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Chen H, Wang Y, Jiang K, Xu Z, Jiang Y, Wu Z, Lu X, Wang C, Weng Y, Wang W, Ding R, Zheng S, Li Y, Fu X, Shi G, Wang J, Chen H, Peng C, Deng X, Qiu Y, Luo Y, Sun B, Shen B. The Effect of Perioperative Dexamethasone on Postoperative Complications After Pancreaticoduodenectomy: A Multicenter Randomized Controlled Trial. Ann Surg 2024; 280:222-228. [PMID: 38385254 DOI: 10.1097/sla.0000000000006240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
OBJECTIVE To evaluate the effect of perioperative dexamethasone on postoperative complications after pancreaticoduodenectomy. BACKGROUND The glucocorticoid dexamethasone has been shown to improve postoperative outcomes in surgical patients, but its effects on postoperative complications after pancreaticoduodenectomy are unclear. METHODS This multicenter, double-blind, randomized controlled trial was conducted in four Chinese high-volume pancreatic centers. Adults undergoing elective pancreaticoduodenectomy were randomized to receive either 0.2 mg/kg dexamethasone or a saline placebo as an intravenous bolus within 5 minutes after anesthesia induction. The primary outcome was the Comprehensive Complication Index (CCI) score within 30 days after the operation, analyzed using the modified intention-to-treat principle. RESULTS Among 428 patients for eligibility, 300 participants were randomized and 265 were included in the modified intention-to-treat analyses. One hundred thirty-four patients received dexamethasone and 131 patients received a placebo. The mean (SD) CCI score was 14.0 (17.5) in the dexamethasone group and 17.9 (20.3) in the placebo group (mean difference: -3.8; 95% CI: -8.4 to 0.7; P = 0.100). The incidence of major complications (Clavien-Dindo grade ≥III; 12.7% vs 16.0%, risk ratio: 0.79; 95% CI: 0.44 to 1.43; P = 0.439) and postoperative pancreatic fistula (25.4% vs 31.3%, risk ratio: 0.81; 95% CI: 0.55 to 1.19; P = 0.286) were not significantly different between the two groups. In the stratum of participants with a main pancreatic duct ≤3 mm (n = 202), the CCI score was significantly lower in the dexamethasone group (mean difference: -6.4; 95% CI: -11.2 to -1.6; P = 0.009). CONCLUSIONS Perioperative dexamethasone did not significantly reduce postoperative complications within 30 days after pancreaticoduodenectomy.
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Affiliation(s)
- Haoda Chen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ying Wang
- Department of Anesthesiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kuirong Jiang
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhiwei Xu
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu Jiang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhichong Wu
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaojian Lu
- Department of Anesthesiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chao Wang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuanchi Weng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weishen Wang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Rui Ding
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shifan Zheng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yilong Li
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xu Fu
- Department of Pancreatic and Metabolic Surgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Guodong Shi
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jiancheng Wang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hao Chen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chenghong Peng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaxing Deng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yudong Qiu
- Department of Pancreatic and Metabolic Surgery, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yan Luo
- Department of Anesthesiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bei Sun
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Baiyong Shen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Gaujoux S, Regimbeau JM, Piessen G, Truant S, Foissac F, Barbier L, Buc E, Adham M, Fuks D, Deguelte S, Muscari F, Sulpice L, Vaillant JC, Schwarz L, Sa Cunha A, Muzzolini M, Dousset B, Sauvanet A. Somatostatin Versus Octreotide for Prevention of Postoperative Pancreatic Fistula: The PREFIPS Randomized Clinical Trial: A FRENCH 007-ACHBT Study. Ann Surg 2024; 280:179-187. [PMID: 38662619 DOI: 10.1097/sla.0000000000006313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2024]
Abstract
OBJECTIVE Pharmacological prevention of postoperative pancreatic fistula (POPF) after pancreatectomy is open to debate. The present study compares clinically significant POPF rates in patients randomized between somatostatin versus octreotide as prophylactic treatment. METHODS Multicentric randomized controlled open study in patient's candidate for pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) comparing somatostatin continuous intravenous infusion for 7 days versus octreotid 100 μg, every 8 hours subcutaneous injection for 7 days, stratified by procedure (PD vs DP) and size of the main pancreatic duct (>4 mm) on grade B/C POPF rates at 90 days based on an intention-to-treat analysis. RESULTS Of 763 eligible patients, 651 were randomized: 327 in the octreotide arm and 324 in the somatostatin arm, with comparable the stratification criteria - type of surgery and main pancreatic duct dilatation. Most patients had PD (n=480; 73.8%), on soft/normal pancreas (n=367; 63.2%) with a nondilated main pancreatic duct (n=472; 72.5%), most often for pancreatic adenocarcinoma (n=311; 47.8%). Almost all patients had abdominal drainage (n=621; 96.1%) and 121 (19.5%) left the hospital with the drain in place (median length of stay=16 days). A total of 153 patients (23.5%) developed a grade B/C POPF with no difference between both groups: 24.1%: somatostatin arm and 22.9%: octreotide arm (χ 2 test, P =0.73, ITT analysis). Absence of statistically significant difference persisted after adjustment for stratification variables and in per-protocol analysis. CONCLUSION Continuous intravenous somatostatin is not statistically different from subcutaneous octreotide in the prevention of grade B/C POPF after pancreatectomy. FINDINGS In the PREFIPS Randomized Clinical Trial including 651 patients, a total of 153 patients (23.5%) developed a grade B/C POPF with no significant difference between both groups: 24.1%: somatostatin arm and 22.9%: octreotide arm (χ 2 test, P =0.73, ITT analysis). Absence of statistically significant difference persisted after adjustment for stratification variables and in per-protocol analysis.
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Affiliation(s)
- Sébastien Gaujoux
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France
- Sorbonne University, Paris, France
| | - Jean-Marc Regimbeau
- Department of Oncology and Digestive Surgery, CHU Amiens-Picardie, Amiens, France
- University of Picardie Jules-Vernes, Amiens, France
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, CHU Lille, Lille, France
- University Lille, CNRS, Inserm, CHU Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, Lille, France
| | - Stéphanie Truant
- University Lille, CNRS, Inserm, CHU Lille, UMR9020-U1277-CANTHER-Cancer Heterogeneity Plasticity and Resistance to Therapies, Lille, France
- Department of Digestive Surgery and Transplantation, CHU Lille, Lille, France
| | - Frantz Foissac
- Clinical Research Unit Necker Cochin Hospital, APHP, Paris, France
| | - Louise Barbier
- Department of Digestive Surgery and Liver Transplantation, CHU Tours Trousseau, Tours, France
- University of Tours, Tours, France
| | - Emmanuel Buc
- Department of Digestive and Hepatobiliary Surgery, Estaing Hospital, CHU Clermont-Ferrand, Clermont-Ferrand, France
- Clermont-Ferrand Faculty of Medicine, Clermont-Ferrand, France
| | - Mustapha Adham
- Digestive Surgery Unit, Edouard Herriot Hospital, Lyon, France
- Hospices Civils of Lyon University, Lyon, France
| | - David Fuks
- Department of Digestive, Pancreatic, Hepatobiliary and Endocrine Surgery, Cochin Hospital, APHP, Paris, France
- University of Paris, Paris, France
| | - Sophie Deguelte
- Digestive Surgery Department, Reims University Hospital, Robert Debré Hospital, Reims, France
- Reims University Hospital, Robert Debré Hospital, Reims, France
| | - Fabrice Muscari
- Digestive Surgery and Liver Transplantation Department, Toulouse University Hospital, Toulouse, France
- Toulouse University, Toulouse, France
| | - Laurent Sulpice
- Department of Hepatobiliary and Digestive Surgery Hospital Rennes, Rennes, France
- Rennes University, Rennes, France
| | - Jean-Christophe Vaillant
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France
- Sorbonne University, Paris, France
| | - Lilian Schwarz
- Department of Digestive Surgery, Charles Nicolle Hospital, Rouen, France
- Rouen University, Rouen, France
| | - Antonio Sa Cunha
- Department of Hepatobiliary Surgery and Liver Transplantation, Paul Brousse Hospital, Villejuif, France
- Paris-Saclay University, Saclay, France
| | - Milena Muzzolini
- Department of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris, France
- Sorbonne University, Paris, France
| | - Bertrand Dousset
- Department of Digestive, Pancreatic, Hepatobiliary and Endocrine Surgery, Cochin Hospital, APHP, Paris, France
- University of Paris, Paris, France
| | - Alain Sauvanet
- Department of Hepatobiliary Surgery, Beaujon Hospital, Clichy, France
- University Paris Cité, Paris, France
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Harrison J, Dua MM, Kastrinakis WV, Fagenholz PJ, Fernandez-Del Castillo C, Lillemoe KD, Poultsides GA, Visser BC, Qadan M. "Duct tape:" Management strategies for the pancreatic anastomosis during pancreatoduodenectomy. Surgery 2024:S0039-6060(24)00270-8. [PMID: 38796390 DOI: 10.1016/j.surg.2024.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 04/11/2024] [Indexed: 05/28/2024]
Affiliation(s)
- Jon Harrison
- Section of Hepatobiliary & Pancreatic Surgery, Stanford University Hospital, Palo Alto, CA.
| | - Monica M Dua
- Section of Hepatobiliary & Pancreatic Surgery, Stanford University Hospital, Palo Alto, CA
| | - William V Kastrinakis
- Division of Gastrointestinal and Oncologic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Peter J Fagenholz
- Division of Gastrointestinal and Oncologic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Carlos Fernandez-Del Castillo
- Division of Gastrointestinal and Oncologic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Keith D Lillemoe
- Division of Gastrointestinal and Oncologic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - George A Poultsides
- Section of Surgical Oncology, Department of Surgery, Stanford Hospital and Clinics, Palo Alto, CA
| | - Brendan C Visser
- Section of Hepatobiliary & Pancreatic Surgery, Stanford University Hospital, Palo Alto, CA
| | - Motaz Qadan
- Division of Gastrointestinal and Oncologic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA
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4
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Fu Z, Gao S, Wu X, Qin J, Dang Z, Wang H, Han J, Ren Y, Zhu L, Ye X, Shi X, Yin X, Shi M, Wang J, Liu X, Guo S, Zheng K, Jin G. Hand-sewn gastrojejunal anastomosis reduces delayed gastric emptying after pancreaticoduodenectomy: A single-center retrospective clinical study of 1,077 consecutive patients. Surgery 2024; 175:1140-1146. [PMID: 38290878 DOI: 10.1016/j.surg.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 08/08/2023] [Accepted: 12/01/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Hand-sewn anastomosis and stapled anastomosis are the 2 main types of gastrojejunal anastomotic methods in pancreaticoduodenectomy. There is ongoing debate regarding the most effective anastomotic method for reducing delayed gastric emptying after pancreaticoduodenectomy. This study aims to identify factors that influence delayed gastric emptying after pancreaticoduodenectomy and assess the impact of different anastomotic methods on delayed gastric emptying. METHODS The study included 1,077 patients who had undergone either hand-sewn anastomosis (n = 734) or stapled anastomosis (n = 343) during pancreaticoduodenectomy between December 2016 and November 2021 at our department. We retrospectively analyzed the clinical data, and a 1:1 propensity score matching was performed to balance confounding variables. RESULTS After propensity score matching, 320 patients were included in each group. Compared with the stapled anastomosis group, the hand-sewn anastomosis group had a significantly lower incidence of delayed gastric emptying (28 [8.8%] vs 55 [17.2%], P = .001) and upper gastrointestinal tract bleeding (6 [1.9%] vs 17 [5.3%], P = .02). Additionally, the hand-sewn anastomosis group had a significantly reduced postoperative length of stay and lower hospitalization expenses. However, the hand-sewn anastomosis group had a significantly longer operative time, which was consistent with the analysis before propensity score matching. Logistic regression analysis showed that stapled anastomosis, intra-abdominal infection, and clinically relevant postoperative pancreatic fistula were independent prognostic factors for delayed gastric emptying. CONCLUSION Hand-sewn anastomosis was associated with a lower incidence rate of clinically relevant delayed gastric emptying after pancreaticoduodenectomy. Stapled anastomosis, intra-abdominal infection, and clinically relevant postoperative pancreatic fistula could increase the incidence of postoperative clinically relevant delayed gastric emptying. Hand-sewn anastomosis should be considered by surgeons to reduce the occurrence of postoperative delayed gastric emptying and improve patient outcomes.
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Affiliation(s)
- Zhendong Fu
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China; Department of Hepatobiliary Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, China
| | - Suizhi Gao
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Xinqian Wu
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Jianwei Qin
- Department of Hepatobiliary Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, China
| | - Zheng Dang
- Department of Hepatobiliary Surgery, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, China
| | - Huan Wang
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Jiawei Han
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Yiwei Ren
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Lingyu Zhu
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Xiaofei Ye
- Department of Medical Statistics, Navy Medical University (Second Military Medical University), Shanghai, China
| | - Xiaohan Shi
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Xiaoyi Yin
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Meilong Shi
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Jian Wang
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Xinyu Liu
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Shiwei Guo
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Kailian Zheng
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China
| | - Gang Jin
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital Affiliated to Navy Medical University (Second Military Medical University), Shanghai, China.
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Rykina-Tameeva N, Samra JS, Sahni S, Mittal A. Non-Surgical Interventions for the Prevention of Clinically Relevant Postoperative Pancreatic Fistula-A Narrative Review. Cancers (Basel) 2023; 15:5865. [PMID: 38136409 PMCID: PMC10741911 DOI: 10.3390/cancers15245865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/06/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Clinically relevant postoperative pancreatic fistula (CR-POPF) is the leading cause of morbidity and mortality after pancreatic surgery. Post-pancreatectomy acute pancreatitis (PPAP) has been increasingly understood as a precursor and exacerbator of CR-POPF. No longer believed to be the consequence of surgical technique, the solution to preventing CR-POPF may lie instead in non-surgical, mainly pharmacological interventions. Five databases were searched, identifying eight pharmacological preventative strategies, including neoadjuvant therapy, somatostatin and its analogues, antibiotics, analgesia, corticosteroids, protease inhibitors, miscellaneous interventions with few reports, and combination strategies. Two further non-surgical interventions studied were nutrition and fluids. New potential interventions were also identified from related surgical and experimental contexts. Given the varied efficacy reported for these interventions, numerous opportunities for clarifying this heterogeneity remain. By reducing CR-POPF, patients may avoid morbid sequelae, experience shorter hospital stays, and ensure timely delivery of adjuvant therapy, overall aiding survival where prognosis, particularly in pancreatic cancer patients, is poor.
