODS

Patients who underwent DP between 2016 and 2023 were retrospectively enrolled and divided into two groups according to the duration of the stapler closure: those who underwent a progressive compression for < 10 min and those for ≥ 10 min.

RESULTS

Among 155 DPs, 83 (53.5%) patients underwent pre-firing compression for < 10 min and 72 (46.5%) for ≥ 10 min. As a whole, 101 (65.1%) developed POPF. A lower incidence rate was found in case of ≥ 10 min compression (34-47.2%) compared to < 10 min compression (67- 80.7%) (p = 0.001). When only clinically relevant (CR) POPFs were considered, a prolonged pre-firing compression led to a lower rate (15-20.8%) than the < 10 min cohort (32-38.6%; p = 0.02). At the multivariate analysis, a compression time of at least 10 min was confirmed as a protective factor for both POPF (OR: 5.47, 95% CI: 2.16-13.87; p = 0.04) and CR-POPF (OR: 2.5, 95% CI: 1.19-5.45; p = 0.04) development. In case of a thick pancreatic gland, a prolonged pancreatic compression for at least 10 min was significantly associated to a lower rate of CR-POPF compared to < 10 min (p = 0.04).

CONCLUSION

A prolonged pre-firing pancreatic compression for at least 10 min seems to significantly reduce the risk of CR-POPF development. Moreover, significant advantages are documented in case of a thick pancreatic gland.

Feasibility and Measurement Value of Pancreatic 2-D Shear Wave Elastography in Healthy Adults: Evaluation, Influencing Factors, Reference Range, Measurement Stability and Reproducibility

OBJECTIVE

The present study was aimed at assessing the success rate and measurement value, determining the influencing factors and reference range and examining the intra-operator stability and inter-operator reproducibility of pancreatic 2-D shear wave elastography (SWE) measurement in healthy adults.

METHODS

In 2022, 387 healthy adults were prospectively recruited. Logistic regression and linear regression analyses were used to explore the factors influencing the success rate and the measurement value of pancreatic 2-D SWE measurement, respectively. A two-sided 95% reference range was estimated accordingly. The intraclass correlation coefficient was calculated to evaluate the intra-operator stability and inter-operator reproducibility of the pancreatic 2-D SWE measurement.

RESULTS

The pancreatic body (89.6%) bore the highest while the tail (72.8%) bore the lowest success rate of pancreatic 2-D SWE measurement. Sex and body mass index (BMI) were the independent factors influencing measurement success rate in all three parts of the pancreas. Mean measurement values (Emean) were not the same in the three parts of the pancreas of the same participant. BMI and image depth were the independent factors influencing Emean in the pancreatic body, while region of interest depth and BMI were the only independent factors influencing Emean in the pancreatic head and tail, respectively. The intra-operator stability of pancreatic 2-D SWE measurement was found to be excellent, whereas its inter-operator reproducibility was poor to good.

CONCLUSION

Pancreatic 2-D SWE is a reliable technique for evaluating pancreatic stiffness in healthy adults, but its success rate and measurement value are influenced by multiple factors.

Application of an innovative pancreaticojejunostomy technique with a modified set of perioperative management in pancreatoduodenectomy: a retrospective cohort study

How to reduce grade C postoperative pancreatic fistula (POPF) incidence after pancreaticoduodenectomy (PD) is the pursuit of pancreatic surgeons. This study introduced an innovative pancreaticojejunostomy (PJ) technique with a complete set of perioperative management. All 144 patients in this single-center retrospective cohort study underwent the same PJ technique and perioperative management. The primary endpoint was grade C POPF incidence. The secondary endpoints were grade B POPF rate, drain fluid amylase level, complications, hospital stay duration, and mortality. Risk factors for clinically-relevant POPF (CR-POPF) were assessed by logistic regression analysis. No patient (0.0%) experienced grade C POPF, while 44 (30.6%) developed grade B. No in-hospital death was recorded. Multivariate analysis found relatively high body mass index, laparoscopic surgery, and soft or moderate pancreatic texture independent risk factors for CR-POPF. Our novel PJ anastomosis with modified perioperative management helped avoid grade C POPF. However, grade B POPF incidence was relatively high to some extent because of the enhanced management itself.

Minimally invasive enucleation of pancreatic tumors: The main pancreatic duct is no longer a restricted area

Background

Tumors involving the main pancreatic duct (MPD) used to be a contraindication for enucleation.

Methods

Clinical data of consecutive patients with pancreatic tumors who received laparoscopic or robotic enucleation (LEN or REN) between January 2019 and December 2021 at Fudan University Shanghai Cancer Center were analyzed.

Results

Ninety-six patients were included in the analysis, with 55 in the LEN group and 41 in the REN group, and no conversion to laparotomy. Most tumors were located in the head of pancreas (71.9 %). The tumor diameter (3.1 vs. 1.9 cm) was larger, and more cystic tumors (92.7 % vs. 56.4 %) and more tumors involving the MPD (34.1 % vs. 3.6 %) were observed in the REN group. MPD support tube insertion was performed in 15 cases, with 11 in the REN group and 4 in the LEN group. The incidence of biochemical and grade B postoperative pancreatic fistula (POPF) was both 46.9 %, and no grade C POPF occurred. Among the 45 patients with grade B POPF, 28 cases (62.2 %) were due to carrying drainage tube >3 weeks without additional treatment, and only 4 cases required invasive treatment. For patients with MPD support tube implantation (n = 15), support tube fall-offs were observed in 12 cases, 2 patients had MPD dilatation, and no MPD stricture, stone formation or pancreatic atrophy was observed during follow-up.

Conclusions

The incidence of POPF was high but still controllable without serious complications after minimally invasive enucleation. The MPD is no longer a restricted area, and the robotic system has advantages in handling complex enucleations.

Risk factors for postoperative pancreatic fistula (POPF) in gastric cancer patients: A systematic review and meta-analysis

BACKGROUND

Postoperative pancreatic fistula (POPF) is a common and serious consequence of gastrectomy. The prevalence of POPF among patients with gastric cancer varies greatly, and the risk factors and outcomes of POPF are also controversial. The meta-analysis aims to comprehensively assess the risk factors for POPF in gastric cancer patients.

METHODS

PubMed, Web of Science, the Cochrane Library, Embase, and Chinese databases (SinoMed, CNKI, WanFang, and VIP Databases) were searched to identify relevant studies (from inception to May 2023). Two researchers evaluated the literature quality and extracted data individually. The Review Manager 5.4 program was used to analyze all of the data.

RESULTS

In our meta-analysis, 22 studies totaling 11,647 patients were analyzed. Male sex (OR = 3.06), older age (OR = 3.22), body mass index (BMI) ≥ 25 kg/m2 (OR = 2.58), visceral fat area (VFA) ≥ 100 cm2 (OR = 3.65), pTNM Ⅲ-Ⅳ (OR = 2.47), the number of lymphlode dissections (OR = 1.04), neoadjuvant chemotherapy (NAC) (OR = 2.91), the application of LigaSure (OR = 3.30), open surgery (OR = 3.23), intraoperative combined organ resection (OR = 4.11), drainage amylase concentration on the first postoperative day (OR = 5.73) and C-reactive protein on the 3rd postoperative day ≥20 mg/dL (OR = 7.29) were the risk factors for POPF in gastric cancer patients. On the other hand, the operation time (OR = 1.34) was not a risk factor for POPF.

CONCLUSION

The frequency of POPF in people undergoing gastrectomy was determined by a variety of risk factors. Medical professionals should identify risk factors early and impose interventions to prevent them to lower the incidence of POPF in gastric cancer patients.

Postoperative Opioid Use Is Associated with Increased Rates of Grade B/C Pancreatic Fistula After Distal Pancreatectomy

BACKGROUND

Clinically relevant postoperative pancreatic fistula (CR-POPF) is a major source of morbidity after distal pancreatectomy. This study examined the association between postoperative opioid use and CR-POPF in the context of opioid-sparing postoperative care.

METHODS

A case-control study was performed on consecutive patients who underwent distal pancreatectomy between October 2016 and April 2022 at a single institution. Patients who developed CR-POPF were compared to controls. Multivariable regression modeling was used to identify factors associated with CR-POPF.

RESULTS

A total of 281 patients underwent 187 open, 20 laparoscopic, and 74 robotic-assisted operations. The rate of CR-POPF was 21% (n = 58). CR-POPF rate declined from 32 to 8% over the study period (p < 0.001). Median oral morphine equivalents (OME) administered on POD 0-1 and 0-3 were 94 and 129 mg, respectively, in patients who did not develop a fistula versus 130 and 180 mg in those who did (both p ≤ 0.001). POD 0-3 OME (OR 1.11, p = 0.044) was independently associated with increased odds of CR-POPF, with each additional 50 mg (equivalent to 10 tramadol pills) increasing the relative risk by 11% and absolute risk by 2%.

CONCLUSION

Early postoperative opioid use after distal pancreatectomy was associated with increased odds of CR-POPF. Decreasing perioperative opioid use through enhanced postoperative management is a low-cost and generalizable approach that may reduce rates of CR-POPF after distal pancreatectomy.

