Predicting the Severity of Pancreatic Fistula after Pancreaticoduodenectomy: Overweight and Blood Loss as Independent Risk Factors: Retrospective Analysis of 277 Patients

Identifying the risk factors for pancreatic fistula after laparoscopic pancreaticoduodenectomy in patients with pancreatic cancer

BACKGROUND

Laparoscopic pancreaticoduodenectomy (LPD) is a surgical procedure for treating pancreatic cancer; however, the risk of complications remains high owing to the wide range of organs involved during the surgery and the difficulty of anastomosis. Pancreatic fistula (PF) is a major complication that not only increases the risk of postoperative infection and abdominal hemorrhage but may also cause multi-organ failure, which is a serious threat to the patient's life. This study hypothesized the risk factors for PF after LPD.

AIM

To identify the risk factors for PF after laparoscopic pancreatoduodenectomy in patients with pancreatic cancer.

METHODS

We retrospectively analyzed the data of 201 patients admitted to the Fudan University Shanghai Cancer Center between August 2022 and August 2023 who underwent LPD for pancreatic cancer. On the basis of the PF's incidence (grades B and C), patients were categorized into the PF (n = 15) and non-PF groups (n = 186). Differences in general data, preoperative laboratory indicators, and surgery-related factors between the two groups were compared and analyzed using multifactorial logistic regression and receiver-operating characteristic (ROC) curve analyses.

RESULTS

The proportions of males, combined hypertension, soft pancreatic texture, and pancreatic duct diameter ≤ 3 mm; surgery time; body mass index (BMI); and amylase (Am) level in the drainage fluid on the first postoperative day (Am > 1069 U/L) were greater in the PF group than in the non-PF group (P < 0.05), whereas the preoperative monocyte count in the PF group was lower than that in the non-PF group (all P < 0.05). The logistic regression analysis revealed that BMI > 24.91 kg/m² [odds ratio (OR) =13.978, 95% confidence interval (CI): 1.886-103.581], hypertension (OR = 8.484, 95%CI: 1.22-58.994), soft pancreatic texture (OR = 42.015, 95%CI: 5.698-309.782), and operation time > 414 min (OR = 15.41, 95%CI: 1.63-145.674) were risk factors for the development of PF after LPD for pancreatic cancer (all P < 0.05). The areas under the ROC curve for BMI, hypertension, soft pancreatic texture, and time prediction of PF surgery were 0.655, 0.661, 0.873, and 0.758, respectively.

CONCLUSION

BMI (> 24.91 kg/m²), hypertension, soft pancreatic texture, and operation time (> 414 min) are considered to be the risk factors for postoperative PF.

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022

BACKGROUND

Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management.

DESIGN

A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline.

RESULTS

These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%.

DISCUSSION

Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality.

CONCLUSION

All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.

A Simple Classification of Pancreatic Duct Size and Texture Predicts Postoperative Pancreatic Fistula: A classification of the International Study Group of Pancreatic Surgery

OBJECTIVE

The aim of this study was to develop a classification system for pancreas-associated risk factors in pancreatoduodenectomy (PD).

SUMMARY BACKGROUND DATA

Postoperative pancreatic fistula (POPF) is the most relevant PD-associated complication. A simple standardized surgical reporting system based on pancreas-associated risk factors is lacking.

METHODS

A systematic literature search was conducted to identify studies investigating clinically relevant (CR) POPF (CR-POPF) and pancreas-associated risk factors after PD. A meta-analysis of CR-POPF rate for texture of the pancreas (soft vs not-soft) and main pancreatic duct (MPD) diameter was performed using the Mantel-Haenszel method. Based on the results, the International Study Group of Pancreatic Surgery (ISGPS) proposes the following classification: A, not-soft (hard) texture and MPD >3 mm; B, not-soft (hard) texture and MPD ≤3 mm; C, soft texture and MPD >3 mm; D, soft texture and MPD ≤3 mm. The classification was evaluated in a multi-institutional, international cohort.