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Affiliation(s)
- Nadya Rykina-Tameeva
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW 2065, Australia
| | - Jaswinder S. Samra
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Upper GI Surgical Unit, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
- Upper GI Surgical Unit, North Shore Private Hospital, St Leonards, NSW 2065, Australia
- Australian Pancreatic Centre, St Leonards, NSW 2065, Australia
| | - Sumit Sahni
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW 2065, Australia
- Australian Pancreatic Centre, St Leonards, NSW 2065, Australia
| | - Anubhav Mittal
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Upper GI Surgical Unit, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
- Upper GI Surgical Unit, North Shore Private Hospital, St Leonards, NSW 2065, Australia
- Australian Pancreatic Centre, St Leonards, NSW 2065, Australia
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Perri G, Marchegiani G, Partelli S, Andreasi V, Luchini C, Bariani E, Bannone E, Fermi F, Mattiolo P, Falconi M, Salvia R, Bassi C. Either High or Low Risk: The Acinar Score at the Resection Margin Dichotomizes the Risk Spectrum of Pancreas-specific Complications After Pancreatoduodenectomy. Ann Surg 2023; 278:e1242-e1249. [PMID: 37325905 DOI: 10.1097/sla.0000000000005943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND Pancreatic acinar content (Ac) has been associated with pancreas-specific complications after pancreatoduodenectomy. The aim of this study was to improve the prediction ability of intraoperative risk stratification by integrating the pancreatic acinar score. METHODS A training and validation cohort underwent pancreatoduodenectomy with a subsequent histologic assessment of pancreatic section margins for Ac, fibrosis (Fc), and fat. Intraoperative risk stratification (pancreatic texture, duct diameter) and pancreas-specific complications (postoperative hyperamylasemia [POH], postpancreatectomy acute pancreatitis [PPAP], pancreatic fistula [POPF]) were classified according to ISGPS definitions. RESULTS In the validation cohort (n= 373), the association of pancreas-specific complications with higher Ac and lower Fc was replicated (all P <0.001). In the entire cohort (n= 761), the ISGPS classification allocated 275 (36%) patients into intermediate-risk classes B (POH 32%/PPAP 3%/POPF 17%) and C (POH 36%/PPAP 9%/POPF 33%). Using the acinar score (Ac ≥60% and/or Fc ≤10%), intermediate-risk patients could be dichotomized into a low-risk (POH 5%/PPAP 1%/POPF 6%) and a high-risk (POH 51%/PPAP 9%/POPF 38%) group (all P <0.001). The acinar score AUC for POPF prediction was 0.70 in the ISGPS intermediate-risk classes. Overall, 239 (31%) patients were relocated into the high-risk group from lower ISGPS risk classes using the acinar score. CONCLUSIONS The risk of pancreas-specific complications appears to be dichotomous-either high or low-according to the acinar score, a tool to better target the application of mitigation strategies in cases of intermediate macroscopic features.
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Affiliation(s)
- Giampaolo Perri
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Stefano Partelli
- Division of Pancreatic Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Valentina Andreasi
- Division of Pancreatic Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Claudio Luchini
- Division of Pathology, Verona University Hospital, Verona, Italy
| | - Elena Bariani
- Division of Pathology, Verona University Hospital, Verona, Italy
| | - Elisa Bannone
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Francesca Fermi
- Division of Pancreatic Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Paola Mattiolo
- Division of Pathology, Verona University Hospital, Verona, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
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7
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Bannone E, Pulvirenti A, Marchegiani G, Vacca PG, Marchetti A, Cattelani A, Salvia R, Bassi C. No role for protease inhibitors as a mitigation strategy for postpancreatectomy acute pancreatitis (PPAP): Propensity score matching analysis. Pancreatology 2023; 23:904-910. [PMID: 37839921 DOI: 10.1016/j.pan.2023.09.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 09/18/2023] [Accepted: 09/28/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND While the use of protease inhibitor gabexate mesylate (GM) is still controversial in acute pancreatitis, it has never been tested for postpancreatectomy acute pancreatitis (PPAP). This study aims to assess the impact of GM on postoperative serum hyperamylasaemia (POH) or PPAP after pancreatoduodenectomy (PD). METHODS Consecutive patients developing POH after PD between 2016 and 2021 were included. According to GM administration, patients were divided into GM-treated and control (CTR) groups. GM was administered from postoperative day 1-3 in POH patients who underwent surgery before 2017. A 2:1 propensity matching was used to minimize the risk of bias. RESULTS Overall, 264 patients with POH were stratified in the GM (59 patients) and CTR (104 patients) cohorts, which showed balanced baseline characteristics after matching. No difference in postoperative complications was observed between the groups (all p > 0.05), except for PPAP occurrence, which was significantly higher in the GM group (37% vs. 22%, p = 0.037). A total of 45 patients (28%) evolved to PPAP. Comparing PPAP patients in the GM and CTR groups, no significant differences in POPF, relaparotomy, and mortality (all p > 0.09) were found. No difference in intravenous crystalloid administration was found in patients with PPAP, whether or not they developed major complications or pancreatic fistula (p > 0.05) CONCLUSION: Protease inhibitor seems ineffective in preventing a PPAP after PD once a POH has occurred. Further studies are needed to achieve benchmarks for treating PPAP and identify mitigation strategies to prevent the evolution of POH into additional morbidity.
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Affiliation(s)
- Elisa Bannone
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy; Department of General Surgery, Poliambulanza Foundation Hospital, Brescia, Italy. https://twitter.com/PancreasVerona
| | - Alessandra Pulvirenti
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Pier Giuseppe Vacca
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alessio Marchetti
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alice Cattelani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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8
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Yang F, Xu Y, Jin C, Windsor JA, Fu D. Predicting pancreatic fistula after central pancreatectomy using current fistula risk scores for pancreaticoduodenectomy and distal pancreatectomy. Pancreatology 2023; 23:843-851. [PMID: 37739874 DOI: 10.1016/j.pan.2023.09.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 08/08/2023] [Accepted: 09/09/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND The incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) after central pancreatectomy (CP) is high, yet an effective predictive method is currently lacking. This study aimed to predict CR-POPF after CP by utilizing existing fistula risk scores (FRSs) for pancreaticoduodenectomy (PD) and distal pancreatectomy (DP). METHODS A retrospective analysis was conducted on patients undergoing CP at our institution between January 2010 and July 2022. The primary outcome was CR-POPF (grade B/C) according to the 2016 International Study Group of Pancreatic Surgery definition. To establish predictive models for CR-POPF after CP, we combined the FRSs for PD and DP using a calculation formula that considers the probability of the union of two events. As a result, we obtained twelve central FRS (C-FRS) models. The performance of each C-FRS was assessed using the area under the curves (AUC) and calibration plots. RESULTS A total of 115 patients undergoing CP were included. Among them, 38 (33%) were male, with a median age of 53 years. CR-POPF occurred in 35 (30.4%) patients, specifically 33 (28.7%) with grade B and 2 (1.7%) with grade C. Multivariate analysis showed that body mass index (BMI) [odds ratio (OR) 1.260, 95% confidence interval (CI) 1.039-1.528, P = 0.019), pancreatic thickness at the cephalic transection site (OR 1.228, 95% CI 1.074-1.405, P = 0.003), cephalic main pancreatic duct (MPD) size (OR 41.872, 95%CI 7.614-230.265, P < 0.001), and distal MPD size (OR 0.142, 95% CI 0.036-0.561, P = 0.005) were independent predictive factors for CR-POPF. Discrimination was generally acceptable for all C-FRS models, with an AUC ranging from 0.748 (DISPAIR-a-FRS: 95% CI, 0.659-0.824) to 0.847 (Intraop-D-a-FRS: 95% CI, 0.768-0.907). The models were calibrated with adequate Brier scores ranging from 0.157 to 0.183. The performance in all subgroups was similar as that of the entire cohort. Three preoperative risk groups (low, intermediate, and high) were identified based on the clinical applicability of the Preop-D-Roberts-FRS, with corresponding incidences of CR-POPF as 0% (0/24), 30% (21/70), and 66.7% (14/21), respectively. CONCLUSION The derived C-FRS models show potential for accurately predicting the development of CR-POPF after CP. However, further validation studies are required to determine the most effective model. In the meantime, the Preop-D-Roberts-FRS is recommended for clinical practice due to its ease of use and preoperative predictability.
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Affiliation(s)
- Feng Yang
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China.
| | - Yecheng Xu
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China
| | - Chen Jin
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, 1142, New Zealand
| | - Deliang Fu
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China.
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9
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Nakamura K, Nagai M, Matsumoto I, Satoi S, Motoi F, Kawai M, Hosouchi Y, Higuchi R, Mizuno S, Ohtsuka T, Akahoshi K, Hakamada K, Unno M, Yamaue H, Nakamura M, Endo I, Sho M. Impact of antithrombotic therapy on postpancreatectomy hemorrhage in 7116 patients: A project study by the Japanese Society of Hepato-Biliary-Pancreatic Surgery. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:1161-1171. [PMID: 37658660 DOI: 10.1002/jhbp.1349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/07/2023] [Accepted: 05/16/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND We previously reported an association between antithrombotic therapy and an increased risk of postpancreatectomy hemorrhage (PPH). To validate our findings, we conducted a large-scale multicenter retrospective study from 63 high-volume centers in Japan. METHODS Between 2015 and 2018, 7116 patients who underwent pancreatectomy were enrolled. The antithrombotic group consisted of 920 patients (12.9%) who received preoperative antithrombotic agents including aspirin, clopidogrel, ticlopidine, prasugrel, warfarin, and direct oral anticoagulants. RESULTS PPH occurred in 235 (3.3%) of the patients. The incidence of PPH and mortality were significantly higher in the antithrombotic group than in the control group (5.7 vs. 3.0% and 2.2 vs. 0.9%, respectively; both p < .001). In multivariate analysis, a history of antithrombotic use was an independent risk factor for grade C PPH (p = .036). In the antithrombotic group, PPH tended to be delayed in the patients with restarting antithrombotic therapy. Notably, the occurrence of delayed PPH after restarting antithrombotic therapy was observed only when antithrombotic therapy was restarted within 10 days after pancreatectomy. CONCLUSIONS This multicenter study demonstrated that a history of antithrombotic use was a significant risk factor for PPH and mortality. In particular, the resumption of antithrombotic therapy in the early postoperative period should be done with caution.
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Affiliation(s)
- Kota Nakamura
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Minako Nagai
- Department of Surgery, Nara Medical University, Nara, Japan
| | - Ippei Matsumoto
- Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Fuyuhiko Motoi
- Department of Surgery, Yamagata University Graduate School of Medical Science, Yamagata, Japan
| | - Manabu Kawai
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yasuo Hosouchi
- Department of Surgery, Gunma Saiseikai Maebashi Hospital, Maebashi, Japan
| | - Ryota Higuchi
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Shugo Mizuno
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Takao Ohtsuka
- Department of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Keiichi Akahoshi
- Department of Hepatobiliary-Pancreatic Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kenichi Hakamada
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Project Committee, Japanese Society of Hepato-Biliary-Pancreatic Surgery, Tokyo, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Nara, Japan
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10
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Chen H, Wang Y, Wang C, Lu X, Li Y, Sun B, Jiang K, Qiu Y, Chen R, Cao L, Chen S, Luo Y, Shen B. The effect of perioperative of dexamethasone on postoperative complications after pancreaticoduodenectomy (PANDEX): a study protocol for a pragmatic multicenter randomized controlled trial. Trials 2023; 24:569. [PMID: 37660052 PMCID: PMC10474642 DOI: 10.1186/s13063-023-07571-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 08/05/2023] [Indexed: 09/04/2023] Open
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) nowadays serves as a standard treatment for patients with disorders of the pancreas, intestine, and bile duct. Although the mortality rate of patients undergoing PD has decreased significantly, postoperative complication rates remain high. Dexamethasone, a synthetic glucocorticoid with potent anti-inflammatory and metabolic effects, has been proven to have a favorable effect on certain complications. However, the role it plays in post-pancreatectomy patients has not been systematically evaluated. The aim of this study is to assess the effect of dexamethasone on postoperative complications after PD. METHODS The PANDEX trial is an investigator-initiated, multicentric, prospective, randomized, double-blinded, placebo-control, pragmatic study. The trial is designed to enroll 300 patients who are going to receive elective PD. Patients will be randomized to receive 0.2 mg/kg dexamethasone or saline placebo, administered as an intravenous bolus within 5 min after induction of anesthesia. The primary outcome is the Comprehensive Complication Index (CCI) score within 30 days after the operation. The secondary outcomes include postoperative major complications (Clavien-Dindo≥3), postoperative pancreatic fistula (POPF), post-pancreatectomy acute pancreatitis (PPAP), infection, and unexpected relaparotomy, as well as postoperative length of stay, 30-day mortality, and 90-day mortality. DISCUSSION The PANDEX trial is the first randomized controlled trial concerning the effect of dexamethasone on postoperative complications of patients undergoing PD, with the hypothesis that the intraoperative use of dexamethasone can reduce the incidence of postoperative complications and improve short-term outcomes after PD. The results of the present study will guide the perioperative use of dexamethasone and help improve the clinical management of post-pancreatectomy patients. TRIAL REGISTRATION ClinicalTrials.gov NCT05567094. Registered on 30 September 30 2022.
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Affiliation(s)
- Haoda Chen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Ying Wang
- Department of Anesthesiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Chao Wang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Xiaojian Lu
- Department of Anesthesiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Yilong Li
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Key Laboratory of Hepatosplenic Surgery (Ministry of Education), The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Bei Sun
- Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Key Laboratory of Hepatosplenic Surgery (Ministry of Education), The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Kuirong Jiang
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yudong Qiu
- Department of Biliary and Pancreatic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Rufu Chen
- Department of Pancreatic Surgery, Department of General Surgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Liping Cao
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shi Chen
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
- Department of Hepatobiliary Pancreatic Surgery, Fujian Provincial Hospital, Fuzhou, China
| | - Yan Luo
- Department of Anesthesiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.
| | - Baiyong Shen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.
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11
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Chui JN, Sahni S, Samra JS, Mittal A. Postoperative pancreatitis and pancreatic fistulae: a review of current evidence. HPB (Oxford) 2023; 25:1011-1021. [PMID: 37301633 DOI: 10.1016/j.hpb.2023.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 04/28/2023] [Accepted: 05/09/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Postoperative pancreatic fistula (POPF) represents one of the most severe complications following pancreatic surgery. Despite being a leading cause of morbidity and mortality, its pathophysiology is poorly understood. In recent years, there has been growing evidence to support the role of postoperative or post-pancreatectomy acute pancreatitis (PPAP) in the development of POPF. This article reviews the contemporary literature on POPF pathophysiology, risk factors, and prevention strategies. METHODS A literature search was conducted using electronic databases, including Ovid Medline, EMBASE, and Cochrane Library, to retrieve relevant literature published between 2005 and 2023. A narrative review was planned from the outset. RESULTS A total of 104 studies fulfilled criteria for inclusion. Forty-three studies reported on technical factors predisposing to POPF, including resection and reconstruction technique and adjuncts for anastomotic reinforcement. Thirty-four studies reported on POPF pathophysiology. There is compelling evidence to suggest that PPAP plays a critical role in the development of POPF. The acinar component of the remnant pancreas should be regarded as an intrinsic risk factor; meanwhile, operative stress, remnant hypoperfusion, and inflammation represent common mechanisms for acinar cell injury. CONCLUSIONS The evidence base for PPAP and POPF is evolving. Future POPF prevention strategies should look beyond anastomotic reinforcement and target underlying mechanisms of PPAP development.