Comparative outcomes of extended distal pancreatectomy and distal pancreatectomy

PURPOSE

Patients with locally advanced pancreatic body/tail tumors, gastric cancer, or colon cancer often have contiguous organ involvement requiring extensive pancreatic resection. This study was performed to compare surgical complications and the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) between distal pancreatectomy (DP) with extended organ resection and standard DP.

METHODS

In total, 128 patients who underwent DP from January 2012 to January 2021 were retrospectively reviewed. Extended DP was defined according to the International Study Group of Pancreatic Surgery definition.

RESULTS

Of the 128 patients, 62 (48.4%) underwent extended DP and 66 (51.6%) underwent DP. Blood loss was greater (p < 0.001), the incidence of major complications was higher (p = 0.032), and the hospital stay was longer (p = 0.002) in the extended DP group than in the DP group. There were no differences in the incidence of CR-POPF, the readmission rate, or the need for postoperative intervention drainage. Univariate and multivariate analyses showed that extended DP was not a risk factor for CR-POPF or major complications.

CONCLUSION

Extended DP can be performed with comparable CR-POPF occurrence and mortality but increased morbidity when compared with standard DP.

Safety and feasibility of modified duct-to-mucosa pancreaticojejunostomy during pancreatoduodenectomy: A retrospective cohort study

BACKGROUND

Pancreatoduodenectomy (PD) is the most effective surgical procedure to remove a pancreatic tumor, but the prevalent postoperative complications, including postoperative pancreatic fistula (POPF), can be life-threatening. Thus far, there is no consensus about the prevention of POPF.

AIM

To determine possible prognostic factors and investigate the clinical effects of modified duct-to-mucosa pancreaticojejunostomy (PJ) on POPF development.

METHODS

We retrospectively collected and analyzed the data of 215 patients who underwent PD between January 2017 and February 2022 in our surgery center. The risk factors for POPF were analyzed by univariate analysis and multivariate logistic regression analysis. Then, we stratified patients by anastomotic technique (end-to-side invagination PJ vs modified duct-to-mucosa PJ) to conduct a comparative study.

RESULTS

A total of 108 patients received traditional end-to-side invagination PJ, and 107 received modified duct-to-mucosa PJ. Overall, 58.6% of patients had various complications, and 0.9% of patients died after PD. Univariate and multivariate logistic regression analyses showed that anastomotic approaches, main pancreatic duct (MPD) diameter and pancreatic texture were significantly associated with the incidence of POPF. Additionally, the POPF incidence and operation time in patients receiving modified duct-to-mucosa PJ were 11.2% and 283.4 min, respectively, which were significantly lower than those in patients receiving traditional end-to-side invagination PJ (27.8% and 333.2 minutes).

CONCLUSION

Anastomotic approach, MPD diameter and pancreatic texture are major risk factors for POPF development. Compared with traditional end-to-side invagination PJ, modified duct-to-mucosa PJ is a simpler and more efficient technique that results in a lower incidence of POPF. Further studies are needed to validate our findings and explore the clinical applicability of our technique for laparoscopic and robotic PD.

Vascular supply of postresection pancreatic remnant after pancreaticoduodenectomy: A cadaveric study

OBJECTIVES

The vascular supply to the neck and body of the pancreas is highly variable. The dorsal pancreatic artery is the dominant artery feeding this area. The aim of this study was to describe the vascular supply of postresection pancreatic remnants after pancreaticoduodenectomy. Patients with hazardous anatomical arrangement may be at a higher risk of postresection remnant ischemia and postoperative pancreatic fistula development.

METHODS

The modified Whipple procedure was performed on 20 cadaveric donors. The macroscopic anatomical supply of the postresection pancreatic remnant of each donor was evaluated.

RESULTS

The arterial supply of the postresection remnant was highly variable. In 30% of cases (6/20), the dorsal pancreatic artery was cut during the pancreatoduodenectomy or it was missing. In these cases, the area of the pancreaticojejunostomy construction was fed only through anastomoses between the transverse pancreatic artery and the pancreatic branches of the splenic artery.

CONCLUSIONS

In 30% of cases, the arterial supply of the postresection pancreatic remnant was dependent on inconstant intraparenchymal arterial anastomoses. These patients may be at a higher risk of postoperative pancreatic fistula development.

Surgical management of pancreatic ductal adenocarcinoma: a narrative review

Background and Objective

Pancreatic ductal adenocarcinoma (PDAC) is the third-leading cause of cancer-related death in the United States and is projected to become the second-leading cause of cancer-related death by 2030. Despite advances in systemic and radiation therapy, for patients with surgically resectable PDAC, complete surgical resection is the only potentially curative treatment option. The conduct of a safe, technically excellent pancreatectomy is essential to achieve optimal perioperative outcomes and long-term survival. In this narrative review, evidence from large, well-executed studies and clinical trials examining the technical aspects of pancreatectomy is reviewed.

Methods

A search was conducted in PubMed, Medline, and Cochrane Review databases to identify English-language randomized clinical trials, meta-analyses, and systematic reviews assessing surgical aspects of pancreatectomy for PDAC published between 2010 to 2023.

Key Content and Findings

We identified retrospective and prospective studies evaluating the technical aspects of surgery for PDAC. In this review, we evaluate data on surgical techniques of pancreatectomy for PDAC, including the role of minimally invasive techniques, extent of lymphadenectomy, reconstruction options after pancreatoduodenectomy, and the role of surgical drainage.

Conclusions

Surgical resection has a critical role in the treatment of operable PDAC. While pancreatic cancer surgery is an active area of research, conducting a technically excellent surgical resection maintains paramount importance for both oncological and perioperative outcomes. In this review, we summarize the latest evidence on surgical technique for operable PDAC.

Early vs late drain removal after pancreatic resection-a systematic review and meta-analysis

BACKGROUND

Reducing clinically relevant post-operative pancreatic fistula (CR-POPF) incidence after pancreatic resections has been a topic of great academic interest. Optimizing post-operative drain management is a potential strategy in reducing this major complication.

METHODS

Studies involving pancreatic resections, including both pancreaticoduodenectomy (PD) and distal pancreatic resections (DP), with intra-operative drain placement were screened. Early drain removal was defined as removal before or on the 3rd post-operative day (POD) while late drain removal was defined as after the 3rd POD. The primary outcome was CR-POPF, International Study Group of Pancreatic Surgery (ISGPS) Grade B and above. Secondary outcomes were all complications, severe complications, post-operative haemorrhage, intra-abdominal infections, delayed gastric emptying, reoperation, length of stay, readmission, and mortality.

RESULTS

Nine studies met the inclusion criteria and were included for analysis. The studies had a total of 8574 patients, comprising 1946 in the early removal group and 6628 in the late removal group. Early drain removal was associated with a significantly lower risk of CR-POPF (OR: 0.24, p < 0.01). Significant reduction in risk of post-operative haemorrhage (OR: 0.55, p < 0.01), intra-abdominal infection (OR: 0.35, p < 0.01), re-admission (OR: 0.63, p < 0.01), re-operation (OR: 0.70, p = 0.03), presence of any complications (OR: 0.46, p < 0.01), and reduced length of stay (SMD: -0.75, p < 0.01) in the early removal group was also observed.

CONCLUSION

Early drain removal is associated with significant reductions in incidence of CR-POPF and other post-operative complications. Further prospective randomised trials in this area are recommended to validate these findings.

Drain fluid biomarkers for the diagnosis of clinically relevant postoperative pancreatic fistula: a diagnostic accuracy systematic review and meta-analysis

BACKGROUND

Pancreatectomy is the only curative treatment available for pancreatic cancer and a necessity for patients with challenging pancreatic pathology. To optimize outcomes, postsurgical complications such as clinically relevant postoperative pancreatic fistula (CR-POPF) should be minimized. Central to this is the ability to predict and diagnose CR-POPF, potentially through drain fluid biomarkers. This study aimed to assess the utility of drain fluid biomarkers for predicting CR-POPF by conducting a diagnostic test accuracy systematic review and meta-analysis.

METHODS

Five databases were searched for relevant and original papers published from January 2000 to December 2021, with citation chaining capturing additional studies. The QUADAS-2 tool was used to assess the risk of bias and concerns regarding applicability of the selected studies.

RESULTS

Seventy-eight papers were included in the meta-analysis, encompassing six drain biomarkers and 30 758 patients with a CR-POPF prevalence of 17.42%. The pooled sensitivity and specificity for 15 cut-offs were determined. Potential triage tests (negative predictive value >90%) were identified for the ruling out of CR-POPF and included postoperative day 1 (POD1) drain amylase in pancreatoduodenectomy (PD) patients (300 U/l) and in mixed surgical cohorts (2500 U/l), POD3 drain amylase in PD patients (1000-1010 U/l) and drain lipase in mixed surgery groups (180 U/l). Notably, drain POD3 lipase had a higher sensitivity than POD3 amylase, while POD3 amylase had a higher specificity than POD1.

CONCLUSIONS

The current findings using the pooled cut-offs will offer options for clinicians seeking to identify patients for quicker recovery. Improving the reporting of future diagnostic test studies will further clarify the diagnostic utility of drain fluid biomarkers, facilitating their inclusion in multivariable risk-stratification models and the improvement of pancreatectomy outcomes.