RESULTS

Of the 2917 articles identified, 108 studies were included in the analyses. Soft pancreatic texture was significantly associated with the development of CR-POPF [odds ratio (OR) 4.24, 95% confidence interval (CI) 3.67-4.89, P < 0.01) following PD. Similarly, MPD diameter ≤3 mm significantly increased CR-POPF risk compared with >3 mm diameter MPDs (OR 3.66, 95% CI 2.62-5.12, P < 0.01). The proposed 4-stage system was confirmed in an independent cohort of 5533 patients with CR-POPF rates of 3.5%, 6.2%, 16.6%, and 23.2% for type A-D, respectively ( P < 0.001).

CONCLUSION

For future pancreatic surgical outcomes studies, the ISGPS recommends reporting these risk factors according to the proposed classification system for better comparability of results.

The visceral pancreatic neck anterior distance may be an effective parameter to predict post-pancreaticoduodenectomy clinically relevant postoperative pancreatic fistula

Background

The clinically relevant postoperative pancreatic fistula (CR-POPF) is significantly correlated with a high post-pancreaticoduodenectomy (PD) mortality rate. Several studies have reported an association between visceral obesity and CR-POPF. Nevertheless, there are many technical difficulties and controversies in the measurement of visceral fat. The aim of this research was to determine whether the visceral pancreatic neck anterior distance (V-PNAD) was a credible predictor for CR-POPF.

Methods

We retrospectively analyzed the data of 216 patients who underwent PD in our center between January 2016 and August 2021. The correlation of patients' demographic information, imaging variables, and intraoperative data with CR-POPF was assessed. Furthermore, areas under the receiver operating characteristic curves for six distances (abdominal thickness, visceral thickness, abdominal width, visceral width, abdominal PNAD, V-PNAD) were used to identify the best imaging distance to predict POPF.

Results

In the multivariate logistic analysis, V-PNAD (P < 0.01) was the most significant risk factor for CR-POPF after PD. Males with a V-PNAD >3.97 cm or females with a V-PNAD >3.66 cm were included into the high-risk group. The high-risk group had a higher prevalence of CR-POPF (6.5% vs. 45.1%, P < 0.001), intraperitoneal infection (1.9% vs. 23.9%, P < 0.001), pulmonary infection (3.7% vs. 14.1%, P = 0.012), pleural effusion (17.8% vs. 33.8%, P = 0.014), and ascites (22.4% vs. 40.8%, P = 0.009) than the low-risk group.

Conclusion

Of all imaging distances, V-PNAD may be the most effective predictor of CR-POPF. Moreover, high-risk patients (males, V-PNAD >3.97 cm; females, V-PNAD >3.66 cm) have a high incidence of CR-POPF and poor short-term post-PD prognosis. Therefore, surgeons should perform PD carefully and take adequate preventive measures to reduce the incidence of pancreatic fistula when the patient has a high V-PNAD.

Nomogram predicts CR-POPF in open central pancreatectomy patients with benign or low-grade malignant pancreatic neoplasms

Introduction

Central pancreatectomy (CP) is a standard surgical procedure for benign and low-grade malignant pancreatic neoplasms in the body and neck of the pancreas. Higher incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) after CP than after pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) has been reported, but no nomogram for prediction of CR-POPF after open CP has been previously established.

Methods

Patients undergoing open CP for benign or low-grade malignant pancreatic neoplasms in the department of Hepatobiliary and Pancreatic (HBP) surgery of Shanghai Changhai Hospital affiliated to Naval Medical University between January 01, 2009 and December 31,2020 were enrolled. Pre-, intra- and post-operative parameters were analyzed retrospectively.

Results

A total of 194 patients, including 60 men and 134 women, were enrolled with median age of 52 years (21~85 years). 84 patients (43.3%) were overweight (BMI>23.0 Kg/m2) and 14 (7.2%) were obese (BMI>28.0 Kg/m2). Pathological diagnoses ranged from serous cystic neoplasm (32.5%), solid pseudopapillary neoplasm (22.2%), pancreatic neuroendocrine tumor (20.1%), intraductal papillary mucinous neoplasm (18.0%) to mucinous cystic neoplasm (5.2%). All patients had soft pancreatic texture. Main pancreatic duct diameters were ≤0.3cm for 158 patients (81.4%) and were ≥0.5cm in only 12 patients (6.2%). A stapler (57.7%) or hand-sewn closure (42.3%) were used to close the pancreatic remnant. The pancreatic anastomosis techniques used were duct to mucosa pancreaticojejunostomy (PJ)-interrupted suture (47.4%), duct to mucosa PJ-continuous suture (43.3%), duct to mucosa "HO" half-purse binding PJ (5.2%) and invaginating pancreaticogastrostomy (4.1%). Post-surgical incidences of CR-POPF of 45.9%, surgical site infection of 28.9%, postpancreatectomy hemorrhage of 7.7% and delayed gastric emptying of 2.1% were found. Obesity and pancreatic anastomosis technique were independent risk factors of CR-POPF, with a concordance index of 0.675 and an Area Under the Curve of 0.678.