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Affiliation(s)
- Juanita N Chui
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, Australia; Faculty of Medical and Health Sciences, The University of Sydney, Sydney, Australia
| | - Sumit Sahni
- Faculty of Medical and Health Sciences, The University of Sydney, Sydney, Australia; Kolling Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Jaswinder S Samra
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, Australia; Faculty of Medical and Health Sciences, The University of Sydney, Sydney, Australia; Australian Pancreatic Centre, Sydney, Australia
| | - Anubhav Mittal
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, Australia; Faculty of Medical and Health Sciences, The University of Sydney, Sydney, Australia; Australian Pancreatic Centre, Sydney, Australia; School of Medicine, The University of Notre Dame, Sydney, Australia.
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12
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Bain CR, Myles PS, Corcoran T, Dieleman JM. Postoperative systemic inflammatory dysregulation and corticosteroids: a narrative review. Anaesthesia 2023; 78:356-370. [PMID: 36308338 PMCID: PMC10092416 DOI: 10.1111/anae.15896] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2022] [Indexed: 12/15/2022]
Abstract
In some patients, the inflammatory-immune response to surgical injury progresses to a harmful, dysregulated state. We posit that postoperative systemic inflammatory dysregulation forms part of a pathophysiological response to surgical injury that places patients at increased risk of complications and subsequently prolongs hospital stay. In this narrative review, we have outlined the evolution, measurement and prediction of postoperative systemic inflammatory dysregulation, distinguishing it from a healthy and self-limiting host response. We reviewed the actions of glucocorticoids and the potential for heterogeneous responses to peri-operative corticosteroid supplementation. We have then appraised the evidence highlighting the safety of corticosteroid supplementation, and the potential benefits of high/repeated doses to reduce the risks of major complications and death. Finally, we addressed how clinical trials in the future should target patients at higher risk of peri-operative inflammatory complications, whereby corticosteroid regimes should be tailored to modify not only the a priori risk, but also further adjusted in response to markers of an evolving pathophysiological response.
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Affiliation(s)
- C R Bain
- Department of Anaesthesiology and Peri-operative Medicine, Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - P S Myles
- Department of Anaesthesiology and Peri-operative Medicine, Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - T Corcoran
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, WA, Australia
| | - J M Dieleman
- Department of Anaesthesia and Peri-operative Medicine, Westmead Hospital, Sydney and Western Sydney University, Sydney, NSW, Australia
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13
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Perioperative Drug Treatment in Pancreatic Surgery-A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12051750. [PMID: 36902534 PMCID: PMC10003556 DOI: 10.3390/jcm12051750] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 02/24/2023] Open
Abstract
INTRODUCTION Pancreatic resections for malignant or benign diseases are associated with major morbidity and changes in physiology. To reduce perioperative complications and enhance recovery, many types of perioperative medical management have been introduced. The aim of this study was to provide an evidence-based overview on the best perioperative drug treatment. METHODS The electronic bibliographic databases Medline, Embase, CENTRAL, and Web of Science were systematically searched for randomized controlled trials (RCT) evaluating perioperative drug treatments in pancreatic surgery. The investigated drugs were somatostatin analogues, steroids, pancreatic enzyme replacement therapy (PERT), prokinetic therapy, antidiabetic drugs, and proton pump inhibitors (PPI). Targeted outcomes in each drug category were meta-analyzed. RESULTS A total of 49 RCT were included. The analysis of somatostatin analogues showed a significantly lower incidence of postoperative pancreatic fistula (POPF) in the somatostatin group compared to the control group (OR 0.58, 95% CI: 0.45 to 0.74). The comparison of glucocorticoids versus placebo showed significantly less POPF in the glucocorticoid group (OR 0.22, 95% CI: 0.07 to 0.77). There was no significant difference in DGE when erythromycin was compared to placebo (OR 0.33, 95% CI: 0.08 to 1.30). The other investigated drug regimens could only be analyzed qualitatively. CONCLUSION This systematic review provides a comprehensive overview on perioperative drug treatment in pancreatic surgery. Some often-prescribed perioperative drug treatments lack high quality evidence and further research is needed.
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14
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Chen H, Wang W, Zou S, Wang X, Ying X, Cheng D, Weng Y, Deng X, Shen B. Serum lipase on postoperative day one is a strong predictor of clinically relevant pancreatic fistula after pancreaticoduodenectomy: A retrospective cohort. Pancreatology 2022; 22:810-816. [PMID: 35717304 DOI: 10.1016/j.pan.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/07/2022] [Accepted: 06/01/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Increased postoperative serum amylase has been recently reported to be associated with increased postoperative morbidity, but studies on postoperative serum lipase are limited. The aim of this study was to evaluate the value of postoperative serum lipase in predicting clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD). METHOD A retrospective analysis was performed on 212 patients who underwent PD from September 2018 and March 2021, focusing on the association between postoperative day (POD) 1 serum lipase and CR-POPF. RESULTS Overall, 108 (50.9%) patients had elevated serum lipase levels (>68 U/L) on POD 1. Patients with elevated serum lipase exhibited a significantly higher incidence of CR-POPF (37.0% vs. 6.7%, p < 0.001). Receiver operating characteristic (ROC) analyses showed improved diagnostic accuracy for POD 1 serum lipase compared with POD 1 serum amylase in predicting CR-POPF (AUC: 0.801 vs. 0.745, p = 0.029). Elevated serum lipase on POD 1 and elevated serum CRP on POD 3 were identified as independent predictors of CR-POPF. A simple early postoperative model, consisting of POD 1 serum lipase levels and POD 3 serum CRP levels, showed good discrimination (AUC 0.76, 95% CI 0.69-0.83) to identify the onset of CR-POPF. CONCLUSION Serum lipase on POD 1 outperformed serum amylase on POD 1 in predicting CR-POPF after PD. The combination of POD 1 serum lipase and POD 3 serum CRP provides a reliable predicting model for CR-POPF.
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Affiliation(s)
- Haoda Chen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weishen Wang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Siyi Zou
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinjing Wang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiayang Ying
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dongfeng Cheng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuanchi Weng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Xiaxing Deng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Baiyong Shen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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15
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Magnin J, Fournel I, Doussot A, Régimbeau JM, Zerbib P, Piessen G, Beyer-Berjot L, Deguelte S, Lakkis Z, Schwarz L, Orry D, Ayav A, Muscari F, Mauvais F, Passot G, Trelles N, Venara A, Benoist S, Messager M, Fuks D, Borraccino B, Trésallet C, Valverde A, Souche FR, Herrero A, Gaujoux S, Lefevre J, Bourredjem A, Cransac A, Ortega-Deballon P. Benefit of a flash dose of corticosteroids in digestive surgical oncology: a multicenter, randomized, double blind, placebo-controlled trial (CORTIFRENCH). BMC Cancer 2022; 22:913. [PMID: 35999521 PMCID: PMC9400297 DOI: 10.1186/s12885-022-09998-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 08/11/2022] [Indexed: 11/12/2022] Open
Abstract
Background The modulation of perioperative inflammation seems crucial to improve postoperative morbidity and cancer-related outcomes in patients undergoing oncological surgery. Data from the literature suggest that perioperative corticosteroids decrease inflammatory markers and might be associated with fewer complications in esophageal, liver, pancreatic and colorectal surgery. Their benefit on cancer-related outcomes has not been assessed. Methods The CORTIFRENCH trial is a phase III multicenter randomized double-blind placebo-controlled trial to assess the impact of a flash dose of preoperative corticosteroids versus placebo on postoperative morbidity and cancer-related outcomes after elective curative-intent surgery for digestive cancer. The primary endpoint is the frequency of patients with postoperative major complications occurring within 30 days after surgery (defined as all complications with Clavien-Dindo grade > 2). The secondary endpoints are the overall survival at 3 years, the disease-free survival at 3 years, the frequency of patients with intraabdominal infections and postoperative infections within 30 days after surgery and the hospital length of stay. We hypothesize a reduced risk of major complications and a better disease-survival at 3 years in the experimental group. Allowing for 5% of drop-out, 1 200 patients (600 per arm) should be included. Discussion This will be the first trial focusing on the impact of perioperative corticosteroids on cancer related outcomes. If significant, it might be a strong improvement on oncological outcomes for patients undergoing surgery for digestive cancers. Trial registration ClinicalTrials.gov, NCT03875690, Registered on March 15, 2019, URL: https://clinicaltrials.gov/ct2/show/NCT03875690. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09998-z.
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Affiliation(s)
- Joséphine Magnin
- Service de Chirurgie Digestive et Cancérologique, CHU François Mitterrand, 14 rue Paul Gaffarel, 21000 , Dijon, France. .,Department of Digestive Surgical Oncology, University Hospital of Dijon, INSERM 1432, University of Bourgogne, Dijon, France.
| | - Isabelle Fournel
- Department of Clinical Epidemiology, University Hospital of Dijon, INSERM CIC 1432, University of Bourgogne, Dijon, France
| | - Alexandre Doussot
- Department of Digestive Surgical Oncology and Liver Transplantation, University Hospital of Besançon, Besançon, France
| | - Jean-Marc Régimbeau
- Department of Digestive Surgical Oncology, University Hospital of Amiens, Amiens, France
| | - Philippe Zerbib
- Department of Digestive Surgical Oncology and Liver Transplantation, Claude Huriez University Hospital, Chu Lille, France
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, Chu Lille, France
| | - Laura Beyer-Berjot
- Department of Digestive Surgical Oncology, North University Hospital, Marseille, France
| | - Sophie Deguelte
- Department of Digestive Surgical Oncology, University Hospital of Reims, Reims, France
| | - Zaher Lakkis
- Department of Digestive Surgical Oncology and Liver Transplantation, University Hospital of Besançon, Besançon, France
| | - Lilian Schwarz
- Department of Digestive Surgical Oncology, University Hospital of Rouen, Rouen, France
| | - David Orry
- Department of Surgical Oncology, Georges François Leclerc Cancer Center, Dijon, France
| | - Ahmet Ayav
- Department of Digestive Surgical Oncology, University Hospital of Nancy, Nancy, France
| | - Fabrice Muscari
- Department of Digestive Surgical Oncology, Rangueil University Hospital, Toulouse, France
| | - François Mauvais
- Department of Digestive Surgery, Simone Veil Hospital, Beauvais, France
| | - Guillaume Passot
- Department of Digestive Surgical Oncology, Pierre Bénite University Hospital, Lyon, France
| | - Nelson Trelles
- Department of Digestive Surgery, René-Dubos Hospital, Cergy-Pontoise, France
| | - Aurélien Venara
- Department of Digestive Surgical Oncology, University Hospital of Angers, Angers, France
| | - Stéphane Benoist
- Department of Digestive Surgical Oncology, Bicêtre University Hospital, Le Kremlin-Bicêtre, France
| | - Mathieu Messager
- Department of Digestive Surgery, Gustave Dron Hospital, Tourcoing, France
| | - David Fuks
- Department of Digestive Surgical Oncology, Cochin University Hospital, Paris, France
| | | | - Christophe Trésallet
- Department of Digestive Surgical Oncology, Avicenne University Hospital, Paris, France
| | - Alain Valverde
- Department of Digestive Surgery, La Croix Saint Simon Hospital, Paris, France
| | - François-Régis Souche
- Department of Digestive Surgical Oncology, University Hospital of Montpellier, Montpellier, France
| | - Astrid Herrero
- Department of Digestive Surgical Oncology and Liver Transplantation, University Hospital of Montpellier, Montpellier, France
| | - Sébastien Gaujoux
- Department of Digestive Surgical Oncology, Pitié Salpêtrière University Hospital, Paris, France
| | - Jérémie Lefevre
- Department of Digestive Surgical Oncology, Saint-Antoine University Hospital, Paris, France
| | - Abderrahmane Bourredjem
- Department of Clinical Epidemiology, University Hospital of Dijon, INSERM CIC 1432, University of Bourgogne, Dijon, France
| | - Amélie Cransac
- Department of Pharmacy, University Hospital of Dijon, Dijon, France
| | - Pablo Ortega-Deballon
- Service de Chirurgie Digestive et Cancérologique, CHU François Mitterrand, 14 rue Paul Gaffarel, 21000 , Dijon, France.,Department of Digestive Surgical Oncology, University Hospital of Dijon, INSERM 1432, University of Bourgogne, Dijon, France
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Lu X, Yu Y, Wang Y, Lyu Y. Effect of Propofol or Etomidate as General Anaesthesia Induction on Gastric Cancer: A Retrospective Cohort Study with 10 Years' Follow-Up. Cancer Manag Res 2022; 14:2399-2407. [PMID: 35967754 PMCID: PMC9373996 DOI: 10.2147/cmar.s361052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 06/25/2022] [Indexed: 12/24/2022] Open
Abstract
Objective The aim is to study the effect of intraoperative application of propofol and etomidate on the long-term prognosis of patients with gastric cancer at the same tumor stage. Methods A total of 1018 patients who underwent radical gastric cancer surgery at the First Affiliated Hospital of Anhui Medical University from January 2010 to December 2010 were selected and divided into the propofol and etomidate groups according to the different anesthetic induction drugs. Results Among 244 patients in TNM stage IIIA, survival times were 36.10 and 41.79 for etomidate and propofol, respectively, which were statistically different (p < 0.05). Among the 82 patients in TNM stage IIIC, survival times were 26.57 and 35.20 for etomidate and propofol, respectively, which were statistically different (p < 0.05). Conclusion In patients undergoing radical gastric cancer surgery, the application of propofol during induction of anaesthesia is more beneficial in improving the postoperative survival time compared to the application of etomidate at a specific TNM stage.