Distal pancreatectomy with or without radical approach, vascular resections and splenectomy: Easier does not always mean easy

Because distal pancreatectomy (DP) has no reconstructive steps and less frequent vascular involvement, it is thought to be the easier counterpart of pancreaticoduodenectomy. This procedure has a high surgical risk and the overall incidences of perioperative morbidity (mainly pancreatic fistula), and mortality are still high, in addition to the challenges that accompany delayed access to adjuvant therapies (if any) and prolonged impairment of daily activities. Moreover, surgery to remove malignancy of the body or tail of the pancreas is associated with poor long-term oncological outcomes. From this perspective, new surgical approaches, and aggressive techniques, such as radical antegrade modular pancreato-splenectomy and DP with celiac axis resection, could lead to improved survival in those affected by more locally advanced tumors. Conversely, minimally invasive approaches such as laparoscopic and robotic surgeries and the avoidance of routine concomitant splenectomy have been developed to reduce the burden of surgical stress. The purpose of ongoing surgical research has been to achieve significant reductions in perioperative complications, length of hospital stays and the time between surgery and the beginning of adjuvant chemotherapy. Because a dedicated multidisciplinary team is crucial to pancreatic surgery, hospital and surgeon volumes have been confirmed to be associated with better outcomes in patients affected by benign, borderline, and malignant diseases of the pancreas. The purpose of this review is to examine the state of the art in distal pancreatectomies, with a special focus on minimally invasive approaches and oncological-directed techniques. The widespread reproducibility, cost-effectiveness and long-term results of each oncological procedure are also taken into deep consideration.

Pancreatectomy and Pancreatic Surgery

Pancreatectomy, including pancreaticoduodenectomy (PD), as well as central pancreatectomy (CP), distal pancreatectomy (DP) and total/subtotal pancreatectomy, is a major, complex and difficult surgical procedure performed for various benign and malignant pancreatic diseases: from chronic pancreatitis, through benign cystic tumors and neuroendocrine neoplasms to malignant neoplasms, including pancreatic ductal adenocarcinoma (PDAC) [...].

Clinical characteristics and predictive factors of postoperative intra-abdominal abscess after distal pancreatectomy

PURPOSE

The postoperative mortality rate of distal pancreatectomy is lower than that of pancreaticoduodenectomy, although persistent complications may occur after distal pancreatectomy. Fluid collection (FC) is frequently observed after distal pancreatectomy; however, FC may occasionally progress to postoperative intra-abdominal abscess (PIAA), which requires conservative or progressive interventional treatment. This study aimed to compare the status between patients with or without PIAA, identify predictive factors for PIAA and clinically relevant postoperative pancreatic fistula, and investigate the clinical characteristics of patients with PIAA with interventional drainage.

METHODS

We retrospectively reviewed data of patients who underwent distal pancreatectomy between January 2012 and December 2019 at two high-volume centers, where hepatobiliary-pancreatic surgeries were performed by expert specialist surgeons. Logistic regression analysis was performed to determine the predictive factors for PIAA.

RESULTS

Overall, 242 patients were analyzed, among whom 49 (20.2%) had PIAA. The median postoperative period of PIAA formation was 9 (range: 3-49) days. Among the 49 patients with PIAA, 25 (51.0%) underwent percutaneous ultrasound, computed tomography, or endoscopic ultrasound-guided interventions for PIAA. In the univariate analysis, preoperative indices representing abdominal fat mass (i.e., body mass index, subcutaneous fat area, and visceral fat area) were identified as predictive factors for PIAA; in the multivariate analysis, C-reactive protein (CRP) level (continuous variable) on postoperative day (POD) 3 (odds ratio: 1.189, 95.0% confidence interval: 1.111 - 1.274; P < 0.001) was the only independent and significant predictive factor for PIAA.

CONCLUSIONS

CRP level on POD 3 was an independent and significant predictive factor for PIAA after distal pancreatectomy.

Laparoscopic versus open central pancreatectomy: a propensity score-matched analysis in a single centre

PURPOSE

Laparoscopic central pancreatectomy (LCP) has been implemented in pancreatic surgery; however, open surgery is still the predominant approach for central pancreatectomy (CP). Our objective was to compare LCP with open CP (OCP).

METHODS

Data were collected from patients with tumours located in the pancreatic neck and proximal body who underwent CP in the Department of Pancreatic Surgery West China Hospital from January 1, 2010, to June 30, 2019. A comparison between the LCP and OCP groups was performed.

RESULTS

Fifteen patients underwent CP via the laparoscopic approach, and 96 patients underwent CP via the open approach. Using 1:2 propensity score matching (PSM), 12 patients in the LCP group were matched to 21 in the OCP group. Regarding safety, postoperative pancreatic fistula (POPF) was not significantly different between the two groups (13.3% vs. 12.5%, P = 1.000), even with PSM (16.7% vs. 14.3%, P = 1.000). However, regarding effectiveness, the operative time in the OCP group was significantly shorter than that in the LCP group before (307.0 ± 92.3 ml vs. 220.6 ± 63.6 ml, P < 0.000) and after (300.3 ± 90.2 ml vs. 212.7 ± 44.4 ml, P = 0.002) PSM. Regarding length of stay (LOS), there was no difference between the two groups before (13.1 ± 13.7 days vs. 12.7 ± 10.1 days, P = 0.376) and after PSM (14.4 ± 15.1 days vs. 14.5 ± 16.2 days, P = 0.985). The length of the resected pancreas was shorter in the OCP group than in the LCP group before PSM (50.0 ± 13.2 mm vs. 41.1 ± 11.1 mm, P = 0.043). However, there was no difference between the two groups after PSM (47.9 ± 12.5 mm vs. 37.9 ± 10.4 mm, P = 0.084). Moreover, the other variables showed no difference between the two groups before and after PSM.

CONCLUSION

LCP can demonstrate similar safety and effectiveness to OCP, even in the early stages of the learning curve.

Application of Clavien-Dindo classfication-grade in evaluating overall efficacy of laparoscopic pancreaticoduodenectomy

Background

The Clavien-Dindo classification (CDC) has been widely accepted and applied in clinical practice. We investigated its effectiveness in prediction of major complications (LPPC) after laparoscopic pancreaticoduodenectomy (LPD) and associated risk factors.

Methods

A retrospective analysis was conducted covering clinical data of 793 patients undergoing LPD from April 2015 to November 2021. CDC was utilized to grade postoperative complications and analyze the differences. Risk factors of LPPC were identified according to univariate and multivariate analyses.

Resluts

For the 793 patients undergoing laparoscopic pancreaticoduodenectomy in the northeast of China, LPPC was reported in 260 (32.8%) patients, pancreatic fistula in 169 (21.3%), biliary fistula in 44 (5.5%), delayed gastric emptying in 17(2.1%), post pancreatectomy hemorrhage in 55 (6.9%), intestinal fistula in 7 (0.8%), abdominal infections in 59 (7.4%) and pulmonary complication in 28 (3.5%). All complications were classified into five levels with the C-D classification (Grade I-V), with 83 (31.9%) patients as grade I, 91 (35.0%) as grade II, 38 (14.6%) as grade IIIa, 24 (9.2%) as grade IIIb, 9 (3.5%) as grade IV and 15 (5.8%) as grade V. 86 (10.8%) patients experienced major complications (grade III-V).The results of univariate and multivariate analysis revealed the independent risk factors for laparoscopic pancreaticoduodenectomy complications to be preoperative total bilirubin (P = 0.029, OR = 1.523), soft pancreas texture (P < 0.001, OR = 1.399), male (P = 0.038, OR = 1.396) and intraoperative transfusion (P = 0.033, OR = 1.517). Preoperative total bilirubin (P = 0.036, OR = 1.906) and intraoperative transfusions (P = 0.004, OR = 2.123) were independently associated with major postoperative complications. The influence of different bilirubin levels on C-D grade of complications was statistically significant (P = 0.036, OR = 1.906).

Conclusions

The Clavien-Dindo classification (CDC) may serve as a valid tool to predict major postoperative complications and contribute to perioperative management and comparison of surgical techniques in different medical centers.

Impact of the transection plan on postoperative pancreatic fistulas occurring after robot-assisted distal pancreatectomy for nonmalignant pancreatic neoplasms

OBJECTIVES

Postoperative pancreatic fistula (POPF) is the main complication of distal pancreatectomy (DP) and affects the prognosis of patients. The impact of several clinical factors mentioned in recent studies on POPF remains controversial. This study aimed to investigate the impact of a remnant pancreas and other perioperative factors on POPFs occurring after robot-assisted distal pancreatectomy (RDP) for nonmalignant pancreatic neoplasms.

METHODS

A total of 197 patients who received robot-assisted distal pancreatectomy (RDP) for nonmalignant pancreatic neoplasms at the Pancreatic Disease Center, Ruijin Hospital Shanghai Jiaotong University School of Medicine from January 2018 to December 2020 were included in this retrospective study. According to the intraoperative transection plan, patients were divided into an RDP body group and an RDP tail group. Clinical and pathological features and perioperative factors affecting POPF were analyzed and compared between the two groups.