Discussion

This novel nomogram constructed according to obesity and pancreatic anastomosis technique showed moderate predictive performance of CR-POPF after open CP.

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 net parenchymal thickness predicts pancreatic fistula after pancreaticoduodenectomy: a retrospective cohort study of objective data

BACKGROUND

The clinically relevant postoperative pancreatic fistula (CR-POPF) is still a challenging complication of pancreaticoduodenectomy (PD). This study aims to explore the predictors of CR-POPF after PD, including net parenchymal thickness (NPT) of pancreatic neck.

METHODS

The consecutive patients who underwent PD at a tertiary hospital were retrospectively reviewed. Univariate and multivariate analyses were conducted on the perioperative data, which was mainly extracted from the objective data, containing the results from the laboratory tests and the imaging examination. NPT refers to the total thickness of pancreatic gland excluding main pancreatic duct (MPD) at the CT film.

RESULTS

Univariate analyses showed that total serum bilirubin (TBiL) and albumin (ALB) levels, MPD size and NPT were significantly different between the patients with and without CR-POPF. The white blood cell count, the rate of intra-abdominal infection (IAI) and the postoperative length of hospital stay (LOS) were associated with the incidence of CR-POPF. The proportion of patients with pancreatic adenocarcinoma or chronic pancreatitis was significantly lower in the CR-POPF group than in the non-CR-POPF group. Multivariate analyses manifested that ALB ≤35 g/L and NPT >10 mm were two of the independent risk factors for CR-POPF.

CONCLUSION

Preoperative ALB ≤35 g/L and NPT > 10 mm were both the independent predictors of CR-POPF. CR-POPF was associated with the higher IAI rate and the extended LOS.

The value of drain fluid amylase as a predictor of postoperative pancreatic fistula after pancreaticogastrostomy

BACKGROUND

Drain fluid amylase is commonly used as a predictor of pancreatic fistula after pancreaticoduodenectomy (PD). This study aimed to determine the ideal cut-off value of drain fluid amylase on postoperative day 1 (DFA1) for predicting pancreatic fistula after pancreaticogastrostomy (PG).

METHODS

Prospective data of 272 consecutive patients undergoing PG between 2010 and 2020 was collected and analysed to determine the postoperative pancreatic fistula (POPF) risk factors.

RESULTS

The incidence of POPF was 143 cases (52.6%). The median DFA1 in patients with POPF was significantly higher than that of patients with NO-POPF (5483 versus 311, P < 0.001). DFA1 correlated with POPF in the area under the curve (AUC) of 0.84 (P < 0.001). When DFA1 was 2300 U/L, Youden index was the highest, with a sensitivity of 72.7% and a specificity of 82.9%. Logistic regression analysis showed that DFA1 ≥ 2300 U/L was an independent predictor of POPF (P < 0.001; OR: 12.855; 95% CI: 7.019-23.544). The AUC of DFA1 and clinically relevant postoperative pancreatic fistula (CR-POPF) was 0.674 (P < 0.001).

CONCLUSION

DFA1 ≥ 2300 U/L can be used as an independent predictor of POPF after PG. DFA1 ≥ 3000 U/L can predict the occurrence of CR-POPF, when DFA1 ≥ 3000 U/L, the patients should be observed closely active for complications.