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Affiliation(s)
- Xianfu Lu
- Department of Anesthesiology High Tech Branch, The First Affiliated Hospital of Anhui Medical University, Hefei, People's Republic of China.,Department of Anesthesiology, Chaohu Hospital of Anhui Medical University, Hefei, People's Republic of China
| | - Yue Yu
- Department of Anesthesiology, Chaohu Hospital of Anhui Medical University, Hefei, People's Republic of China
| | - Yan Wang
- Department of Anesthesiology High Tech Branch, The First Affiliated Hospital of Anhui Medical University, Hefei, People's Republic of China
| | - Yi Lyu
- Department of Anesthesiology, Minhang Hospital, Fudan University, Shanghai, People's Republic of China
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17
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Wu S, Wu H, Xu G, Zhao Y, Xue F, Dong S, Han L, Wang Z, Wu Z. Risk Factors and Clinical Impacts of Post-Pancreatectomy Acute Pancreatitis After Pancreaticoduodenectomy: A Single-Center Retrospective Analysis of 298 Patients Based on the ISGPS Definition and Grading System. Front Surg 2022; 9:916486. [PMID: 35860201 PMCID: PMC9289243 DOI: 10.3389/fsurg.2022.916486] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
Background The definition and grading system of post-pancreatectomy acute pancreatitis (PPAP) has recently been proposed by ISGPS. This study aimed to put this definition and classification into practice and investigate the potential risk factors and clinical impacts of PPAP. Methods Demographic and perioperative data of consecutive patients who underwent pancreaticoduodenectomy (PD) from January 2019 to July 2021 were collected and analyzed retrospectively. The diagnostic criteria of PPAP published by ISGPS, consisting of biochemical, radiologic, and clinical parameters, were adopted. The risk factors were analyzed by univariate and multivariate analyses. Results A total of 298 patients were enrolled in this study, and the total incidence of PPAP was 52.4% (150 patients). Stratified by clinical impacts of PPAP, the incidences of grades B and C PPAP were 48.9% and 3.5%, respectively. PPAP after PD was significantly associated with pancreatic fistula and other unfavorable complications. Soft pancreatic texture (OR 3.0) and CRP ≥ 180 mg/L (OR 3.6) were the independent predictors of PPAP, AUC 0.613. Stratified by the grade of PPAP, soft pancreatic texture (OR 2.7) and CRP ≥ 180 mg/L (OR 3.4) were the independent predictors of grade B PPAP, and soft pancreatic texture (OR 19.3), operation duration >360 min (OR 13.8), and the pancreatic anastomosis by using conventional duct to mucosa methods (OR 10.4) were the independent predictors of grade C PPAP. PPAP complicated with pancreatic fistula significantly increased the severe complications and mortality compared to only PPAP occurrence. Conclusion PPAP was not an uncommon complication after PD and was associated with unfavorable clinical outcomes, especially since it was complicated with pancreatic fistula. Soft pancreatic texture and CRP ≥ 180 mg/L were the independent predictors of PPAP. Higher-volume multicenter and prospective studies are strongly needed.
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Affiliation(s)
- Shuai Wu
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Hanxue Wu
- Department of Physiology and Pathophysiology, School of Basic Medicine, Xi’an Jiaotong University, Xi’an, China
| | - Guiping Xu
- Department of Radiology, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yaling Zhao
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Feng Xue
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Shunbin Dong
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Liang Han
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Zheng Wang
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Zheng Wu
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- Correspondence: Zheng Wu
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18
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Aziz H, Ahmed Z, Abdimajid M, Sekigami Y, Hertl M, Goodman MD. Association between Preoperative Steroids and Outcomes in Patients Undergoing Pancreaticoduodenectomy using the National Surgical Quality Improvement Program. J Gastrointest Surg 2022; 26:1198-1204. [PMID: 35141835 DOI: 10.1007/s11605-022-05260-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 01/22/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND A national study analyzing the association between preoperative steroid use and outcomes after pancreatic resections is lacking. The purpose of this study is to evaluate the association between preoperative steroids and outcomes after pancreaticoduodenectomy using a national database. MATERIALS AND METHODS A retrospective analysis of patients undergoing pancreaticoduodenectomy was performed using the National Surgical Quality Improvement Program (NSQIP) database (2014-2019). In addition, we utilized propensity score matching to compare patients on preoperative steroids to those who were not. Outcomes measured included 30-day complications and mortality, need for readmission, a prolonged hospital length of stay, delayed gastric emptying, and pancreatic fistula. RESULTS After propensity score matching, there were 438 patients in the steroid group and 876 patients in the no steroid group. There was no difference in pancreatic fistula (23.8% vs. 21.7%; p-0.3), delayed gastric emptying (21.1% vs.20.1%; p-0.06), major complications (31.8% vs. 30.1%; p-0.1), and mortality (3.5% vs. 3.2%; p-0.6) between the two groups. CONCLUSION Glucocorticoids did not reduce the incidence of overall complications, postoperative fistula, and delayed gastric emptying following pancreaticoduodenectomy.
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Affiliation(s)
- Hassan Aziz
- Tufts Medical Center, Tufts University School of Medicine, South Building, Floor 4, 860 Washington St, Boston, MA, 02111, USA.
| | - Zubair Ahmed
- Tufts Medical Center, Tufts University School of Medicine, South Building, Floor 4, 860 Washington St, Boston, MA, 02111, USA
| | - Mohamed Abdimajid
- Tufts Medical Center, Tufts University School of Medicine, South Building, Floor 4, 860 Washington St, Boston, MA, 02111, USA
| | - Yurie Sekigami
- Tufts Medical Center, Tufts University School of Medicine, South Building, Floor 4, 860 Washington St, Boston, MA, 02111, USA
| | - Martin Hertl
- Tufts Medical Center, Tufts University School of Medicine, South Building, Floor 4, 860 Washington St, Boston, MA, 02111, USA
| | - Martin D Goodman
- Tufts Medical Center, Tufts University School of Medicine, South Building, Floor 4, 860 Washington St, Boston, MA, 02111, USA
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19
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Cecire J, Adams K, Pham H, Pang T, Burnett D. Pharmacological prevention of post-operative pancreatitis: systematic review and meta-analysis of randomized controlled trials on animal studies. ANZ J Surg 2021; 92:1338-1346. [PMID: 34936178 DOI: 10.1111/ans.17417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) remains a significant complication of pancreatic resection with recent evidence showing a strong association between post-operative pancreatitis and subsequent development of POPF. Incidence and severity of pancreatitis following endoscopic therapy has been effectively reduced with indomethacin prophylaxis, however further agents require evaluation. We present a systematic literature review and meta-analysis of the prophylactic treatment with corticosteroids or n-acetyl cysteine (NAC) of induced pancreatitis in rodent models. METHODS A systematic literature search was conducted using Pubmed, Medline, Embase and Cochrane library to identify eligible randomized control trials (RCT) involving animal models that examined NAC or corticosteroids. The primary outcome was the subsequent effect on serum amylase and IL-6 and the histopathological markers of severity such as pancreatic oedema and necrosis. RESULTS Four RCTs (n = 178) met inclusion criteria examining NAC and eight RCTs (n = 546) examining corticosteroid agents (dexamethasone, hydrocortisone, methylprednisolone). Prophylactic administration of all corticosteroid agents showed a net effect in favour of reducing markers of severity of pancreatitis. NAC showed a significant reduction in severity of amylase and necrosis. CONCLUSION The RCTs examined suggest that prophylactic administration of corticosteroid agents and NAC can reduce the severity of pancreatitis as indicated by histopathologic markers, serum amylase and IL-6 levels.
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Affiliation(s)
- Jack Cecire
- Surgical Innovations Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Kristian Adams
- Surgical Innovations Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Helen Pham
- Surgical Innovations Unit, Westmead Hospital, Sydney, New South Wales, Australia.,Western Clinical School, Faculty of Medical and Health Sciences, The University of Sydney, Sydney, New South Wales, Australia.,Department of Hepatobiliary, Pancreatic/Upper Gastrointestinal Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Tony Pang
- Surgical Innovations Unit, Westmead Hospital, Sydney, New South Wales, Australia.,Western Clinical School, Faculty of Medical and Health Sciences, The University of Sydney, Sydney, New South Wales, Australia.,Department of Hepatobiliary, Pancreatic/Upper Gastrointestinal Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - David Burnett
- Department of Surgery, John Hunter Hospital, Newcastle, New South Wales, Australia
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20
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Kuan LL, Dennison AR, Garcea G. Outcomes of peri-operative glucocorticosteroid use in major pancreatic resections: a systematic review. HPB (Oxford) 2021; 23:1789-1798. [PMID: 34593313 DOI: 10.1016/j.hpb.2021.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 07/12/2021] [Accepted: 07/12/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is increasing evidence that peri-operative glucocorticosteroid can ameliorate the systemic response following major surgery. Preliminary evidence suggests peri-operative usage of glucocorticosteroid may decrease post-operative complications. These positive associations have been observed in a range of different operations including intra-abdominal, thoracic, cardiac, and orthopaedic surgery. This review aims to investigate the impact of peri-operative glucocorticosteroid in major pancreatic resections. METHODS A systematic review based on a search in Medline and Embase databases was performed. PRISMA guidelines for systematic reviews were followed. RESULTS A total of five studies were analysed; three randomised controlled trials and two retrospective cohort studies. The total patient population was 1042. The glucocorticosteroids used were intravenous hydrocortisone or dexamethasone. Three studies reported significantly lower morbidity in the peri-operative glucocorticosteroid group. The number needed to treat to prevent one major complication with hydrocortisone is four patients. Two studies demonstrated that dexamethasone was associated with a statistically significantly improved median overall survival in pancreatic cancer. CONCLUSION This is the first systematic review conducted to investigate the significance of peri-operative glucocorticosteroid in patients undergoing pancreatic resection. This review shows a correlation of positive outcomes with the administration of glucocorticosteroid in the peri-operative setting following a major pancreatic resection.. More randomised clinical trials are required to confirm if this is a true effect, as it would have significant implications.
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Affiliation(s)
- Li Lian Kuan
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Discipline of Surgery, The University of Adelaide, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia.
| | - Ashley R Dennison
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Giuseppe Garcea
- Department of Hepatobiliary and Pancreatic Surgery, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
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21
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Zhang Y, Li S, Yan C, Chen J, Shan F. Perioperative Use of Glucocorticoids and Intraoperative Hypotension May Affect the Incidence of Postoperative Infection in Patients with Gastric Cancer: A Retrospective Cohort Study. Cancer Manag Res 2021; 13:7723-7734. [PMID: 34675668 PMCID: PMC8517416 DOI: 10.2147/cmar.s333414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/20/2021] [Indexed: 12/24/2022] Open
Abstract
Background In patients undergoing surgical resection for gastric cancer, postoperative complications—in particular, postoperative infections—remain an important problem and can result in delayed recovery and increased postoperative mortality. Objective To investigate the association between perioperative anesthesia management and postoperative infectious complications in patients undergoing resection for gastric cancer. Design Retrospective cohort study. Setting A single-center study performed from April 1, 2015, to June 30, 2018, at Peking University Cancer Hospital. Patients Patients who underwent resection for gastric cancer. Main Outcome Measures Demographic information, perioperative data (including anesthesia-related data, surgery-related data, and cancer diagnosis), and information on postoperative recovery were recorded. The primary outcome was incidence of postoperative infection; the secondary outcome was length of hospital stay. The associations between perioperative factors and postoperative infectious complications were analyzed using multivariable logistic regression models and the classification tree method. Results A total of 880 patients were included in the study; of these, 111 (12.6%) had postoperative infectious complications during hospitalization, including 78 surgical site infections and 62 remote infections. After correction for confounding factors on logistic multivariable analysis, perioperative use of glucocorticoids was associated with a lower incidence of postoperative infection (hazard ratio 0.968, 95% confidence interval 0.939 to 0.997, P=0.029), and intraoperative systolic blood pressure <90 mmHg for >10 min was associated with a higher incidence of postoperative infection (hazard ratio 2.112, 95% confidence interval 1.174 to 3.801, P=0.013). In addition, older age, preoperative hypoproteinemia, and total gastrectomy were identified as independent predictors of postoperative infection. Conclusion For patients with gastric cancer, perioperative use of glucocorticoids and avoiding intraoperative hypotension may decrease the incidence of postoperative infectious complications.
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Affiliation(s)
- Yunxiao Zhang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Anesthesiology, Peking University Cancer Hospital & Institute, Beijing, People's Republic of China
| | - Shuo Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Anesthesiology, Peking University Cancer Hospital & Institute, Beijing, People's Republic of China
| | - Chao Yan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), The First Department of Gastrointestinal Surgery, Peking University Cancer Hospital & Institute, Beijing, People's Republic of China
| | - Jiheng Chen
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Anesthesiology, Peking University Cancer Hospital & Institute, Beijing, People's Republic of China
| | - Fei Shan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), The First Department of Gastrointestinal Surgery, Peking University Cancer Hospital & Institute, Beijing, People's Republic of China
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22
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Zhang T, Xu Y, Yao Y, Jin L, Liu H, Zhou Y, Gu L, Ji Q, Zhu W, Gong J. Randomized Controlled Trial: Perioperative Dexamethasone Reduces Excessive Postoperative Inflammatory Response and Ileus After Surgery for Inflammatory Bowel Disease. Inflamm Bowel Dis 2021; 27:1756-1765. [PMID: 33749741 DOI: 10.1093/ibd/izab065] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND An excessive postoperative inflammatory response is common after surgery for inflammatory bowel disease (IBD) and may be associated with an increased incidence of postoperative ileus. This study assessed the role of perioperative dexamethasone in postoperative ileus after IBD surgery. METHOD Patients undergoing elective IBD surgery were randomized to either an intravenous 8-mg dose of dexamethasone (n = 151) or placebo (n = 151) upon induction of anesthesia. The primary outcome was the incidence of prolonged postoperative ileus. Secondary outcomes included incidence of reported nausea or vomiting, time to first passage of flatus and stool, GI-2 recovery, postoperative pain, length of stay, and surgical complications. RESULTS An intention-to-treat analysis revealed that patients who received dexamethasone exhibited a lower incidence of prolonged postoperative ileus (22.5% vs 38.4%; P = 0.003), shorter time to first passage of stool (28 vs 48 h, P < 0.001), GI-2 recovery (72 vs 120 h; P < 0.001), reduced postoperative length of stay (9.0 vs 10.0 d; P = 0.002), and less postoperative pain (P < 0.05) compared with controls. Moreover, there were no significant differences in postoperative nausea or vomiting (P = 0.531), major postoperative complications (P = 0.165), or surgical site infections (P = 0.337) between the groups. A benefit was only observed in patients with Crohn's disease, restored bowel continuity, colon/rectal resections, and those who underwent open operations. CONCLUSION A single, intravenous 8-mg dose of dexamethasone upon induction of anesthesia reduced the incidence of prolonged postoperative ileus, the intensity of postoperative pain, and shortened the postoperative length of stay for IBD patients undergoing elective surgery. ClinicalTrials.gov: NCT03456752.