RESULTS

The results showed that a transection plan involving the tail of the pancreas (OR = 2.133, 95% CI 1.109-4.103, p = 0.023) and spleen preservation (OR = 2.588, 95% CI 1.435-4.665, p = 0.001) independently increased the incidence of POPF in patients with nonmalignant pancreatic neoplasms treated by RDP. A transection plan involving the tail of the pancreas was also an independent risk factor (OR = 3.464, 95% CI 1.270-9.450, p = 0.015) for grade B/C POPF. Length of remnant pancreas > 6.23 cm was an independent risk factor for POPF (OR = 3.116, 95% CI 1.364-7.121, p = 0.007). Length of remnant pancreas > 9.82 cm was an independent risk factor for grade B/C POPF (OR = 3.340, 95% CI 1.386-8.051, p = 0.007).

CONCLUSION

This retrospective study suggests that a transection plan involving the tail of the pancreas is an independent risk factor for POPF in patients with nonmalignant neoplasms treated by RDP. We also propose that the postoperative length of the remnant pancreas evaluated by computed tomography scans can be used to identify patients with a high risk of POPF in order to optimize the individualized strategy.

Association between the Preoperative C-Reactive Protein-to-Albumin Ratio and the Risk for Postoperative Pancreatic Fistula following Distal Pancreatectomy for Pancreatic Cancer

Postoperative pancreatic fistula (POPF) are major postoperative complications (POCs) following distal pancreatectomy (DP). Notably, POPF may worsen the prognosis of patients with pancreatic cancer. Previously reported risks for POCs include body mass index, pancreatic texture, and albumin levels. Moreover, the C-reactive protein-to-albumin ratio (CAR) is a valuable parameter for prognostication. On the other hand, POCs sometimes lead to a worse prognosis in several cancer types. Thus, we assumed that CAR could be a risk factor for POPFs. This study investigated whether CAR can predict POPF risk in patients with pancreatic cancer following DP. This retrospective study included 72 patients who underwent DP for pancreatic cancer at Ehime University between January 2009 and August 2022. All patients underwent preoperative CAR screening. Risk factors for POPF were analyzed. POPF were observed in 17 of 72 (23.6%) patients. POPF were significantly associated with a higher CAR (p = 0.001). The receiver operating characteristic curve analysis determined the cutoff value for CAR to be 0.05 (sensitivity: 76.5%, specificity: 88.9%, likelihood ratio: 6.88), indicating an increased POPF risk. Univariate and multivariate analysis revealed that CAR ≥ 0.05 was a statistically independent factor for POPF (p < 0.001, p = 0.013). Therefore, CAR has the potential to predict POPF following DP.

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.

Personal predictive model based on systemic inflammation markers for estimation of postoperative pancreatic fistula following pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (PF) is a serious life-threatening complication after pancreaticoduodenectomy (PD). Our research aimed to develop a machine learning (ML)-aided model for PF risk stratification.

AIM

To develop an ML-aided model for PF risk stratification.

METHODS

We retrospectively collected 618 patients who underwent PD from two tertiary medical centers between January 2012 and August 2021. We used an ML algorithm to build predictive models, and subject prediction index, that is, decision curve analysis, area under operating characteristic curve (AUC) and clinical impact curve to assess the predictive efficiency of each model.

RESULTS

A total of 29 variables were used to build the ML predictive model. Among them, the best predictive model was random forest classifier (RFC), the AUC was [0.897, 95% confidence interval (CI): 0.370–1.424], while the AUC of the artificial neural network, eXtreme gradient boosting, support vector machine, and decision tree were between 0.726 (95%CI: 0.191–1.261) and 0.882 (95%CI: 0.321–1.443).

CONCLUSION

Fluctuating serological inflammatory markers and prognostic nutritional index can be used to predict postoperative PF.

Closure and anastomosis of the pancreas using a four-needle three-loop suture device

Pancreatic juice can leak not only from the main pancreatic duct but also from unclosed ductal branches appearing on the pancreatic stump. We have developed a suture device consisting of three loops of suture attached to four small-curvature needles with the aim to maximize the area of pancreatic parenchyma to be ligated and reduce the number of punctures made on the pancreas during pancreatic closure or anastomosis. In pancreatojejunostomy, the dorsal wall of the jejunum and then the pancreatic parenchyma are sutured using the four needles. Following duct-to-mucosa anastomosis, the ventral jejunal wall is sutured, and the three threads are finally tied sequentially to complete the reconstruction following the Blumgart method. In distal pancreatectomy, the pancreatic stump is sutured from the dorsal aspect sequentially using the four needles, before or after the pancreatic transection. The three threads are then respectively tied on the ventral surface of the pancreas. This device was used in six pancreatoduodenectomies (including two minimally invasive procedures) and five distal pancreatectomies. A postoperative pancreatic fistula requiring additional drainage or repositioning of abdominal drains developed in two patients. No adverse events associated with this device were encountered. The four-needle three-loop suture device can be an alternative to conventional staplers or sutures for closure and anastomosis of the pancreatic stump.

Geriatric nutritional risk index as a potential prognostic marker for patients with resectable pancreatic cancer: a single-center, retrospective cohort study

In pancreatic cancer, postoperative complications (POCs) are associated with disease outcomes. The geriatric nutritional risk index (GNRI) is known to predict POCs after pancreatoduodenectomy (PD) or distal pancreatectomy (DP) in patients with hepatobiliary pancreatic tumors, including pancreatic cancer. Through POC occurrence risk, we aimed to determine whether GNRI could predict prognosis in patients who underwent PD or DP for resectable pancreatic cancer. This retrospective study examined 139 patients who underwent radical pancreatectomy for resectable pancreatic cancer at Ehime University. All patients were subjected to nutritional screening using GNRI and were followed up for POC diagnosis and patient outcomes such as overall survival (OS). Patients were divided based on the GNRI value of 99 (Low group: N = 74, GNRI < 99; High group: N = 65, GNRI ≥ 99), which was determined by receiver operating characteristic curve analysis. Multivariate analysis showed that GNRI < 99 was statistically correlated with POCs after curative pancreatic resection (p = 0.02). Univariate and multivariate analyses confirmed that GNRI < 99 was significantly associated with long OS (p = 0.04). GNRI could be a potential prognostic marker for resectable pancreatic cancer after curative pancreatic resection despite being a simple and noninvasive approach.

Complications in Distal Pancreatectomy versus Radical Antegrade Modular Pancreatosplenectomy: A Disease Risk Score Analysis Utilizing National Surgical Quality Improvement Project Data

INTRODUCTION

Radical antegrade modular pancreatosplenectomy (RAMPS) was developed to improve R0 resections and lymph node harvests versus distal pancreatectomy (DP) in pancreatic adenocarcinoma (PDAC); relative complication rates are understudied.

METHODS

Patients undergoing distal pancreas resections from 2006 to 2020 were identified from our institutional NSQIP database, grouped by resection method, and evaluated for the following outcomes: postoperative pancreatic fistula (POPF), clinically relevant POPF (crPOPF), incisional surgical site infection (iSSI), organ space SSI (osSSI), and Clavien-Dindo grade ≥ 3 (CD ≥ 3) complications using logistic regression. Patients were matched 1:1 based on disease risk score.

RESULTS

Two-hundred-thirty-six and 117 patients underwent DP and RAMPS, respectively. POPF, crPOPF, CD ≥ 3 complications, iSSI, and osSSIs occurred in 105 (30%), 43 (12%), 74 (21%), 34 (10%) and 52 (15%) patients, respectively. Disease risk score matching yielded 89 similar patients per group. On multivariable analysis, patients undergoing RAMPS were not significantly more likely to experience POPF (OR 0.69, P = 0.26), crPOPF (OR 0.41, P = 0.72), CD ≥ 3 complication (OR 0.78, P = 0.44), iSSI (OR 0.58, P = 0.27), or osSSI (OR 0.93, P = 0.86). Of patients with PDAC (n = 108) mean nodal harvest were 14.8 (SD 11.30) and 19.4 (SD 7.19) nodes for patients undergoing DP and RAMPS, respectively (P = 0.01). Six patients (20%) undergoing DP had positive margins versus 12 (15%) undergoing RAMPS (P = 0.56). At a median follow-up of 17 months, there was no difference in locoregional recurrence-free survival (P = 0.32) or overall survival (P = 0.92) on Kaplan-Meier analysis.

CONCLUSION

RAMPS does not result in increased complications compared to DP and routine use is encouraged in pancreatic malignancies.

Risk factors of clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy: A systematic review and meta-analysis

BACKGROUND

Clinically relevant postoperative pancreatic fistula (CR-POPF) is a common and troublesome complication after pancreatoduodenectomy (PD). We conducted a systematic review and meta-analysis to identify the risk factors of CR-POPF after PD.

METHODS

We searched PubMed, EMBASE, and Cochrane Library databases for studies related to risk factors of CR-POPF after PD. Odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were extracted from the included studies, then a meta-analysis was conducted. If necessary, sensitivity analysis would be performed by changing the effect model or excluding 1 study at a time. Publication bias was assessed by funnel plot and Begg test and Egger test.