Preoperative and intraoperative risk factors of postoperative pancreatic fistula after pancreaticoduodenectomy – systematic review and meta-analysis

Introduction: Postoperative pancreatic fistula (POPF) is a potentially life-threatening complication after pancreaticoduodenectomy (PD). It is observed when the amylase activity in the drain fluid exceeds three times the normal upper value. Grades B and C of POPF are considered as clinically relevant. Fistula might originate due to failure of healing of a pancreatic anastomosis or from raw pancreatic surface. Materials and methods: 18 retrospective and prospective studies published between 2015 and 2020 were included in this meta-analysis. Total number of patients was 5836. To investigate potential risk factors associated with the occurrence of POPF, odds ratios (OR) with 95% confidence intervals (CI) were calculated. To compare discontinuous data, mean differences (MD) were calculated. Results: 13 factors were divided into preoperative and intraoperative groups. Male sex, higher BMI, soft pancreatic texture and small pancreatic duct were considered as significant risk factors while vascular resection lowered the risk of development pancreatic fistula. Discussion: It is considered that the development of POPF is associated with intrapancreatic fat. More severe infiltration with fat tissue is responsible for soft texture of the gland, while higher BMI is one of the risk factors of increased pancreatic fat. On the contrary, diabetes is associated with fibrotic pancreas which could lower the risk of developing POPF.

Preoperative prediction of clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy

OBJECTIVES

To develop a radiomics model and a combined model for preoperative prediction of clinically relevant postoperative pancreatic fistula (CR-POPF) in patients undergoing pancreaticoduodenectomy and to compare the predictive performance of the two models with the traditional Fistula Risk Score system.

METHODS

A total of 250 patients who underwent pancreaticoduodenectomy (PD) with preoperative computed tomography (CT) were divided into a training set (n = 175) and validation set (n = 75). The pancreatic area was automatically segmented on the portal venous phase CT images using a 3D U-Net segmentation model. A radiomics model was developed using radiomics features extracted from the volume of interest (VOI) and a combined model was developed using radiomics features, demographic information and radiological features. The FRS was also used to predict POPF. The predictive performance of the prediction models was assessed using receiver operating characteristic (ROC) curves, calibration curves and decision curve analysis (DCA).

RESULTS

Eleven and 18 features were extracted for the radiomics model and combined model, respectively. The combined model showed excellent predictive value, with an AUC of 0.871 (95 %CI 0.816,0.926) and 0.869 (95 %CI 0.779,0.958) in the training cohort and validation cohort, respectively. Calibration curves and DCA showed that the combined model outperformed the traditional FRS system and radiomics model.

CONCLUSION

The combined model exhibited excellent predictive performance and outperformed the traditional FRS system and radiomics model in the preoperative prediction of CR-POPF.

[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.

Influence of Body Mass Index on Perioperative Outcomes Following Pancreaticoduodenectomy

Background: Overweight and obesity are increasing year by year all over the world, and there is a correlation between overweight and obesity and the risk of pancreatic cancer. However, the relationship between overweight and obesity and perioperative outcomes of pancreaticoduodenectomy (PD) was controversial. The purpose of this study was to investigate the effect of body mass index (BMI) on the perioperative outcome of PD. Methods: This study retrospectively evaluated 227 patients who underwent PD from 2015 to 2019. The patients were divided into three groups: underweight group (BMI <18.5 kg/m²), normal weight group (18.5 ≤ BMI <25 kg kg/m²), and overweight group (BMII ≥25 kg/m²). The association between different BMI groups and different perioperative results was discussed. Finally, the independent risk factors of clinically relevant-postoperative pancreatic fistula (CR-POPF) were analyzed by multivariate logistic regression. Results: The level of preoperative albumin was higher in patients of overweight group (P = .03). The incidence of hypertension increased gradually in the three BMI groups (P = . 039). The preoperative median CA19-9 level was significantly higher in the underweight group than that in the control groups (P = .001). The median operation time in the high BMI group was significantly longer than that in the other two groups. High BMI was an independent risk factor influencing CR-POPF after PD (P = .022, odds ratio 2.253, 95% confidence interval 1.123-4.518). Conclusions: Operation time of PD was increased in patients with high BMI. High BMI was an independent risk factor for the incidence of CR-POPF after PD. However, PD surgery is safe and feasible for patients with different BMI, and overweight and obese patients should not refuse PD surgery because of their BMI.