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Affiliation(s)
- Tenghui Zhang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yi Xu
- Department of General Surgery, Jinling Hospital, Medical School of Southeast University, Nanjing, China
| | - Yao Yao
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Lingling Jin
- Department of Anesthesiology, Jinling Hospital, Nanjing, China.,School of Public Health, Nanjing Medical University, Nanjing, China
| | - Haoxin Liu
- Department of Anesthesiology, Jinling Hospital, Nanjing, China
| | - Yan Zhou
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Lili Gu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Qing Ji
- Department of Anesthesiology, Jinling Hospital, Nanjing, China
| | - Weiming Zhu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jianfeng Gong
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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23
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Wennerblom J, Ateeb Z, Jönsson C, Björnsson B, Tingstedt B, Williamsson C, Sandström P, Ansorge C, Blomberg J, Del Chiaro M. Reinforced versus standard stapler transection on postoperative pancreatic fistula in distal pancreatectomy: multicentre randomized clinical trial. Br J Surg 2021; 108:265-270. [PMID: 33793753 DOI: 10.1093/bjs/znaa113] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/11/2020] [Accepted: 11/06/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula is the leading cause of morbidity after distal pancreatectomy. Strategies investigated to reduce the incidence have been disappointing. Recent data showed a reduction in postoperative pancreatic fistula with the use of synthetic mesh reinforcement of the staple line. METHODS An RCT was conducted between May 2014 and February 2016 at four tertiary referral centres in Sweden. Patients scheduled for distal pancreatectomy were eligible. Enrolled patients were randomized during surgery to stapler transection with biological reinforcement or standard stapler transection. Patients were blinded to the allocation. The primary endpoint was the development of any postoperative pancreatic fistula. Secondary endpoints included morbidity, mortality, and duration of hospital stay. RESULTS Some 107 patients were randomized and 106 included in an intention-to-treat analysis (56 in reinforced stapling group, 50 in standard stapling group). No difference was demonstrated in terms of clinically relevant fistulas (grade B and C): 6 of 56 (11 per cent) with reinforced stapling versus 8 of 50 (16 per cent) with standard stapling (P = 0.332). There was no difference between groups in overall postoperative complications: 45 (80 per cent) and 39 (78 per cent) in reinforced and standard stapling groups respectively (P = 0.765). Duration of hospital stay was comparable: median 8 (range 2-35) and 9 (2-114) days respectively (P = 0.541). CONCLUSION Biodegradable stapler reinforcement at the transection line of the pancreas did not reduce postoperative pancreatic fistula compared with regular stapler transection in distal pancreatectomy. Registration number: NCT02149446 (http://www.clinicaltrials.gov).
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Affiliation(s)
- J Wennerblom
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Z Ateeb
- Division of Surgery, Department of Clinical Sciences, Intervention and Technology (CLINTECH), Karolinska Institutet at Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - C Jönsson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - B Björnsson
- Department of Surgery in Linköping, Linköping University, Linköping, Sweden.,Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - B Tingstedt
- Department of Surgery, Clinical Sciences Lund, Skåne University Hospital at Lund and Lund University, Lund, Sweden
| | - C Williamsson
- Department of Surgery, Clinical Sciences Lund, Skåne University Hospital at Lund and Lund University, Lund, Sweden
| | - P Sandström
- Department of Surgery in Linköping, Linköping University, Linköping, Sweden.,Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - C Ansorge
- Division of Surgery, Department of Clinical Sciences, Intervention and Technology (CLINTECH), Karolinska Institutet at Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - J Blomberg
- Division of Surgery, Department of Clinical Sciences, Intervention and Technology (CLINTECH), Karolinska Institutet at Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - M Del Chiaro
- Division of Surgery, Department of Clinical Sciences, Intervention and Technology (CLINTECH), Karolinska Institutet at Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgical Oncology, Department of Surgery, University of Colorado at Denver-Anschutz Medical Campus, Aurora, Colorado, USA
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24
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Sallinen V, Tarvainen T. The Hydrocortisone vs Pasireotide in Reducing Pancreatic Surgery Complications Noninferiority Trial-Reply. JAMA Surg 2021; 155:995-996. [PMID: 32667629 DOI: 10.1001/jamasurg.2020.2001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Ville Sallinen
- Department of Gastroenterological Surgery, University of Helsinki, Helsinki, Finland.,Department of Transplantation and Liver Surgery, University of Helsinki, Helsinki, Finland.,Helsinki University Hospital, Helsinki, Finland
| | - Timo Tarvainen
- Department of Gastroenterological Surgery, University of Helsinki, Helsinki, Finland.,Helsinki University Hospital, Helsinki, Finland
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25
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Honselmann KC, Antoine C, Frohneberg L, Deichmann S, Bolm L, Braun R, Lapshyn H, Petrova E, Keck T, Wellner U, Bausch D. A simple nomogram for early postoperative risk prediction of clinically relevant pancreatic fistula after pancreatoduodenectomy. Langenbecks Arch Surg 2021; 406:2343-2355. [PMID: 34009458 PMCID: PMC8578094 DOI: 10.1007/s00423-021-02184-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 04/28/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE Postoperative pancreatic fistulae (POPF) present a serious and life-threatening complication after pancreatic head resections (PD). Therefore, reliable risk stratification to identify those at risk is urgently needed. The aim of this study was to identify postoperative laboratory parameters for the prediction of POPF in the early postoperative period. METHODS One hundred eighty-two patients who underwent PD from 2012 until 2017 were retrospectively analyzed. Multivariate logistic regression was performed using the GLM (general linear model) method for model building. Two nomograms were created based on the GLM models of postoperative day one and postoperative day one to five. A cohort of 48 patients operated between 2018 and 2019 served as internal validation. RESULTS Clinically relevant pancreatic fistulae (CR-POPF) were present in 16% (n = 29) of patients. Patients with CR-POPF experienced significantly more insufficiencies of gastroenterostomies, delayed gastric emptying, and more extraluminal bleeding than patients without CR-POPF. Multivariate analysis revealed multiple postoperative predictive models, the best one including ASA, main pancreatic duct diameter, operation time, and serum lipase as well as leucocytes on day one. This model was able to predict CR-POPF with an accuracy of 90% and an AUC of 0.903. Two nomograms were created for easier use. CONCLUSION Clinically relevant fistula can be predicted using simple laboratory and clinical parameters. Not serum amylase, but serum lipase is an independent predictor of CR-POPF. Our simple nomograms may help in the identification of patients for early postoperative interventions.
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Affiliation(s)
- K C Honselmann
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - C Antoine
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - L Frohneberg
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - S Deichmann
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - L Bolm
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - R Braun
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - H Lapshyn
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - E Petrova
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - T Keck
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - U Wellner
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - D Bausch
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany. .,Department of Surgery, Marien Hospital Herne-University Medical Center of the Ruhr-Universität Bochum, Hölkeskampring 40, 44625, Herne, Germany.
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26
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Doussot A, Decrock M, Calame P, Georges P, Turco C, Lakkis Z, Heyd B. Fluorescence-based pancreas stump perfusion is associated with postoperative acute pancreatitis after pancreatoduodenectomy a prospective cohort study. Pancreatology 2021; 21:S1424-3903(21)00161-7. [PMID: 34030965 DOI: 10.1016/j.pan.2021.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/30/2021] [Accepted: 05/10/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Postoperative acute pancreatitis (POAP) emerges as a distinct pancreas-specific complication increasing both the risk and the burden of POPF after pancreatoduodenectomy. Among various risk factors, pancreas stump (PS) hypoperfusion might play a role in POAP occurrence but has never been investigated. The current study aimed at evaluating the feasibility of intraoperative fluorescence angiography (IOFA) of the PS using ICG and its association with POAP. METHODS Consecutive patients who underwent pancreatoduodenectomy for a periampullary tumor with pancreatojejunostomy and PS perfusion assessment using IOFA between January 2020 and November 2020 were prospectively included. Perioperative management and surgical strategy were standardized. IOFA of the pancreas stump was performed before fashioning pancreatojejunostomy. POAP was defined according to the Connor definition and was confirmed upon radiological blind review. Outcomes between patients with normally perfused and hypoperfused PS were compared. POAP was the primary endpoint. RESULTS Among 30 patients, nine patients (30%) developed POAP according to the Connor definition, and six patients (20%) had CT-confirmed POAP. Upon IOFA, six patients (20%) presented PS hypoperfusion; of which one patient underwent extended pancreatectomy further to the left. PS hypoperfusion was statistically associated with the occurrence of POAP (80% vs. 16%; p = 0.011) and CT-confirmed POAP (60% vs. 12%; p = 0.041). Clinically relevant POPF rate was 40% in case of PS hypoperfusion and 4% in case of normal PS perfusion (p = 0.064). CONCLUSIONS PS perfusion assessment using IOFA seems safe and reliable to anticipate POAP. PS IOFA could be considered as a potential tool for perioperative assessment of surgical risk after pancreatoduodenectomy.
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Affiliation(s)
- Alexandre Doussot
- Department of Digestive Surgical Oncology - Liver Transplantation Unit, University Hospital of Besançon, France.
| | - Marc Decrock
- Department of Digestive Surgical Oncology - Liver Transplantation Unit, University Hospital of Besançon, France
| | - Paul Calame
- Department of Radiology, University Hospital of Besançon, France
| | - Pauline Georges
- Department of Digestive Surgical Oncology - Liver Transplantation Unit, University Hospital of Besançon, France
| | - Célia Turco
- Department of Digestive Surgical Oncology - Liver Transplantation Unit, University Hospital of Besançon, France
| | - Zaher Lakkis
- Department of Digestive Surgical Oncology - Liver Transplantation Unit, University Hospital of Besançon, France
| | - Bruno Heyd
- Department of Digestive Surgical Oncology - Liver Transplantation Unit, University Hospital of Besançon, France
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Kim DG, Seo WJ, Cho M, Kim YM, Huh KH, Cheong JH, Hyung WJ, Kim MS, Kim HI. Perioperative, short-, and long-term outcomes of gastric cancer surgery: Propensity score-matched analysis of patients with or without prior solid organ transplantation. Eur J Surg Oncol 2021; 47:3105-3112. [PMID: 33906787 DOI: 10.1016/j.ejso.2021.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 03/28/2021] [Accepted: 04/15/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Details of perioperative outcomes and survival after gastric cancer surgery in prior transplant recipients have received minimal research attention. METHODS We performed an observational cohort study using the database of 20,147 gastric cancer patients who underwent gastrectomy at a single gastric cancer center in Korea. Forty-one solid organ recipients [kidney (n = 35), liver (n = 5), or heart (n = 1)] were matched with 205 controls using propensity score matching. RESULTS Operation time, blood loss, and postoperative pain were similar between groups. Short-term complication rates were similar between transplantation and control groups (22.0% vs. 20.1%, P = 0.777). Transplantation group patients with stage 1 gastric cancer experienced no recurrence, while those with stage 2/3 cancer had significantly higher recurrence risk compared to the controls (P = 0.049). For patients with stage 1 cancer, the transplantation group had a significantly higher rate of non-gastric cancer-related deaths compared to the controls (19.2% vs. 1.4%, P = 0.001). For those with stage 2/3 cancer, significantly lower proportion of the transplantation group received adjuvant chemotherapy compared to the control group (26.7% vs. 80.3%, P < 0.001). The transplantation group had a higher (albeit not statistically significant) rate of gastric cancer-related deaths compared to the controls (40.0% vs. 18.0%, P = 0.087). CONCLUSION Transplant recipients and non-transplant recipients exhibited similar perioperative and short-term outcomes after gastric cancer surgery. From long-term outcome analyses, we suggest active surveillance for non-gastric cancer-related deaths in patients with early gastric cancer, as well as strict oncologic care in patients with advanced cancer, as effective strategies for transplant recipients.
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Affiliation(s)
- Deok Gie Kim
- Transplantation Center, Department of Transplantation Surgery, Wonju Severance Christian Hospital, Wonju, South Korea; Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | - Won Jun Seo
- Department of Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Minah Cho
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea; Gastric Cancer Center, Yonsei Cancer Center, Seoul, South Korea; Open NBI Convergence Technology Research Laboratory, Severance Hospital, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Yoo-Min Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea; Gastric Cancer Center, Yonsei Cancer Center, Seoul, South Korea; Open NBI Convergence Technology Research Laboratory, Severance Hospital, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Kyu Ha Huh
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea; The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae-Ho Cheong
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea; Gastric Cancer Center, Yonsei Cancer Center, Seoul, South Korea; Open NBI Convergence Technology Research Laboratory, Severance Hospital, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Woo Jin Hyung
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea; Gastric Cancer Center, Yonsei Cancer Center, Seoul, South Korea; Open NBI Convergence Technology Research Laboratory, Severance Hospital, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Myoung Soo Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea; The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyoung-Il Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea; Gastric Cancer Center, Yonsei Cancer Center, Seoul, South Korea; Open NBI Convergence Technology Research Laboratory, Severance Hospital, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea.
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Surgeon vs Pathologist for Prediction of Pancreatic Fistula: Results from the Randomized Multicenter RECOPANC Study. J Am Coll Surg 2021; 232:935-945.e2. [PMID: 33887486 DOI: 10.1016/j.jamcollsurg.2021.03.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/07/2021] [Accepted: 03/10/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Surgically assessed pancreatic texture has been identified as the strongest predictor of postoperative pancreatic fistula. However, texture is a subjective parameter with no proven reliability or validity. Therefore, a more objective parameter is needed. In this study, we evaluated the fibrosis level at the pancreatic neck resection margin and correlated fibrosis and all clinico-pathologic parameters collected over the course of the Pancreatogastrostomy vs Pancreatojejunostomy for RECOnstruction (RECOPANC) study. STUDY DESIGN The RECOPANC trial was a multicenter randomized prospective trial of patients undergoing pancreatoduodenectomy. There were 261 hematoxylin and eosin-stained slides allocated for histopathologic analyses. Pancreatic fibrosis was scored from 0 to III (no fibrosis up to severe fibrosis) by 2 blinded independent pathologists. All variables possibly associated with POPF were entered into a generalized linear model for multivariable analysis. RESULTS The fibrosis grade and pancreatic texture were scored in all 261 patients. In POPF B/C (postoperative pancreatic fistula grade B or C) patients, 71% had a soft pancreas, and fibrosis grades were distributed as follows: 48% with score 0, 28% with score I, 20% with score II, and 7% with score III, respectively. Fibrosis grading showed substantial inter-rater reliability (kappa = 0.74) and correlated positively with hard pancreatic texture (p < 0.05). In univariable analysis, area under the curve (AUC) for POPF B/C prediction was higher for fibrosis grade than for pancreatic texture (0.71 vs 0.59). In multivariate analysis, the following predictors were selected: sex, surgeon volume, pancreatic texture, and fibrosis grade. However, the addition of pancreatic texture only led to an incremental improvement (AUC 0.794 vs 0.819). CONCLUSIONS Histologically evaluated pancreatic fibrosis is an easily applicable and highly reproducible POPF predictor and superior to surgically evaluated pancreatic texture. Future studies might use fibrosis grade for risk stratification in pancreatoduodenectomy.