RESULTS

A total of 27 studies with 24,740 patients were included, and CR-POPF occurred in 3843 patients (incidence = 17%, 95% CI: 16%-19%). Male (OR = 1.56, 95% CI: 1.42-1.70), body mass index >25 kg/m2 (OR = 1.98, 95% CI: 1.23-3.18), pancreatic duct diameter <3 mm (OR = 1.87, 95% CI: 1.66-2.12), soft pancreatic texture (OR = 3.49, 95% CI: 2.61-4.67), and blood transfusion (OR = 3.10, 95% CI: 2.01-4.77) can significantly increase the risk of CR-POPF. Pancreatic adenocarcinoma (OR = 0.54, 95% CI: 0.47-0.61), vascular resection (OR = 0.57, 95% CI: 0.39-0.83), and preoperative chemoradiotherapy (OR = 0.68, 95% CI: 0.57-0.81) can significantly decrease the factor of CR-POPF. Diabetes mellitus was not statistically associated with CR-POPF (OR = 0.66, 95% CI: 0.40-1.08). However, the analysis of body mass index, pancreatic texture, and diabetes mellitus had a high heterogeneity, then sensitivity analysis was performed, and the result after sensitivity analysis showed diabetes mellitus can significantly decrease the risk of CR-POPF. There was no significant publication bias in this meta-analysis.

CONCLUSIONS

The current review assessed the effects of different factors on CR-POPF. This can provide a basis for the prevention and management of CR-POPF. Effective interventions targeting the above risk factors should be investigated in future studies for decreasing the occurrence of CR-POPF.

The clinical impact of modified transpancreatic mattress sutures with polyglactin 910 woven mesh on postoperative pancreatic fistula in distal pancreatectomy

BACKGROUND

We previously reported the stump closure method for the remnant pancreas in distal pancreatectomy, in which soft coagulation and polyglycolic acid felt attached with fibrin glue were utilized. Transpancreatic mattress suture with polyglactin 910 woven mesh was recently reported as a novel stump closure technique. We developed the modified transpancreatic mattress suture with polyglactin 910 woven mesh method, which combined our polyglycolic acid felt method with the transpancreatic mattress suture with polyglactin 910 woven mesh method.

METHODS

The polyglycolic acid felt group included patients undergoing distal pancreatectomy in whom the pancreatic stump was closed with the polyglycolic acid felt method from 2017 to 2018 (n = 54); whereas the modified transpancreatic mattress suture with polyglactin 910 woven mesh group included those whose stump was closed with the modified transpancreatic mattress suture with polyglactin 910 woven mesh method from 2019 to 2020 (n = 51). Perioperative parameters, including grade B/C postoperative pancreatic fistula (clinically relevant postoperative pancreatic fistula), were assessed according to the stump closure method.

RESULTS

The incidence of clinically relevant postoperative pancreatic fistula was significantly lower in the modified transpancreatic mattress suture with polyglactin 910 woven mesh group than in the polyglycolic acid felt group (7.8% vs 22.2%, P = .036). In multivariate analysis, the use of neoadjuvant chemoradiotherapy and the transpancreatic mattress suture with polyglactin 910 woven mesh method were independent factors for preventing clinically relevant postoperative pancreatic fistula (P = .011 and 0.0038, respectively). Moreover, in the modified transpancreatic mattress suture with polyglactin 910 woven mesh group, the incidence of clinically relevant postoperative pancreatic fistula in patients with a thick pancreas (≥13 mm, 6.7%) was comparably as low as that in patients with a thin pancreas (<13 mm, 9.5%).

CONCLUSION

The modified transpancreatic mattress suture with polyglactin 910 woven mesh method is an effective stump closure technique to prevent clinically relevant postoperative pancreatic fistula after distal pancreatectomy. Our results warrant further prospective investigation to evaluate the efficacy of the modified transpancreatic mattress suture with polyglactin 910 woven mesh method compared with other standard closure methods (eg, stapler closure or hand-sewn closure).

The Role of Diabetes Mellitus in the Malignant Pancreatic Cyst Neoplasm Diagnosis and Prognosis

Purpose

Pancreatic cyst neoplasm (PCN) is a precursor of pancreatic cancer. Previous studies reported PCN was often concurrent with diabetes. We aim to examine the association between diabetes with PCN malignancy and to detect the potential role of diabetes in PCN management and treatment.

Patients and Methods

A total of 224 patients who were diagnosed with the three major types of PCN (IPMN, MCN, and SCN) and underwent surgical resection were selected. Patients were divided into three groups (normal group, new-onset diabetes group (NODM) (<4years), and long-standing diabetes group (LSDM) (>4years)) according to diabetic history and diagnostic time interval. Diabetes, fast blood glucose level, HbA1c, and insulin resistance level were measured. Malignant PCN (mPCN) radiological features (worrisome features and high-risk stigmata) were analyzed. Pathological features (PCN type, dysplasia grade, tumor stage, and tumor volume) and immunohistology of Ki67 and SMAD4 were performed. Diagnostic efficacy of each variable was determined by the ROC curve. mPCN diagnosis was the main outcome in diagnostic prediction and overall survival as the glucose controlling outcome variables.

Results

Diabetes groups (NODM and LSDM) showed difference with the normal group in age, weight loss, malignancy, CA19-9 value, CEA value, Ki-67 value, tumor volume, pathological grade, and a lowered pancreatic fistula risk. NODM was related to insulin resistance, weight loss, and SMAD4 mutation. NODM (87.3%) and high insulin resistance rate (93.6%) significantly increased the sensitivity of radiological evidence-based mPCN diagnosis. Moreover, long-standing diabetes and elevated HbA1c led to reduced survival in mPCN patients than the normal PCN group. Anti-diabetic drugs showed limited influence on PCN malignancy and tumor volume.

Conclusion

NODM in PCN patients was associated with malignancy, insulin resistance, weight loss, and SMAD4 mutation. Prediabetic status and NODM diagnosis enhanced the diagnostic accuracy of radiological standards (worrisome features and high-risk stigmata). Stable glucose surveillance is necessary for mPCN patients’ survival.

Robotic Distal Gastrectomy Reduces Drain Amylase Values in Patients With a Small Pancreas-left Gastric Artery Angle

PURPOSE

Pancreatic fistula is a severe complication after laparoscopic distal gastrectomy (LDG). We previously evaluated the pancreas-left gastric artery angle (PLA) as a risk indicator for developing a pancreatic fistula after LDG. This study evaluated the incidence of pancreatic fistula with robotic distal gastrectomy (RDG) in comparison to LDG from the view of the PLA.

MATERIALS AND METHODS

An association between the PLA and the incidence of pancreatic fistula in 165 patients who underwent either RDG (n=45) or LDG (n=120) was investigated retrospectively.

RESULTS

RDG patients had significantly lower drain amylase values (postoperative day 2) than LDG patients. As opposed to LDG patients, drain amylase values were similar for patients with small (PLA <62 degrees) and large (PLA ≥62 degrees) PLA in RDG patients.

CONCLUSION

Robotic surgery may reduce the risk of postoperative pancreatic fistula in patients with a small PLA.

Effect of overtime pancreaticoduodenectomy on the short-term prognosis of patients

BACKGROUND

Due to the large number of operations, surgeons sometimes need to work overtime or even stay up late to perform pancreaticoduodenectomy. Fatigue and sleep deprivation can result in an increased error rate at work. There have been numerous studies about the effect of overtime surgery on the prognosis of patients. However, the effect of overtime work for pancreaticoduodenectomy on the prognosis of patients is unclear. This study explores the impact of overtime work for pancreaticoduodenectomy on the prognosis of patients.

AIM

To explore the impact of overtime work for pancreaticoduodenectomy on the short-term prognosis of patients.

METHODS

This was a single-center, retrospective cohort study. The patients who underwent pancreaticoduodenectomy between January 2017 and December 2019 were included. Patients were stratified by operative start time into the control group (surgery that started between 8:00 and 16:49) and the overtime group (surgery that started between 17:00 and 22:00) and compared intraoperative and postoperative parameters. The following parameters were compared between the overtime group and the control group: Operative time, blood loss, number of lymph nodes removed, duration of treatment in the Intensive Care Unit (ICU), and incidence of complications.

RESULTS

From January 2017 to December 2019, a total of 239 patients underwent pancreaticoduodenectomy in the Department of Hepatobiliary Surgery of our institution. Four patients were excluded from this study due to lack of clinical data. A total of 235 patients were included, with 177 in the control group and 58 in the overtime group. There was no difference between the two groups in operative time, blood loss, number of lymph nodes removed, ICU length of stay, hospital length of stay, mortality during hospitalization. Compared with the control group, the overtime group had a higher incidence of pancreatic fistula (32.8% vs 15.8%, P < 0.05). Multivariate analysis showed that overtime work, higher Body Mass Index were independent risk factors for pancreatic fistula (P < 0.05).

CONCLUSION

Overtime work for pancreaticoduodenectomy increases the incidence of pancreatic fistula. The effect of overtime surgery on the long-term prognosis of patients’ needs to be further studied.