Computed tomography-adjusted fistula risk score for predicting clinically relevant postoperative pancreatic fistula after pancreatoduodenectomy: Training and external validation of model upgrade

BACKGROUND

To develop a modified Fistula Risk Score (FRS) for predicting clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD) based on both FRS and contrast-enhanced computed tomography (CE-CT).

METHODS

In this multicenter retrospective analysis, we focused on 990 consecutive patients with pancreatoduodenectomy performed at four institutions between 2009 and 2019. The enhanced CT-FRS model initially targeted 26 pre- and intraoperative factors, including CT descriptors, FRS elements and clinical factors, using LASSO-penalized multivariable logistic regression for predicting CR-POPF events in discovery (n = 718) and externally validated (n = 272) datasets. Probabilities generated were further correlated with histologic features of pancreatic stumps in 356 patients. C-indices were analyzed to compare the predictive potential between the original FRS and the CT-FRS.

FINDINGS

CR-POPF developed in 112 (15.6%) and 36 (13.2%) patients in discovery and validation datasets, respectively. The final CT-FRS construct, incorporating remnant pancreatic volume (RPV), stump area, fat and atrophy scores by CT, and main pancreatic duct size, offered significantly greater overall predictability than the original FRS in discovery (C-index: 0.825 vs 0.794; p = 0.04) and validation (0.807 vs 0.741; p = 0.05) cohorts. Importantly, it outperformed the FRS in patients at moderate risk levels (FRS: 3-6), showing remarkably improved C-indices (discovery: 0.729 vs 0.626 [p<0.001], validation: 0.722 vs 0.573 [p = 0.006]). CT-FRS probabilities increased in conjunction with less extensive pancreatic fibrosis (p<0.001), ample glandular acini (p<0.001), and advanced lipomatosis (p<0.001).

INTERPRETATION

The enhanced CT-FRS performed significantly better than the original FRS in predicting CR-POPF occurrences after PD, especially at moderate FRS levels.

Risk factors and preventive measures for postoperative pancreatic fistula after pancreaticoduodenectomy

Postoperative pancreatic fistula (POPF) is the most serious complication after pancreaticoduodenectomy (PD), which can lead to slow recovery, deterioration, and even reoperation and death. At present, the mortality rate after PD has decreased, but the incidence of POPF is still high. Therefore, exploring the risk factors and prevention strategies for pancreatic fistula has become a hot research topic in pancreatic surgery. This paper summarizes the nature, risk factors, and preventive measures for POPF.

Prediction of clinically relevant Pancreatico-enteric Anastomotic Fistulas after Pancreatoduodenectomy using deep learning of Preoperative Computed Tomography

Rationale: Clinically relevant postoperative pancreatic fistula (CR-POPF) is among the most formidable complications after pancreatoduodenectomy (PD), heightening morbidity/mortality rates. Fistula Risk Score (FRS) is a well-developed predictor, but it is an intraoperative predictor and quantifies >50% patients as intermediate risk. Therefore, an accurate and easy-to-use preoperative index is desired. Herein, we test the hypothesis that quantitative analysis of contrast-enhanced computed tomography (CE-CT) with deep learning could predict CR-POPFs.

Methods: A group of 513 patients underwent pancreatico-enteric anastomosis after PD at three institutions between 2006 and 2019 was retrospectively collected, and formed a training (70%) and a validation dataset (30%) randomly. A convolutional neural network was trained and generated a deep-learning score (DLS) to identify the patients with higher risk of CR-POPF preoperatively using CE-CT images, which was further externally tested in a prospective cohort collected from August 2018 to June 2019 at the fourth institution. The biological underpinnings of DLS were assessed using histomorphological data by multivariate linear regression analysis.