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Nahm CB, Alzaabi S, Sahni S, Gill AJ, Samra JS, Mittal A. Increased postoperative pancreatic fistula rate after distal pancreatectomy compared with pancreatoduodenectomy is attributable to a difference in acinar scores. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 28:533-541. [PMID: 33665934 DOI: 10.1002/jhbp.934] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/15/2020] [Accepted: 11/20/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is a potentially lethal complication of pancreatic surgery. POPF rate is consistently higher after distal pancreatectomy (DP) compared with pancreatoduodenectomy (PD). The acinar score of the remnant pancreas is associated with postoperative pancreatitis and POPF. This study aimed to: (i) confirm the difference in POPF rate after DP vs PD; (ii) confirm the association between acinar score and POPF; and (iii) evaluate the difference in acinar scores between DP and PD. METHODS Patients undergoing DP or PD at a single institution from 2011 to 2017 were included. Hematoxylin and eosin-stained slides of the pancreatic resection margin were evaluated for all patients and scored for acinar cell density. Clinicopathological data were retrieved from a prospectively maintained database. RESULTS Two hundred and ninety-four patients were included in the analysis (206 PD, 88 DP). The POPF rate was significantly higher after DP than PD (20.4% vs 11.2%, P = .043). Acinar score >50 was independently associated with the development of POPF (OR 6.457, P = .003). DP was associated with a higher median acinar score than PD (65 vs 50, P < .001). CONCLUSION The POPF rate is significantly higher after DP compared with PD and is attributable to a higher acinar score of the pancreatic resection margin.
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Affiliation(s)
- Christopher B Nahm
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St. Leonards, NSW, Australia
- Sydney Vital, Sydney, Australia
- Northern Clinical School, Faculty of Medical and Health Sciences, The University of Sydney, Sydney, NSW, Australia
| | - Saeed Alzaabi
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St. Leonards, NSW, Australia
| | - Sumit Sahni
- Sydney Vital, Sydney, Australia
- Northern Clinical School, Faculty of Medical and Health Sciences, The University of Sydney, Sydney, NSW, Australia
- Australian Pancreatic Centre, Royal North Shore Hospital, St. Leonards, NSW, Australia
| | - Anthony J Gill
- Sydney Vital, Sydney, Australia
- Northern Clinical School, Faculty of Medical and Health Sciences, The University of Sydney, Sydney, NSW, Australia
- Australian Pancreatic Centre, Royal North Shore Hospital, St. Leonards, NSW, Australia
- Cancer Diagnosis and Pathology Group, Kolling Institute, The University of Sydney, Sydney, NSW, Australia
| | - Jaswinder S Samra
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St. Leonards, NSW, Australia
- Sydney Vital, Sydney, Australia
- Cancer Diagnosis and Pathology Group, Kolling Institute, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medical and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - Anubhav Mittal
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, St. Leonards, NSW, Australia
- Sydney Vital, Sydney, Australia
- Northern Clinical School, Faculty of Medical and Health Sciences, The University of Sydney, Sydney, NSW, Australia
- Cancer Diagnosis and Pathology Group, Kolling Institute, The University of Sydney, Sydney, NSW, Australia
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Bläuer M, Sand J, Laukkarinen J. Regulation of p38 MAPK and glucocorticoid receptor activation by hydrocortisone in mono-and co-cultured pancreatic acinar and stellate cells. Pancreatology 2021; 21:384-389. [PMID: 33454208 DOI: 10.1016/j.pan.2020.12.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/17/2020] [Accepted: 12/29/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Acute pancreatitis develops as an inflammatory response to pancreatic tissue injury. Postoperative pancreatitis has recently been associated with increased occurrence of complications. Activation of the mitogen-activated protein kinase p38 (p38 MAPK) pathway occurs early in acute pancreatitis and its inhibition has been suggested to alleviate pancreatic inflammation. Glucocorticoids are potent anti-inflammatory steroids whose use in the management of acute pancreatitis remains controversial. Our aim was to examine the effect of crosstalk between pancreatic acinar cells (PACs) and stellate cells (PSCs) on p38 MAPK and glucocorticoid receptor (GR) activation and to assess the impact of hydrocortisone on these events. METHODS The long-term co-culture setting for mouse PACs and PSCs developed in our laboratory was used. Parallel 4d mono- and co-cultures with or without 10 nM hydrocortisone were performed followed by immunocytochemical analysis of nuclear GR and phospho-p38 MAPK (pp38 MAPK). RESULTS Hydrocortisone inhibited pp38 MAPK up-regulation evoked by co-culture in PACs and PSCs and increased nuclear translocation of GR in PAC monocultures and in co-cultured PACs and PSCs. In PSC monocultures and co-cultured PACs, ligand-independent expression of nuclear GR was observed. In the former no change in nuclear GR but a significant decrease in total GR as analyzed by Western blot was caused by hydrocortisone. CONCLUSIONS Cellular microenvironment plays a significant role on p38 MAPK and GR activation in PACs and PSCs. Hydrocortisone is an effective means to inhibit p38 MAPK activation in PACs and PSCs. Both ligand-dependent and -independent regulatory roles for GR are suggested in the exocrine pancreas.
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Affiliation(s)
- Merja Bläuer
- Tampere Pancreas Laboratory and Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital and Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Juhani Sand
- Tampere Pancreas Laboratory and Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital and Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Johanna Laukkarinen
- Tampere Pancreas Laboratory and Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital and Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
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Teränen V, Rinta-Kiikka I, Holli-Helenius K, Laaninen M, Sand J, Laukkarinen J. Perioperative acinar cell count method works well in the prediction of postoperative pancreatic fistula and other postoperative complications after pancreaticoduodenectomy. Pancreatology 2021; 21:487-493. [PMID: 33531257 DOI: 10.1016/j.pan.2021.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 11/30/2020] [Accepted: 01/10/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Earlier we have shown that high frequency of acinar cells in the pancreatic transsection line predicts postoperative pancreatic fistula after pancreaticoduodenectomy (PD). Acinar cell count method (ACM) is fast to perform during operation. In this study our aim was to validate the accuracy of ACM to compare it with other published risk prediction methods. METHODS 87 patients who underwent PD without any trial including perioperative medications were collected from a single hospital. Data on demographics, surgical details, postoperative complications clinically relevant pancreatic fistulae (CR-POPF) and clinically relevant Clavien-Dindo complications (CR-CDC) were registered. Thirteen previously published risk prediction methods were included in the comparison, such as pancreatic duct diameter, palpable texture of pancreas, Braga score (BC), Fistula Risk Score, Modified Fistula Risk Score, Alternative Fistula Risk Score and multiple radiological parameters. ROC-curves were calculated to compare sensitivity and specificity for identifying high risk patients for CR-POPF and CR-CDC. RESULTS The three most accurate risk prediction methods for CR-POPF were ACM (sensitivity 88.9%, specificity 52.6%; p = 0.043), BC (87.5%, 56.6%; p = 0.039) and visceral fat area to subcutaneous fat area ratio (75.5%, 80.0%; p = 0.032). In predicting CR-CDC the three most accurate methods were ACM (73.9%, 56.2%; p = 0.033), BC (68.4%, 59.5%; p = 0.036) and TPAI (78.3%, 41.7%; p = 0.012). CONCLUSION ACM was shown to be as good as the more complicated risk scoring methods in the prediction of CR-POPF. It was good also in predicting all clinically relevant complications. ACM is easy to use during operation and can be recommended as a routine risk prediction method.
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Affiliation(s)
- Ville Teränen
- Dept. of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Irina Rinta-Kiikka
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Dept. of Radiology, Tampere University Hospital, Tampere, Finland
| | - Kirsi Holli-Helenius
- Dept. of Radiology, Tampere University Hospital, Tampere, Finland; Dept. of Medical Physics, Medical Imaging Centre, Pirkanmaa Hospital District, Tampere, Finland
| | - Matias Laaninen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Juhani Sand
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Päijät-Häme Central Hospital, Lahti, Finland
| | - Johanna Laukkarinen
- Dept. of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
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Mungroop TH, Klompmaker S, Wellner UF, Steyerberg EW, Coratti A, D'Hondt M, de Pastena M, Dokmak S, Khatkov I, Saint-Marc O, Wittel U, Abu Hilal M, Fuks D, Poves I, Keck T, Boggi U, Besselink MG. Updated Alternative Fistula Risk Score (ua-FRS) to Include Minimally Invasive Pancreatoduodenectomy: Pan-European Validation. Ann Surg 2021; 273:334-340. [PMID: 30829699 DOI: 10.1097/sla.0000000000003234] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of the study was to validate and optimize the alternative Fistula Risk Score (a-FRS) for patients undergoing minimally invasive pancreatoduodenectomy (MIPD) in a large pan-European cohort. BACKGROUND MIPD may be associated with an increased risk of postoperative pancreatic fistula (POPF). The a-FRS could allow for risk-adjusted comparisons in research and improve preventive strategies for high-risk patients. The a-FRS, however, has not yet been validated specifically for laparoscopic, robot-assisted, and hybrid MIPD. METHODS A validation study was performed in a pan-European cohort of 952 consecutive patients undergoing MIPD (543 laparoscopic, 258 robot-assisted, 151 hybrid) in 26 centers from 7 countries between 2007 and 2017. The primary outcome was POPF (International Study Group on Pancreatic Surgery grade B/C). Model performance was assessed using the area under the receiver operating curve (AUC; discrimination) and calibration plots. Validation included univariable screening for clinical variables that could improve performance. RESULTS Overall, 202 of 952 patients (21%) developed POPF after MIPD. Before adjustment, the original a-FRS performed moderately (AUC 0.68) and calibration was inadequate with systematic underestimation of the POPF risk. Single-row pancreatojejunostomy (odds ratio 4.6, 95 confidence interval [CI] 2.8-7.6) and male sex (odds ratio 1.9, 95 CI 1.4-2.7) were identified as important risk factors for POPF in MIPD. The updated a-FRS, consisting of body mass index, pancreatic texture, duct size, and male sex, showed good discrimination (AUC 0.75, 95 CI 0.71-0.79) and adequate calibration. Performance was adequate for laparoscopic, robot-assisted, and hybrid MIPD and open pancreatoduodenectomy. CONCLUSIONS The updated a-FRS (www.pancreascalculator.com) now includes male sex as a risk factor and is validated for both MIPD and open pancreatoduodenectomy. The increased risk of POPF in laparoscopic MIPD was associated with single-row pancreatojejunostomy, which should therefore be discouraged.
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Affiliation(s)
- Timothy H Mungroop
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Sjors Klompmaker
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
| | - Ulrich F Wellner
- Clinic of Surgery, UKSH Campus Lübeck, Lübeck, Germany
- Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV) Studien-, Dokumentations- und Qualitätszentrum (StuDoQ|Pancreas), Germany
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Andrea Coratti
- Department of Oncology and Robotic Surgery, Careggi University Hospital, Florence, Italy
| | - Mathieu D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - Matteo de Pastena
- Department of Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Safi Dokmak
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, Clichy, France
| | - Igor Khatkov
- Department of Surgery, Moscow Clinical Scientific Center, Moscow, Russia
| | - Olivier Saint-Marc
- Department of Surgery, Centre Hospitalier Régional Orleans, Orleans, France
| | - Uwe Wittel
- Department of Visceral and General Surgery, University of Freiburg Medical Center, Freiburg, Germany
| | - Mohammed Abu Hilal
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, United Kingdom
| | - David Fuks
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, Université Paris Descartes, Paris, France
| | - Ignasi Poves
- Department of Surgery, Hospital del Mar, Barcelona, Spain
| | - Tobias Keck
- Clinic of Surgery, UKSH Campus Lübeck, Lübeck, Germany
- Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV) Studien-, Dokumentations- und Qualitätszentrum (StuDoQ|Pancreas), Germany
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, The Netherlands
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Zhang YX, Mu DL, Jin KM, Li XY, Wang DX. Perioperative Glucocorticoids are Associated with Improved Recurrence-Free Survival After Pancreatic Cancer Surgery: A Retrospective Cohort Study with Propensity Score-Matching. Ther Clin Risk Manag 2021; 17:87-101. [PMID: 33519206 PMCID: PMC7837557 DOI: 10.2147/tcrm.s287572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/28/2020] [Indexed: 01/06/2023] Open
Abstract
Purpose Perioperative anesthetic management may affect long-term outcome after cancer surgery. This study investigated the effect of perioperative glucocorticoids on long-term survival in patients after radical resection for pancreatic cancer. Methods In this retrospective cohort study with propensity score-matching, patients who underwent radical resection for pancreatic cancer from January 2005 to December 2016 were recruited. Baseline and perioperative data including use of glucocorticoids for prevention of postoperative nausea and vomiting were collected. Patients were followed up by qualified personnel for cancer recurrence and survival. The primary outcome was the recurrence-free survival. Outcomes were compared before and after propensity matching. The association between perioperative glucocorticoid use and recurrence-free survival was analyzed with multivariable regression models. Results A total of 215 patients were included in the study; of these, 112 received perioperative glucocorticoids and 103 did not. Patients were followed up for a median of 74.0 months (95% confidence interval [CI] 68.3–79.7). After propensity score-matching, 64 patients remained in each group. The recurrence-free survivals were significantly longer in patients with glucocorticoids than in those without (full cohort: median 12.0 months [95% CI 6.0–28.0] vs 6.9 months [4.2–17.0], P<0.001; matched cohort: median 12.0 months [95% CI 5.8–26.3] vs 8.3 months [4.3–18.2], P=0.015). After correction for confounding factors, perioperative glucocorticoids were significantly associated with prolonged recurrence-free survivals (full cohort: HR 0.66, 95% CI 0.48–0.92, P=0.015; matched cohort: HR 0.54, 95% CI 0.35–0.84, P=0.007). Conclusion Perioperative use of low-dose glucocorticoids is associated with improved recurrence-free survival in patients following radical surgery for pancreatic cancer.
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Affiliation(s)
- Yun-Xiao Zhang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, People's Republic of China.,Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), The Department of Anesthesiology, Peking University Cancer Hospital & Institute, Beijing, People's Republic of China
| | - Dong-Liang Mu
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, People's Republic of China
| | - Ke-Min Jin
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), The First Department of Hepatic, Biliary & Pancreatic Surgery, Peking University Cancer Hospital & Institute, Beijing, People's Republic of China
| | - Xue-Ying Li
- Department of Biostatistics, Peking University First Hospital, Beijing, People's Republic of China
| | - Dong-Xin Wang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, People's Republic of China.,Outcomes Research Consortium, Cleveland, Ohio, United States of America
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Nicholas E, van Roessel S, de Burlet K, Hore T, Besselink MG, Connor S. Using Textbook Outcomes to benchmark practice in pancreatic surgery. ANZ J Surg 2021; 91:361-366. [PMID: 33475226 DOI: 10.1111/ans.16555] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 12/25/2020] [Accepted: 12/26/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Textbook Outcome (TO) is a novel composite measure of clinical outcomes that can be used to measure the quality of surgical outcomes. TOs for pancreatic surgery were published by the Dutch Pancreatic Cancer Group (DPCG) in 2020. The aim of this study was to explore how a medium volume hepatopancreaticobiliary unit could use TO to benchmark local outcomes following pancreatic surgery. METHODS Retrospective analysis of prospectively collected data from patients who underwent pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) for all indications between March 2005 and February 2020 at Christchurch Hospital (CH). Analysis of TO items as defined by the DPCG was performed and compared to nationwide Dutch outcomes (2014-2017), including cumulative analysis using CuSum. RESULTS In total, 273 patients were included (median age 63 years; 51% female) of which 182 (67%) underwent PD and 91 (33%) underwent DP (median annual volume 12 PDs/6 DPs). Overall, 58% of patients undergoing PD and 74% of patients undergoing DP achieved TO, compared with 58% and 67%, P = 0.944 and P = 0.231, respectively, for the Netherlands (median annual volume 33 PDs/8 DPs per hospital). CONCLUSIONS TO offers a useful quality measure to benchmark local outcomes following pancreatic surgery against an external nationwide analysis. The results show that as a medium volume centre performance was comparable to previously published Dutch results, which included high volume centres. Applying CuSum methodology to the TO metric allows a continuous measure of performance. This offers the potential to provide feedback for quality improvement strategies.