An analysis of the effectiveness of stapler closure combined with a titanium clip in distal pancreatectomy

PURPOSES

Postoperative pancreatic fistula is the most common and severe postoperative complication of distal pancreatectomy. Treatment of pancreatic stump to reduce the incidence of postoperative pancreatic fistula is crucial. This study evaluated the effectiveness of stapler closure combined with a titanium clip in distal pancreatectomy.

METHODS

Prospectively collected data of consecutive patients who underwent distal pancreatectomy from April 2013 to May 2020 with pancreatic transection performed by the bare stapler method (131 patients), stapler + hand-sewn closure method (199 patients), and stapler + titanium clip method (209 patients) were reviewed retrospectively and compared between groups.

RESULTS

No statistically significant differences were observed in basic data among the three groups. There were also no significant differences among the three groups in terms of the intraoperative data or tumor pathological types, except for the number of laparoscopic treatment cases (23, 53, and 80 for bare stapler method, stapler + hand-sewn closure method, and stapler + titanium clip method, respectively; P < 0.05) and pancreatic neuroendocrine tumor cases (15, 29, and 12, respectively; P < 0.05). There were no significant differences in postoperative complications or parameters, except for the number of clinical pancreatic fistula cases (31, 27, and 13 for bare stapler method, stapler + hand-sewn closure method, and stapler + titanium clip method, respectively; P < 0.05) and postoperative length of hospital stay (11.6 ± 8.3, 10.6 ± 9.7, and 9.3 ± 6.9 days, respectively; P < 0.05). The stapler + titanium clip group had a significantly lower number of clinical pancreatic fistula cases and shorter postoperative length of hospital stay than the other groups. The univariate analysis showed that pancreatic resection line thickness was an independent risk factor for clinical pancreatic fistula after operation.

CONCLUSION

Stapler closure combined with titanium clips to reinforce the pancreatic stump is simple and easy to implement, effectively reduces the incidence of clinical pancreatic fistula, and shortens the postoperative length of hospital stay.

A randomized controlled trial of stapled versus ultrasonic transection in distal pancreatectomy

BACKGROUND

The pancreatic transection method during distal pancreatectomy is thought to influence postoperative fistula rates. Yet, the optimal technique for minimizing fistula occurrence is still unclear. The present randomized controlled trial compared stapled versus ultrasonic transection in elective distal pancreatectomy.

METHODS

Patients undergoing distal pancreatectomy from July 2018 to July 2020 at two high-volume institutions were considered for inclusion. Exclusion criteria were contiguous organ resection and a parenchymal thickness > 17 mm on intraoperative ultrasound. Eligible patients were randomized in a 1:1 ratio to stapled transection (Endo GIA Reinforced Reload with Tri-Staple Technology®) or ultrasonic transection (Harmonic Focus® + or Harmonic Ace® + shears). The primary endpoint was postoperative pancreatic fistula. Secondary endpoints included overall complications, abdominal collections, and length of hospital stay.

RESULTS

Overall, 72 patients were randomized in the stapled transection arm and 73 patients in the ultrasonic transection arm. Postoperative pancreatic fistula occurred in 23 patients (16%), with a comparable incidence between groups (12% in stapled transection versus 19% in ultrasonic dissection arm, p = 0.191). Overall complications did not differ substantially (35% in stapled transection versus 44% in ultrasonic transection arm, p = 0.170). There was an increased incidence of abdominal collections in the ultrasonic dissection group (32% versus 14%, p = 0.009), yet the need for percutaneous drain did not differ between randomization arms (p = 0.169). The median length of stay was 8 days in both groups (p = 0.880). Intraoperative blood transfusion was the only factor independently associated with postoperative pancreatic fistula on logistic regression analysis (OR 4.8, 95% CI 1.2-20.0, p = 0.032).

CONCLUSION

The present randomized controlled trial of stapled versus ultrasonic transection in elective distal pancreatectomy demonstrated no significant difference in postoperative pancreatic fistula rates and no substantial clinical impact on other secondary endpoints.

Protective or Risk Factors for Postoperative Pancreatic Fistulas in Malignant Pathology

Introduction: Malignant tumors are associated with a low incidence of postoperative pancreatic fistulas. The presence of peritumoral fibrosis is considered the protective factor for the development of postoperative pancreatic fistulas after pancreatic resections for pancreatic ductal adenocarcinomas. Methods: We analyzed a series of 109 consecutive patients with pancreatic resections for malignant pathology: pancreatic ductal adenocarcinomas and periampullary adenocarcinomas. The incidence of postoperative pancreatic fistulas has been reported in tumor histological type, in the presence of peritumoral fibrosis, and in the association between adenocarcinomas and areas of acute pancreatitis. The data obtained were processed with the statistical analysis program SPSS, and statistically significant p were considered at a value <0.05. Results: For the entire study group, the incidence of postoperative pancreatic fistulas was 11.01%. The lowest incidence was observed in the group of patients with pancreatic ductal adenocarcinomas (4.06% vs. 25.72% in the group with periampullary adenocarcinoma), with a p = 0.002. The presence of peritumoral fibrous tissue was observed in 49.31% of cases without pancreatic fistulas, and in 54.54% of cases that developed this postoperative complication (p = 0.5). Also, the peritumoral fibrous tissue had a uniform distribution depending on the main diagnosis (56.14% in pancreatic ductal adenocarcinoma group vs. 37.04% in periampullary adenocarcinoma group, with a p = 0.08). In the group of patients who associated areas of acute pancreatitis on the resections, the incidence of postoperative pancreatic fistulas was 7.8 times higher (30% vs. 3.8%, p = 0.026). Conclusions: Peritumoral fibrous tissue was not a factor involved in the developing of postoperative pancreatic fistulas. The association of adenocarciomas with areas of acute pancreatitis has led to a significant increase in postoperative pancreatic fistulas, which is a significant and independent risk factor.

An easy-to-use score to predict Clinically Relevant Post-Operative Pancreatic Fistula after distal pancreatectomy

BACKGROUND

Postoperative Pancreatic Fistula (POPF) is a common and serious complication after Distal Pancreatectomy (DP). An effective and accepted score to predict the occurrence of Clinically Relevant (CR-) POPF does not exist.

METHODS

Data regarding 103 consecutive patients undergoing DP from 2015 to 2019 were collected. A multivariate logistic regression was performed, in order to build a simplified score. The accuracy in predicting a categorical outcome was evaluated using the Receiver Operating Characteristic (ROC) curves. Youden's J test was performed to evaluate the performance of a positive score on the POPF occurrence.

RESULTS

33 patients developed a CR-POPF. Based on multivariate analysis results, a 4 points score was created by assigning 1 point if operation time was >4 hours, amylase levels on drains' fluid >500 UI on POD 3, pancreatic thickness >10mm and if the BMI was > 30. The discriminating ability was tested on the ROC curve, showing an area under the curve of 0.83 (CI 95%=0.75 - 0.92). The score threshold was determined at 2 points/4, the highest value according to the Youden index (0.53). The sensitivity is calculated at 82% (CI95% 69-95) and the specificity at 71 (CI95% 61 - 82). A threshold of 3 points/4 allows to reach a specificity of 99% (CI95% 99 - 100).

CONCLUSIONS

An easy to use post-operative score based on operation time, obesity, amylase level on drains on POD3 and pancreatic thickness on preoperative CT seems to predict the risk of developing CR-POPF.

Postoperative aggressive diuresis prevents postoperative tissue edema and complications in patients undergoing distal pancreatectomy

PURPOSE

Intraoperative fluid restriction is reported to be associated with reduced postoperative tissue edema and decreased incidence of postoperative pancreatic fistula (POPF) in pancreatic surgery. However, there is limited information regarding the postoperative approach to prevent postoperative tissue edema and reduce POPF.

METHODS

Patients undergoing distal pancreatectomy from 2013 to 2018 in our institute were retrospectively enrolled (n = 128). The patients were classified into the two groups: an early diuresis group (ED group: patients administered diuretic agents on postoperative day 2 or earlier between 2016 and 2018, n = 69) and a conventional diuresis group (CD group: patients administered diuretic agents on postoperative day 3 or later between 2013 and 2015, n = 59). Postoperative tissue edema assessed by CT imaging and the incidence of clinically relevant POPF (CR-PF; grade B or C) were compared.

RESULTS

Postoperative tissue edema was significantly reduced in the ED group (p < 0.0001). The incidence of CR-PF was lower in the ED group (19% vs. 32%, p = 0.082), especially in patients with postoperative diuresis on POD 1 (12%, p = 0.044).

CONCLUSION

Early and aggressive postoperative diuresis potentially reduced postoperative visceral tissue edema. This postoperative approach to prevent tissue edema may reduce the incidence of CR-PF in pancreatic surgery.

Postoperative Outcome of Surgery with Pancreatic Resection for Retroperitoneal Soft Tissue Sarcoma: Results of a Retrospective Bicentric Analysis on 50 Consecutive Patients

BACKGROUNDS

Multivisceral resection is the standard treatment for retroperitoneal sarcoma (RPS) during which pancreas resection may be necessary.

METHODS

All consecutive patients operated for RPS with pancreatectomy in 2 expert centers between 1993 and 2018 were retrospectively analyzed.