Results: CR-POPFs developed in 95 patients (16.3%) in total. Compared to FRS, the DLS offered significantly greater predictability in training (AUC:0.85 [95% CI, 0.80-0.90] vs. 0.78 [95% CI, 0.72-0.84]; P = 0.03), validation (0.81 [95% CI, 0.72-0.89] vs. 0.76 [95% CI, 0.66-0.84], P = 0.05) and test (0.89 [95% CI, 0.79-0.96] vs. 0.73 [95% CI, 0.61-0.83], P < 0.001) cohorts. Especially in the challenging patients of intermediate risk (FRS: 3-6), the DLS showed significantly higher accuracy (training: 79.9% vs. 61.5% [P = 0.005]; validation: 70.3% vs. 56.3% [P = 0.04]; test: 92.1% vs. 65.8% [P = 0.013]). Additionally, DLS was independently associated with pancreatic fibrosis (coefficients: -0.167), main pancreatic duct (coefficients: -0.445) and remnant volume (coefficients: 0.138) in multivariate linear regression analysis (r² = 0.512, P < 0.001). The user satisfaction score in the test cohort was 4 out of 5.

Conclusions: Preoperative CT based deep-learning model provides a promising novel method for predicting CR-POPF occurrences after PD, especially at intermediate FRS risk level. This has a potential to be integrated into radiologic reporting system or incorporated into surgical planning software to accommodate the preferences of surgeons to optimize preoperative strategies, intraoperative decision-making, and even postoperative care.

Impact of Blood Loss and Intraoperative Blood Transfusion During Liver Transplantation on the Incidence of Early Biliary Complications and Mortality

Biliary complications are one of the most serious and dangerous complications following liver transplantation. Factors that may determine their occurrence are still being assessed. The retrospective analysis of 239 consecutive liver transplantations (LT) performed between January 2013 and December 2018 was conducted in compliance with the Helsinki Congress and the Istanbul Declaration. We divided recipients into 2 groups depending on whether biliary complications occurred. The first (biliary complication [BC group]) consisted of patients who developed biliary complications (n = 41) and the second (nonbiliary complications [NBC group]) without them (n = 198). Demographic and statistical data analysis showed no differences between the groups in terms of age, Model for End-Stage Liver Disease with sodium serum concentration (MELD-Na) score, and average cold or warm ischemia time. In comparison, estimated intraoperative blood loss, 1341 mL in the NBC and 1399 mL in the BC, was not significantly different, as were the number of transfused red blood cells (RBC) units, which were respectively 1.7 and 2.1 (P = ns). The recipients' hemoglobin levels just before surgery were (11.5 g/dL vs 11.6 g/dL; P = ns) and after transplantation (9.8 g/dL vs 9.8 g/dL; P = ns). Eleven patients died within 30 days of transplantation. This group was characterized by a higher MELD-Na score (25 vs 17; P = .01), lower pretransplant hemoglobin level (10 g/dL vs 11.6 g/dL; P = .02), and the number of transfused RBC units (3.3 vs 1.7; P = .01). However, there was no correlation between intraoperative blood loss, the number of transfused RBC units, pre- and postoperative hemoglobin levels, and the incidence of biliary complications after LT. Lower pretransplant hemoglobin levels and a higher amount of intraoperatively transfused blood products were associated with a higher fatality rate after LT.

Comparison of three fistula risk scores after pancreatoduodenectomy: A single-institution retrospective study

BACKGROUND

Postoperative pancreatic fistula (POPF) after pancreatoduodenectomy greatly influences patients' postoperative course. Several evaluation methods have been used to assess the risk of clinically relevant POPF (CR-POPF) after pancreatoduodenectomy namely, the original, alternative, and updated alternative fistula risk scores (o-FRS, a-FRS, and ua-FRS, respectively).

METHODS

We enrolled 106/179 patients who underwent pancreatoduodenectomy in our institution between April 2013 and Mar 2018. CR-POPF was defined as grade B and C POPF according to the 2016 definitions of the International Study Group on Pancreatic Surgery.

RESULTS

Pancreatic gland texture was the only significant risk factor for CR-POPF (p = 0.007). The CR-POPF incidence increased significantly according to the risk groups defined by both o-FRS (p = 0.004) and a-FRS (p = 0.004). The area under the curve for o-FRS, a-FRS, and ua-FRS was 0.693, 0.693, and 0.671, respectively.

CONCLUSION

o-FRS, a-FRS, and ua-FRS were almost equally useful for risk evaluation for CR-POPF after pancreatoduodenectomy. Further studies, especially for preoperative objective evaluation of pancreatic gland texture, are needed for more useful and accurate risk evaluation.