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Affiliation(s)
- Ella Nicholas
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Stijn van Roessel
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Kirsten de Burlet
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Todd Hore
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Saxon Connor
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
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Liu R, Cai Y, Cai H, Lan Y, Meng L, Li Y, Peng B. Dynamic prediction for clinically relevant pancreatic fistula: a novel prediction model for laparoscopic pancreaticoduodenectomy. BMC Surg 2021; 21:7. [PMID: 33397337 PMCID: PMC7784027 DOI: 10.1186/s12893-020-00968-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 11/17/2020] [Indexed: 02/08/2023] Open
Abstract
Background With the recent emerge of dynamic prediction model on the use of diabetes, cardiovascular diseases and renal failure, and its advantage of providing timely predicted results according to the fluctuation of the condition of the patients, we aim to develop a dynamic prediction model with its corresponding risk assessment chart for clinically relevant postoperative pancreatic fistula after laparoscopic pancreaticoduodenectomy by combining baseline factors and postoperative time-relevant drainage fluid amylase level and C-reactive protein-to-albumin ratio. Methods We collected data of 251 patients undergoing LPD at West China Hospital of Sichuan University from January 2016 to April 2019. We extracted preoperative and intraoperative baseline factors and time-window of postoperative drainage fluid amylase and C-reactive protein-to-albumin ratio relevant to clinically relevant pancreatic fistula by performing univariate and multivariate analyses, developing a time-relevant logistic model with the evaluation of its discrimination ability. We also established a risk assessment chart in each time-point. Results The proportion of the patients who developed clinically relevant postoperative pancreatic fistula after laparoscopic pancreaticoduodenectomy was 7.6% (19/251); preoperative albumin and creatine levels, as well as drainage fluid amylase and C-reactive protein-to-albumin ratio on postoperative days 2, 3, and 5, were the independent risk factors for clinically relevant postoperative pancreatic fistula. The cut-off points of the prediction value of each time-relevant logistic model were 14.0% (sensitivity: 81.9%, specificity: 86.5%), 8.3% (sensitivity: 85.7%, specificity: 79.1%), and 7.4% (sensitivity: 76.9%, specificity: 85.9%) on postoperative days 2, 3, and 5, respectively, the area under the receiver operating characteristic curve was 0.866 (95% CI 0.737–0.996), 0.896 (95% CI 0.814–0.978), and 0.888 (95% CI 0.806–0.971), respectively. Conclusions The dynamic prediction model for clinically relevant postoperative pancreatic fistula has a good to very good discriminative ability and predictive accuracy. Patients whose predictive values were above 14.0%, 8.3%, and 7.5% on postoperative days 2, 3, and 5 would be very likely to develop clinically relevant postoperative pancreatic fistula after laparoscopic pancreaticoduodenectomy.
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Affiliation(s)
- Runwen Liu
- West China Clinical Medicine Academy, Sichuan University, Chengdu, China.,Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Yunqiang Cai
- Department of General Surgery, Chengdu Shangjin Nanfu Hospital, Chengdu, China
| | - He Cai
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China
| | - Yajia Lan
- West China School of Public Health, SCU, Chengdu, China
| | - Lingwei Meng
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China.,Department of General Surgery, Chengdu Shangjin Nanfu Hospital, Chengdu, China
| | - Yongbin Li
- Department of General Surgery, Chengdu Shangjin Nanfu Hospital, Chengdu, China
| | - Bing Peng
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan Province, China. .,Department of General Surgery, Chengdu Shangjin Nanfu Hospital, Chengdu, China.
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Laukkarinen J. Commentary on: Postoperative acute pancreatitis. Surgery 2020; 169:742-743. [PMID: 33293030 DOI: 10.1016/j.surg.2020.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 10/25/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, and Tampere University, Tampere, Finland.
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Kriger AG, Gorin DS, Kaldarov AR, Galkin GV. [Prevention of pancreatic fistula after pancreatoduodenectomy]. Khirurgiia (Mosk) 2020:61-65. [PMID: 33210509 DOI: 10.17116/hirurgia202011161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Prospective randomized investigation of the efficiency of somatostatin analogues and glucocorticoids in pancreatic fistula prevention after pancreatoduodenectomy by using. MATERIAL AND METHODS In period from December 2018 till March 2020 78 patients underwent pancreatoduodenectomy for pancreatobilliary tumors in department of abdominal surgery of National Medical Research Center of Surgery named after A.V. Vishnevsky. Intraoperative frozen section investigation of pancreatic functioning acinar structures (FAS) was held for all patients. 38 patients had more than 40% of FAC and were related with high risk of pancreatic fistula (PF), while 40 patients with less than 40% FAC were included in low risk of PF group. In both groups patients were randomized to main and control subgroups. In main subgroup of high risk group patients combination of somatostatin analogues and glucocorticoids was used, while in control subgroup patients received only somatostatin analogue. In low risk of PF group patients of main subgroup preventively got somatostatin analogue, while control group patients had no specific prophylaxis of PF. To assess the effect of drug prophylaxis on the development of pancreatic fistula we used logistic regression models with the inclusion of the drug use factor as an independent variable. RESULTS 25 patients were included in main subgroup of high risk group. Clinically relevant pancreatic fistula (CRPF) developed in 14 (56%) cases. From 13 patients of control subgroup CRPF developed in 5 (38%) cases. In main subgroup of low risk group 18 patients were included and 3 (16%) of them had CRPF. In control subgroup were 22 patients and there were no cases of CRPF. CONCLUSION In our series combination of somatostatin analogue and glucocorticoid didn't show efficiency in prevention of CRPF in high risk patients, although difference between subgroups wasn't statistically significant (p=0.34). In low risk group patients prophylactic use of somatostatin analogue also didn't show decline of CRPF incidence and the difference between subgroups also wasn't statistically significant (p=0.46).
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Affiliation(s)
- A G Kriger
- National Medical Research Center of Surgery named after A.V. Vishnevsky of Ministry of health of the Russian Federation, Moscow, Russia
| | - D S Gorin
- National Medical Research Center of Surgery named after A.V. Vishnevsky of Ministry of health of the Russian Federation, Moscow, Russia
| | - A R Kaldarov
- National Medical Research Center of Surgery named after A.V. Vishnevsky of Ministry of health of the Russian Federation, Moscow, Russia
| | - G V Galkin
- National Medical Research Center of Surgery named after A.V. Vishnevsky of Ministry of health of the Russian Federation, Moscow, Russia
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Tarvainen T, Sirén J, Kokkola A, Sallinen V. Effect of Hydrocortisone vs Pasireotide on Pancreatic Surgery Complications in Patients With High Risk of Pancreatic Fistula: A Randomized Clinical Trial. JAMA Surg 2020; 155:291-298. [PMID: 32022887 PMCID: PMC7042940 DOI: 10.1001/jamasurg.2019.6019] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Question Is hydrocortisone noninferior compared with pasireotide in reducing pancreatic surgery complications? Findings In this randomized clinical trial that included 126 patients undergoing partial pancreatectomy, the mean Comprehensive Complication Index score (a measurement of overall postoperative morbidity) was –6.16 points lower in patients receiving pasireotide and the lower limit of the 90% CI crossed the prespecified noninferiority margin (–9). In subgroup analyses of patients undergoing distal pancreatectomy, the mean Comprehensive Complication Index score was significantly lower (10.3 points) in the pasireotide vs hydrocortisone group. Meaning In this study, hydrocortisone is not noninferior compared with pasireotide, and pasireotide may be more effective in reducing postoperative complications in patients undergoing distal pancreatectomy. Importance Both hydrocortisone and pasireotide have been shown in randomized clinical trials to be effective in reducing postoperative complications of pancreatic surgery, but to date no randomized clinical trial has evaluated the effectiveness of pasireotide compared with hydrocortisone. Objective To assess the noninferiority of hydrocortisone compared with pasireotide in reducing complications after partial pancreatectomy. Design, Setting, and Participants A noninferiority, parallel-group, individually randomized clinical trial was conducted at a single academic center between May 19, 2016, and December 17, 2018. Outcome collectors and analyzers were blinded. A total of 281 patients undergoing partial pancreatectomy were assessed for inclusion. Patients younger than 18 years, those allergic to hydrocortisone or pasireotide, patients undergoing pancreaticoduodenectomy with hard pancreas or dilated pancreatic duct, and patients not eventually undergoing partial pancreatectomy were excluded. Modified intention-to-treat analysis was used in determination of the results. Interventions Treatment included pasireotide, 900 μg, subcutaneously twice a day for 7 days or hydrocortisone, 100 mg, intravenously 3 times a day for 3 days. Main Outcomes and Measures The primary outcome was the Comprehensive Complication Index (CCI) score within 30 days. The noninferiority limit was set to 9 CCI points. Results Of the 281 patients (mean [SD] age, 63.8 years) assessed for eligibility, 168 patients (mean [SD] age, 63.6 years) were randomized and 126 were included in the modified intention-to-treat analyses. Sixty-three patients received pasireotide (35 men [56%]; median [interquartile range] age, 64 [56-70] years) and 63 patients received hydrocortisone (25 men [40%]; median [interquartile range] age, 67 [56-73] years). The mean (SD) CCI score was 23.94 (17.06) in the pasireotide group and 30.11 (20.47) in the hydrocortisone group (mean difference, –6.16; 2-sided 90% CI, –11.73 to –0.60), indicating that hydrocortisone was not noninferior. Postoperative pancreatic fistula was detected in 34 patients (54%) in the pasireotide group and 39 patients (62%) in the hydrocortisone group (odds ratio, 1.39; 95% CI, 0.68-2.82; P = .37). One patient in the pasireotide group and 2 patients in the hydrocortisone group died within 30 days. In subgroup analyses of patients undergoing distal pancreatectomy, the CCI score was a mean of 10.3 points lower (mean [SD], 16.03 [11.94] vs 26.28 [21.76]; 2-sided 95% CI, −19.34 to −2.12; P = .03) and postoperative pancreatic fistula rate was lower (37% vs 67%; P = .02) in the pasireotide group compared with the hydrocortisone group. Conclusions and Relevance In this study, hydrocortisone was not noninferior compared with pasireotide in patients undergoing partial pancreatectomy. Pasireotide may be more effective than hydrocortisone in patients undergoing distal pancreatectomy. Trial Registration ClinicalTrials.gov identifier: NCT02775227; EudraCT identifier: 2016-000212-16
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Affiliation(s)
- Timo Tarvainen
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jukka Sirén
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Arto Kokkola
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ville Sallinen
- Department of Gastroenterological Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Transplantation and Liver Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Adiamah A, Kushairi A, Gomez D. The Hydrocortisone vs Pasireotide in Reducing Pancreatic Surgery Complications Noninferiority Trial: Comparing Apples and Pears? JAMA Surg 2020; 155:994-995. [PMID: 32667633 DOI: 10.1001/jamasurg.2020.1998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Alfred Adiamah
- Department of Hepatobiliary and Pancreatic Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, England
| | - Anisa Kushairi
- Department of Hepatobiliary and Pancreatic Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, England
| | - Dhanwant Gomez
- Department of Hepatobiliary and Pancreatic Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, England
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Pancreatic Inflammation and Proenzyme Activation Are Associated With Clinically Relevant Postoperative Pancreatic Fistulas After Pancreas Resection. Ann Surg 2020; 272:863-870. [DOI: 10.1097/sla.0000000000004257] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Nakamura K, Sho M, Satoi S, Kosaka H, Akahori T, Nagai M, Nakagawa K, Takagi T, Yamamoto T, Yamaki S. Impact of Antithrombotic Agents on Postpancreatectomy Hemorrhage: Results from a Retrospective Multicenter Study. J Am Coll Surg 2020; 231:460-469.e1. [PMID: 32634474 DOI: 10.1016/j.jamcollsurg.2020.06.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/16/2020] [Accepted: 06/16/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND This retrospective multicenter study aimed to evaluate the risk of postpancreatectomy hemorrhage (PPH) in patients receiving antithrombotic agents (ATAs). PPH is the most severe complication after pancreatectomy. However, there is little known about the strength of the association between ATA use, PPH, and other clinical outcomes. STUDY DESIGN Between 2007 and 2016, 1,297 patients underwent pancreatectomy at 2 surgical centers. ATA use included aspirin, clopidogrel, ticlopidine, warfarin, direct oral anticoagulants, and intravenous unfractionated heparin. The ATA group was composed of 144 patients who were taking ATAs before surgery. RESULTS A total of 35 patients developed PPH. The patients in the ATA group showed higher frequency (8.3% vs 2.0%, p < 0.001) of PPH compared with the control group (n = 1,153). In multivariate analysis, ATA use was an independent adverse risk factor for PPH (odds ratio [OR] 3.58, 95% CI 1.29-9.91, p = 0.014). Stratification by preoperative ATA therapy revealed a significant risk of PPH Grade C in patients receiving combined AT therapy. The median onset of late hemorrhage (>24 hours post-surgery) in the ATA group was later than in the control group (17.5 vs 8.5 days, p = 0.032), and the incidence tended to be higher in patients who restarted ATAs postoperatively. CONCLUSIONS History of ATA use is a significant risk factor for PPH, and postoperative resumption of ATAs appears to be associated with an increased risk of PPH. Patients receiving combined antithrombotic therapy may be at particularly high risk for PPH.