RESULTS

Fifty patients (median age: 57 years, IQR: [46-65]) with a primary (n = 33) or recurrent (n = 17) RPS underwent surgery requiring pancreas resection (distal pancreatectomy (DP) (n = 43), pancreaticoduodenectomy (PD) (n = 5), central pancreatectomy (n = 1), and atypical resection (n = 1)). Severe postoperative morbidity (Clavien-Dindo III-IV) was observed in 14 patients (28%), and 7 of them (14%) required reoperation for anastomotic bowel leakage (n = 5), gastric volvulus (n = 1), or hemorrhage (n = 1). Pancreas-related complications occurred in 25 patients (50%): 10 postoperative pancreatic fistulas (POPF) (grade A (n = 12), grade B (n = 6), grade C (n = 1)), 13 delayed gastric emptying (grade A (n = 8), grade B (n = 4), grade C (n = 1)), 1 hemorrhage (grade C). Postoperative mortality was 4% (n = 2), all following PD, caused by a massive intraoperative air embolism and by a multiple organ failure after anastomotic leakage. Pathological analysis confirmed pancreatic involvement in 17 (34%) specimens. Microscopically complete resection (R0) was achieved in 22 (44%) patients. After a follow-up of 60 months, 36 patients (75%) were still alive, among whom 27 without recurrence (56%).

CONCLUSION

Pancreatic resection during RPS surgery is associated with significant postoperative morbidity and mortality. PD should be avoided whenever possible while other procedures seemed achievable without excessive morbidity and with long-term survival.

Details and Outcomes of Distal Pancreatectomy with Celiac Axis Resection Preserving the Left Gastric Arterial Flow

BACKGROUND

To describe the technical details and efficacy of distal pancreatectomy with celiac axis resection (DP-CAR) and left gastric artery (LGA) flow preservation for pancreatic ductal adenocarcinoma (PDAC).

METHOD

This single-center, retrospective analysis investigated short- and long-term outcomes of DP-CAR performed on 55 patients with PDAC from 2011 to 2019. Our method included LGA reconstruction after total resection of the CA (rDP-CAR group; 24 patients) or LGA preservation if the tumor invasion was away from its root (pDP-CAR group; 31 patients), a CA-first approach to reduce blood loss during dissection, and conservative drain management with or without jejunal serosal patching at the pancreatic stump.

RESULTS

Among the study patients, 23 had locally advanced PDAC and 22 had borderline resectable PDAC. Median operation duration was 443 min (248-810), estimated blood loss was 600 mL (150-2280), and incidence of transfusion was 2%. Ischemic complications occurred exclusively in the rDP-CAR group, including two patients with ischemic gastropathy (8%) and three patients with findings of liver ischemia on computed tomography (13%). One patient underwent relaparotomy for stomach perforations, and 19 patients (35%) had pancreatic fistula, including 8 patients who underwent conservative drain placement for more than 3 weeks without specific symptoms. There were no Clavien-Dindo grade 4 or higher postoperative complications. Preoperative therapy showed improved 3-year overall survival rates than without (54% vs. 37%, p = 0.027).

CONCLUSIONS

Using the standardized technique, DP-CAR was safely performed with no mortality and acceptable long-term survival.

Clinical application of "Double R" anastomosis technique in laparoscopic pancreaticoduodenectomy procedure

Laparoscopic pancreaticoduodenectomy (LPD) is widely used as a treatment for periampullary tumors and pancreatic head tumors. However, postoperative pancreatic fistula (POPF), which significantly affects mortality and length of hospital stay of patients, remains one of the most common and serious complications following LPD. Though numerous technical modifications for pancreaticojejunostomy (PJ) have been proposed, POPF is still the "Achilles heel" of LPD.To reduce POPF rate and other postoperative complications following LPD by exploring the best approach to manage with the pancreatic remnant, a novel duct-to-mucosa anastomosis technique named Double Layer Running Suture (Double R) for the PJ was established. During 2018 and 2020, a totally 35 patients who underwent LPD with Double R were included, data on the total operative time, PJ duration, estimated blood loss, recovery of bowel function, postoperative complications, and length of hospital stay were collected and analyzed.The average duration of surgery was (380 ± 69) minutes. The mean time for performing PJ was (34 ± 5) minutes. The average estimated blood loss was (180 ± 155) mL. The overall POPF rate was 8.6% (3/35), including 8.6% (3/35) for the biochemical leak, 0% (0/35) for Grade B, and 0% (0/35) for Grade C. No patient suffered from biliary fistula, post-pancreatectomy hemorrhage, and intra-abdominal infection, the 30-day mortality was 0%.Double R anastomosis is potentially a safe, reliable, and rapid anastomosis with a low rate of POPF and post-pancreatectomy hemorrhage. It provides surgeons more options when performing LPD. However, its safety and effectiveness should be verified further by a larger prospective multicenter study.

Optimal stapler cartridge selection to reduce post-operative pancreatic fistula according to the pancreatic characteristics in stapler closure distal pancreatectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is associated with potentially fatal complications, but there is lack of data on relationship between pancreas thickness, and stapler size and the POPF rate. This study aimed to suggest optimal stapler that reduces POPF rate according to the pancreas thickness.

METHODS

This retrospective cohort study was conducted in two tertiary high-volume pancreas centers. 599 patients who underwent distal pancreatectomy were assessed for stump reinforcement methods, pathology findings, pancreas thickness, and cartridge used. The cartridges were grouped as I, II, III according to the closed height ≤1.5 mm, 1.8 mm, and ≥2.0 mm, respectively.

RESULTS

The POPF rate increased according to the thickness. The stapler Groups I, II, and III had an overall POPF rate of 66.4% vs. 61.7% vs. 57.8%, but Group II stapler cartridge showed a significant reduction in the POPF rate than other cartridges in pancreas with thickness <13 mm (53.5% vs. 21.7% vs. 36.0%, p = 0.031). There was no significant difference between the POPF rate according to stapler groups when the pancreas was thicker than 13 mm.

CONCLUSION

Thickness is the strongest risk factor in predicting POPF. Use of Group II stapler cartridge for pancreas with a thickness of <13 mm can help reduce POPF.

Division of the pancreas at the neck reduces postoperative pancreatic fistula in laparoscopic distal pancreatectomy: Comparison of pancreatic division at the body

BACKGROUND

objectives: During laparoscopic distal pancreatectomy (LDP), the optimal site for pancreatic division with consideration of postoperative pancreatic fistula (POPF) is unclear. We evaluate which site of pancreatic division, neck or body, has better outcomes after LDP.

METHODS

This was a retrospective, observational study. LDP was performed in 102 consecutive patients between December 2009 and May 2020. After excluding 14 patients with pancreatic division at tail, 88 patients (pancreatic division at neck n = 46, at body n = 42) were included in this study. Short- and long-term outcomes after LDP were compared between pancreatic division at neck and body.

RESULTS

The pancreatic transection site was thicker at body than at neck (17.5 vs. 11.9 mm, P < 0.001), although there were no significant differences of pancreatic texture and pancreatic duct size. The Grade B/C POPF rate was significantly higher when the pancreas was divided at body than when divided at neck (21.4 vs. 6.5%, P = 0.042). We found no significant differences between pancreatic division at neck and body in residual pancreatic volume (34.0 vs. 34.8 ml, P = 0.855), incidence of new-onset or worsening diabetes mellitus more than six months after LDP (P = 0.218), or body weight change (six-month: P = 0.116, one-year: P = 0.108, two-year: P = 0.195, tree-year: P = 0.131, four-year: P = 0.608, five-year: P = 0.408).

CONCLUSION

This study suggests that the pancreatic division at neck might reduce the Grade B/C POPF incidence after LDP, compared to division at body. A potential reason is that the pancreas at body is thicker than that at neck. However, further large-scale studies are necessary to confirm our results.

Pancreatic fistulas following distal pancreatectomy are unrelated to the texture quality of the pancreas

PURPOSE

The relevance of pancreatic texture for pancreatic fistula (POPF) formation after distal pancreatectomy (DP) remains ill defined. Recent POPF definition adjustments and common subjective pancreatic texture assessment are further drawbacks in the investigation of pancreatic texture as a factor for POPF development after DP.

METHODS

The predictive value of pancreatic texture by histologic assessment was investigated for POPF formation after DP, respecting the updated 2016 fistula definition. Histologic evaluation at the resection margin included amount of steatosis, degree of fibrosis, and pancreatic duct size.

RESULTS

A total of 102 patients who underwent DP were included. Thirty-six patients developed POPF. There was no difference in histologic variables in patients with and without POPF. In the univariate analysis, none of the three histologic features showed significant correlation with POPF formation. The ROC (receiver operating characteristic) curve demonstrated poor utility for the grade of steatosis 0.481 ± 0.058 (p = 0.75) and grade of fibrosis 0.466 ± 0.058 (p = 0.57) as predictive factors for POPF formation.

CONCLUSION

Results indicate that pancreatic texture does not predict POPF formation following DP. This is particularly relevant in the context of the increasing use of robotic and laparoscopic approaches for DPs with limited clinical pancreatic texture assessment by palpation.

Preoperative CT anthropometric measurements and pancreatic pathology increase risk for postoperative pancreatic fistula in patients following pancreaticoduodenectomy

Postoperative pancreatic fistula (POPF) is a common complication following pancreaticoduodenectomy (PD). However, risk factors for this complication remain controversial. We conducted a retrospective analysis of 107 patients who underwent PD. POPF was diagnosed in strict accordance with the definition of the 2016 update of pancreatic fistula from the International Study Group on Pancreatic Fistula (ISGPF). Univariate and multivariate logistic regression analyses were performed to identify independent risk factors for POPF. A total of 19 (17.8%) subjects of pancreatic fistula occurred after PD, including 15 (14.1%) with grade B POPF and 4 (3.7%) with grade C POPF. There were 33 (30.8%) patients with biochemical leak. Risk factors for POPF (grade B and C) were larger area of visceral fat (odds ratio [OR], 1.40; p = 0.040) and pathology other than pancreatic adenocarcinoma or pancreatitis (OR, 12.45; p = 0.017) in the multivariate regression analysis. This result could assist the surgeon to identify patients at a high risk of developing POPF.

Irrigation and passive drainage of pancreatic stump after distal pancreatectomy in high-risk patients: an innovative approach to reduce pancreatic fistula

INTRODUCTION

Postoperative pancreatic fistula (POPF) represents the most common form of morbidity after distal pancreatectomy (DP). The aim of this study was to illustrate an innovative technique of irrigation and passive drainage to reduce clinically relevant POPF (CR-POPF) incidence in high-risk patients undergoing DP.

MATERIAL AND METHODS

Twelve consecutive high-risk patients received irrigation and passive drainage of the pancreatic stump with a Salem sump drainage after DP. The Salem sump was irrigated with 100 ml/h of Ringer solution for 2 postoperative days (POD). In the case of low-drain amylase and lipase levels on POD 3, the irrigation was reduced to 50 ml/h. Persistence of low-drain pancreatic enzymes on POD 4 allowed for interruption of irrigation and subsequent removal of drainage from POD 7 onward in the absence of evidence of any pancreatic fistula.

RESULTS

Overall, 16.6% of the patients experienced a grade 3 or higher surgical complication. We experienced only one case of POPF: the fistula was classified as grade B and it was managed with radiologic drainage of the fluid collection. We did not experience any case of re-operation nor in-hospital mortality.

CONCLUSIONS

Irrigation with passive drainage of the pancreatic stump after DP is an interesting approach for CR-POPF prevention in high-risk patients.

[Predictors of external pancreatic fistulae after pancreatic resection]

Despite a significant decrease in postoperative mortality after pancreatic resections in recent years (5.2-15% after pancreatoduodenectomy and about 5% after distal pancreatectomy), incidence of postoperative complications remains high (30-50% and 22-50%, respectively). Postoperative pancreatic fistula is one of the most common and formidable complications. Currently, most authors use the classification proposed by the International Study Group for Pancreatic Fistula (biochemical failure, fistula type B and C). Prediction of the risk of postoperative fistula is still a complex and unresolved problem of modern surgical pancreatology. According to the literature, the main risk factors of postoperative pancreatic fistulae are obesity and high body mass index, concomitant cardiovascular diseases, no neoadjuvant chemo- and radiotherapy, soft pancreatic texture, narrow pancreatic duct, no fibrotic changes in parenchyma, adipose infiltration of the pancreas, advanced intraoperative blood loss, as well as center experience. Most often, magnetic resonance imaging, computed tomography, ultrasound elastography and various multivariate risk assessment systems are used to estimate the risk of pancreatic fistulae. However, a generally accepted technique does not exist. This manuscript is devoted to analysis of risk factors of postoperative pancreatic fistulae and diagnostic methods for assessment of this risk.

The Oncologic Impact of Pancreatic Fistula After Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma of the Body and the Tail: A Multicenter Retrospective Cohort Analysis

OBJECTIVES

The aim of this study was to assess the impact of clinically relevant postoperative pancreatic fistula (CR-POPF) on patient disease-specific survival and recurrence after curative distal pancreatectomy (DP) for pancreatic cancer.

DESIGN

This was a retrospective case-control analysis.

METHODS

We examined the data of adult patients with a diagnosis of pancreatic ductal adenocarcinoma (PDAC) of the body and tail of the pancreas undergoing curative DP, over a 10-year period in 12 European surgical departments, from a prospectively implemented database.

RESULTS

Among the 382 included patients, 283 met the strict inclusion criteria; 139 were males (49.1%) and the median age of the entire population was 70 years (range 37-88). A total of 121 POPFs were observed (42.8%), 42 (14.9%) of which were CR-POPFs. The median follow-up period was 24 months (range 3-120). Although poorer in the POPF group, overall survival (OS) and disease-free survival (DFS) did not differ significantly between patients with and without CR-POPF (p = 0.224 and p = 0.165, respectively). CR-POPF was not significantly associated with local or peritoneal recurrence (p = 0.559 and p = 0.302, respectively). A smaller percentage of patients benefited from adjuvant chemotherapy after POPF (76.2% vs. 83.8%), but the difference was not significant (p = 0.228).

CONCLUSIONS

CR-POPF is a major complication after DP but it did not affect the postoperative therapeutic path or long-term oncologic outcomes. CR-POPF was not a predictive factor for disease recurrence and was not associated with an increased incidence of peritoneal or local relapse.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT04348084.

Analysis of pancreatic fistula risk in patients with laparoscopic pancreatoduodenectomy: what matters

Objective

To analyse potential risk factors for postoperative pancreatic fistula (POPF).

Methods

A retrospective study on risk factors for POPF was conducted in patients undergoing laparoscopic pancreatoduodenectomy. Basic characteristics, and preoperative, intraoperative and postoperative patient data were collected and analysed.

Results

A total of 268 patients were enrolled in this study, including 54 patients with POPF following surgery (POPF incidence, 20.15%). Univariate analysis indicated that patient’s age, body mass index (BMI), preoperative bilirubin level, pancreas texture, and drainage fluid amylase level on day 1 following surgery were associated with POPF. Multiple logistic regression analysis indicated that preoperative bilirubin level ≥170 µmol/l, soft pancreas texture, BMI ≥25, and age ≥65 years were independent risk factors associated with POPF.

Conclusions

For patients with preoperative bilirubin level ≥170 µmol/l, soft pancreas texture, BMI ≥25 and age ≥65 years, clinically relevant measures should be taken as early as possible for the prophylaxis of POPF.

Utilization of the Falciform Ligament to Buttress the Pancreatic Transection Staple Line: A Novel Technique

BACKGROUND

Postoperative pancreatic fistula (POPF) remains a common complication after distal pancreatectomy and is a major source of operative morbidity. Although various mechanical, biological, and synthetic aids have been used to reduce the risk of POPF, none have a proven benefit.

MATERIALS AND METHODS

The authors describe (and present a video, Supplemental Digital Content 1, http://links.lww.com/SLE/A256) a novel technique in which the autologous falciform ligament was harvested, wrapped around the pancreas at the site of proposed pancreatic transection, and secured with sutures to buttress the pancreatic transection staple line. The pancreas was then transected with a triple-row stapler.

RESULTS

Two male patients aged 40 and 57 years each with a 4.3 and 4.2 cm solid mass in the body of the pancreas respectively underwent laparoscopic anterior radical antegrade modular pancreaticosplenectomy, the former patient underwent an en block transverse colectomy for suspected malignancy. Both patients had soft pancreata. They experienced no POPF, made an uneventful recovery, and were discharged from the hospital on the second and fourth postoperative days, respectively. No pancreatic complications were encountered at 5 and 6 months follow-up, respectively.

CONCLUSIONS

The use of the falciform ligament to buttress the staple line at the time of pancreatic transection is a novel technique. Its potential benefit in reducing the risk of POPF warrants further assessment.

Predictive Factors Associated with Complications after Laparoscopic Distal Pancreatectomy

Although laparoscopic distal pancreatectomy (LDP) has become more popular, the postoperative complication rate remains high. We sought to identify the risk factors for post-LDP complications. We examined 1227 patients who underwent LDP between March 2005 and December 2015 at a single large-volume center. We used logistic regression for the analysis. The overall (13.2%) and major (3.3%) complication rates were determined. Postoperative pancreatic fistula was the most frequent complication, and 58 patients (4.7%) had clinically significant (grade B) pancreatic fistulas. No 90-day mortality was recorded. Long operative time (≥200 min), large estimated blood loss (≥320 mL), LDP performed by an inexperienced surgeon (<50 cases), and concomitant splenectomy were identified as risk factors for overall complications using a logistic regression model. For major complications, male sex (p = 0.020), long operative time (p = 0.005), and LDP performed by an inexperienced surgeon (p = 0.026) were significant predictive factors. Using logistic regression analysis, surgery-related factors, including long operative time and LDP performed by an inexperienced surgeon, were correlated with overall and major complications of LDP. As LDP is a technically challenging procedure, surgery-related variables emerged as the main risk factors for postoperative complications. Appropriate patient selection and sufficient surgeon experience may be essential to reduce the complications of LDP.