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Affiliation(s)
- Kota Nakamura
- Departments of Surgery, Nara Medical University, Nara, Japan
| | - Masayuki Sho
- Departments of Surgery, Nara Medical University, Nara, Japan.
| | | | | | | | - Minako Nagai
- Departments of Surgery, Nara Medical University, Nara, Japan
| | - Kenji Nakagawa
- Departments of Surgery, Nara Medical University, Nara, Japan
| | - Tadataka Takagi
- Departments of Surgery, Nara Medical University, Nara, Japan
| | | | - So Yamaki
- Kansai Medical University, Osaka, Japan
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Taniguchi K, Matsuyama R, Yabushita Y, Homma Y, Ota Y, Mori R, Morioka D, Endo I. Prophylactic drain management after pancreaticoduodenectomy without focusing on the drain fluid amylase level: A prospective validation study regarding criteria for early drain removal that do not include the drain fluid amylase level. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:950-961. [DOI: 10.1002/jhbp.746] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/26/2020] [Accepted: 04/01/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Koichi Taniguchi
- Department of Gastroenterological Surgery Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Ryusei Matsuyama
- Department of Gastroenterological Surgery Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Yasuhiro Yabushita
- Department of Gastroenterological Surgery Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Yuki Homma
- Department of Gastroenterological Surgery Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Yohei Ota
- Department of Gastroenterological Surgery Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Ryutaro Mori
- Department of Gastroenterological Surgery Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Daisuke Morioka
- Department of Gastroenterological Surgery Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery Yokohama City University Graduate School of Medicine Yokohama Japan
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Comprehensive Analysis of the Effect of Ketorolac Administration after Pancreaticoduodenectomy. J Am Coll Surg 2020; 230:935-942.e2. [DOI: 10.1016/j.jamcollsurg.2020.02.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/22/2020] [Accepted: 02/07/2020] [Indexed: 12/18/2022]
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Vanbrugghe C, Birnbaum DJ, Boucekine M, Ewald J, Marchese U, Guilbaud T, Berdah SV, Moutardier V. Prospective study on predictability of complications by pancreatic surgeons. Langenbecks Arch Surg 2020; 405:155-163. [PMID: 32285190 DOI: 10.1007/s00423-020-01866-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 03/20/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE We evaluated the intuition of expert pancreatic surgeons, in predicting the associated risk of pancreatic resection and compared this "intuition" to actual operative follow-up. The objective was to avoid major complications following pancreatic resection, which remains a challenge. METHODS From January 2015 to February 2018, all patients who were 18 years old or more undergoing a pancreatic resection (pancreaticoduodenectomy [PD], distal pancreatectomy [DP], or central pancreatectomy [CP]) for pancreatic lesions were included. Preoperatively and postoperatively, all surgeons completed a form assessing the expected potential occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF: grade B or C), postoperative hemorrhage, and length of stay. RESULTS Preoperative intuition was assessed for 101 patients for 52 PD, 44 DP, and 5 CP cases. Overall mortality and morbidity rates were 6.9% (n = 7) and 67.3% (n = 68), respectively, and 38 patients (37.6%) developed a POPF, including 27 (26.7%) CR-POPF. Concordance between preoperative intuition of CR-POPF occurrence and reality was minimal, with a Cohen's kappa coefficient (κ) of 0.175 (P value = 0.009), and the same result was obtained between postoperative intuition and reality (κ = 0.351; P < 0.001). When the pancreatic parenchyma was hard, surgeons predicted the absence of CR-POPF with a negative predictive value of 91.3%. However, they were not able to predict the occurrence of CR-POPF when the pancreas was soft (positive predictive value 48%). CONCLUSIONS This study assessed for the first time the surgeon's intuition in pancreatic surgery, and demonstrated that pancreatic surgeons cannot accurately assess outcomes except when the pancreatic parenchyma is hard.
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Affiliation(s)
- Charles Vanbrugghe
- Department of Digestive Surgery, Hospital Nord, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France.
| | - David Jérémie Birnbaum
- Department of Digestive Surgery, Hospital Nord, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France
| | - Mohamed Boucekine
- EA 3279 - Self-perceived Health Assessment Research Unit, Aix-Marseille University, 13005, Marseille, France
| | - Jacques Ewald
- Department of Digestive Surgery and Oncology, Institut Paoli Calmettes, 232 Boulevard Sainte Marguerite, 13009, Marseille, France
| | - Ugo Marchese
- Department of Digestive Surgery and Oncology, Institut Paoli Calmettes, 232 Boulevard Sainte Marguerite, 13009, Marseille, France
| | - Théophile Guilbaud
- Department of Digestive Surgery, Hospital Nord, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France
| | - Stéphane Victor Berdah
- Department of Digestive Surgery, Hospital Nord, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France
| | - Vincent Moutardier
- Department of Digestive Surgery, Hospital Nord, Aix-Marseille University, Chemin des Bourrely, 13015, Marseille, France
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Casciani F, Vollmer CM. Pasireotide and Corticosteroids for Prevention of Pancreatic Fistula-Over-HYPed? JAMA Surg 2020; 155:299. [PMID: 32022829 DOI: 10.1001/jamasurg.2019.6020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Fabio Casciani
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Charles M Vollmer
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Pitter SET, Kehlet H, Hansen CP, Bundgaard‐Nielsen M, Storkholm J, Aasvang EK. Persistent severe post-operative hypotension after pancreaticoduodenectomy is related to increased inflammatory response. Acta Anaesthesiol Scand 2020; 64:455-463. [PMID: 31828772 DOI: 10.1111/aas.13522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/30/2019] [Accepted: 11/24/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hypotension during major surgery is frequent, resulting in increased need for observation in the post-anaesthesia care unit and treatment including vasopressors and fluids. However, although severe hypotension in the immediate post-operative recovery phase after major surgery is suggested to be related to increased morbidity and mortality, the underlying risk factors are not well described, hindering advancements in prevention and treatment. METHODS We performed a retrospective study assessing factors (age, gender, body-mass index, cardiac co-morbidity, haemoglobin, absolute and increase in c-reactive protein on the first post-operative day, bleeding, fluid balance at the end of surgery and the first post-operative day) related to severe persistent hypotension (SPH) (SPH: need for noradrenaline to maintain a mean arterial blood pressure (MAP) >65.0 mm Hg on the morning after surgery) and occurrence of other early (24 hours) complications. One hundred patients undergoing pancreaticoduodenectomy (PD) with pre-operative high-dose glucocorticoid and goal-directed fluid therapy were enrolled and perioperative data collected from anaesthetic and medical records. RESULTS Forty-five patients had SPH, who had a significantly higher increase in CRP levels the morning after surgery (median 50 mg L-1 vs 41 mg L-1 , SPH vs non-SPH, respectively, P = .028), and a significantly more positive fluid balance at discharge (median 1457 ml vs 1031 ml, respectively, P = .027) vs patients without SPH. CONCLUSIONS Severe persistent hypotension after PD was associated with significantly increased inflammatory response and increased need for fluids. Future studies should investigate the effect of further inflammatory control in PD to improve haemodynamics and morbidity.
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Affiliation(s)
- Sandra E. Taylor Pitter
- Department of Anaesthesiology Centre for Cancer and Organ Diseases Rigshospitalet, Copenhagen Denmark
- Section for Surgical Pathophysiology Juliane Marie Centre Rigshospitalet Copenhagen Denmark
| | - Henrik Kehlet
- Section for Surgical Pathophysiology Juliane Marie Centre Rigshospitalet Copenhagen Denmark
| | - Carsten P. Hansen
- Department of Surgery Centre for Cancer and Organ Diseases Rigshospitalet Copenhagen Denmark
| | - Morten Bundgaard‐Nielsen
- Department of Anaesthesiology Centre for Cancer and Organ Diseases Rigshospitalet, Copenhagen Denmark
| | - Jan Storkholm
- Department of Surgery Centre for Cancer and Organ Diseases Rigshospitalet Copenhagen Denmark
| | - Eske K. Aasvang
- Department of Anaesthesiology Centre for Cancer and Organ Diseases Rigshospitalet, Copenhagen Denmark
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Schaefer MS, Raub D, Xu X, Shay D, Teja B, Chhangani K, Grabitz SD, O'Gara B, Kienbaum P, Houle TT, Landoni G, Eikermann M. Association between propofol dose and 1-year mortality in patients with or without a diagnosis of solid cancer. Br J Anaesth 2020; 124:271-280. [PMID: 31902588 DOI: 10.1016/j.bja.2019.11.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/12/2019] [Accepted: 11/29/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Preclinical data suggest suppression of cancer proliferation by propofol, and retrospective studies suggest improved survival after cancer surgery with propofol-based anaesthesia. METHODS To determine whether propofol dose administered for anaesthesia is associated with 1-yr mortality in patients with and without a diagnosis of solid cancer, we analysed adult patients undergoing monitored anaesthesia care or general anaesthesia at two academic medical centres in Boston, MA, USA. Logistic regression with interaction term analysis was applied with propofol dose (mg kg-1) as primary and diagnosis of solid cancer as co-primary exposure, and 1-yr mortality as the primary outcome. RESULTS Of 280 081 patient cases, 10 744 (3.8%) died within 1 yr. Increasing propofol dose was associated with reduced odds of 1-yr mortality (adjusted odds ratio [aOR] 0.93 per 10 mg kg-1; 95% confidence interval [CI]: 0.89-0.98; absolute risk reduction fifth vs first quintile 0.5%; 95% CI: 0.2-0.7). This association was modified by a diagnosis of solid cancer (P<0.001 for interaction). Increasing propofol dose was associated with reduced odds of 1-yr mortality in patients without solid cancer (aOR: 0.78; 95% CI: 0.71-0.85), but not in patients with solid cancer (0.99; 0.94-1.04), a finding that was replicated when examining 5-yr mortality. CONCLUSIONS Increasing propofol dose is associated with lower 1-yr mortality in patients without, but not in patients with, a diagnosis of solid cancer. We found evidence for competing effects, modifying the association between propofol dose and mortality.
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Affiliation(s)
- Maximilian S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA; Department of Anaesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Dana Raub
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA; Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Xinling Xu
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Denys Shay
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA; Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Bijan Teja
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Khushi Chhangani
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA; Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Stephanie D Grabitz
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Brian O'Gara
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Peter Kienbaum
- Department of Anaesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Timothy T Houle
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Matthias Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA; Department of Anaesthesiology and Intensive Care Medicine, University of Duisburg-Essen, Essen, Germany.
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48
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Chen H, Wang W, Ying X, Deng X, Peng C, Cheng D, Shen B. Predictive factors for postoperative pancreatitis after pancreaticoduodenectomy: A single-center retrospective analysis of 1465 patients. Pancreatology 2020; 20:211-216. [PMID: 31831390 DOI: 10.1016/j.pan.2019.11.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 11/10/2019] [Accepted: 11/23/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postoperative acute pancreatitis (POAP) after pancreaticoduodenectomy (PD) has been recently recognized as an independent complication that is associated with undesirable postoperative outcomes and often precedes other complications, yet predictive factors attributable to POAP after PD remain elusive. METHODS The data from 1465 consecutive patients who underwent laparotomy or minimally invasive robotic PD from March 2010 to December 2018 were retrospectively reviewed. POAP was defined as an elevation of the serum amylase levels above the institution's normal upper limit (100 U/L) on postoperative day (POD) 1. Univariate and multivariate analyses were performed to investigate the predictive factors for POAP after PD and the association between POAP and clinically relevant postoperative pancreatic fistulas (CR-POPFs). RESULTS Among the 1465 patients, 411 (28%) underwent minimally invasive robotic surgeries, and the overall POAP and CR-POPFs rates were 770 (53%) and 277 (19%), respectively. The female sex (OR 1.76), a normal bilirubin level (OR 1.55), the robotic surgery (OR 1.36), a main pancreatic duct (MPD) ≤3 mm (OR 5.69) and a high-risk nonadenocarcinoma pathology (cystic disease: OR 4.33; pNETs: OR 4.34; others: OR 2.74) were considered independent risk factors for POAP. A nondilated MPD was a predominant predictor for POAP, with 72.2% sensitivity and 71.8% specificity. POAP was also an independent predictive factor for CR-POPFs (OR 3.48). CONCLUSION A nondilated MPD, a high-risk pathology, the female sex, a normal bilirubin level and the robotic surgery were independent predictive factors for POAP after PD. Prevention and early treatment strategy changes can be made based on these preoperative predictive factors.
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Affiliation(s)
- Haoda Chen
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiaotong University, School of Medicine, China
| | - Weishen Wang
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiaotong University, School of Medicine, China
| | - Xiayang Ying
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiaotong University, School of Medicine, China
| | - Xiaxing Deng
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiaotong University, School of Medicine, China
| | - Chenghong Peng
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiaotong University, School of Medicine, China
| | - Dongfeng Cheng
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiaotong University, School of Medicine, China.
| | - Baiyong Shen
- Department of General Surgery, Ruijin Hospital Affiliated to Shanghai Jiaotong University, School of Medicine, China.
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49
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Kambakamba P, Mannil M, Herrera PE, Müller PC, Kuemmerli C, Linecker M, von Spiczak J, Hüllner MW, Raptis DA, Petrowsky H, Clavien PA, Alkadhi H. The potential of machine learning to predict postoperative pancreatic fistula based on preoperative, non-contrast-enhanced CT: A proof-of-principle study. Surgery 2019; 167:448-454. [PMID: 31727325 DOI: 10.1016/j.surg.2019.09.019] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/12/2019] [Accepted: 09/23/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula remains an unsolved challenge after pancreatoduodenectomy. Important in this regard is the presence of a soft pancreatic texture which is a major risk factor. Advances in machine learning and texture analysis of medical images allow identification of features of parenchyma that are invisible to the human eye. The aim of this study was to investigate the potential of machine learning to predict postoperative pancreatic fistula based on preoperative, non-contrast-enhanced computed tomography. METHODS We screened a prospectively assessed database including all patients undergoing pancreatoduodenectomy at a tertiary center from 2008 until 2018 for patients based on the occurrence of postoperative pancreatic fistula. In total, 110 patients were included, consisting of 55 patients who developed a postoperative pancreatic fistula and 55 without postoperative pancreatic fistula. For machine learning-based texture analysis preoperative, non-contrast-enhanced computed tomography axial images were used. Machine learning results were tested using 10-fold cross validation. Previously validated clinical fistula risk scores (original and alternative fistula risk scores) served as reference tests. RESULTS Both the original and the alternative fistula risk scores showed good discrimination between patients without and with postoperative pancreatic fistula (area under the curve 0.76 and 0.72, respectively). Machine learning-based texture analysis showed potential to detect histologic fibrosis (area under the curve 0.84, sensitivity 75%; specificity 92%), histologic lipomatosis (area under the curve 0.82, sensitivity 78%; specificity 89%), and intraoperative pancreatic hardness (area under the curve 0.70, sensitivity 78%; specificity 74%). The features of the machine learning-based texture analysis were most accurate in predicting the occurrence of postoperative pancreatic fistula (area under the curve 0.95, sensitivity of 96%; specificity 98%) after pancreatoduodenectomy. CONCLUSION This proof-of-principle study suggests the ability of machine learning in recognizing important features of pancreatic texture associated with an increased risk of postoperative pancreatic fistula based on preoperative computed tomography.
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Affiliation(s)
- Patryk Kambakamba
- Swiss HPB Center Department of General and Transplant Surgery, University of Zurich, University Hospital Zurich, Switzerland.
| | - Manoj Mannil
- Institute of Diagnostic and Interventional Radiology, University of Zurich, University Hospital Zurich, Switzerland
| | - Paola E Herrera
- Institute of Diagnostic and Interventional Radiology, University of Zurich, University Hospital Zurich, Switzerland
| | - Philip C Müller
- Swiss HPB Center Department of General and Transplant Surgery, University of Zurich, University Hospital Zurich, Switzerland
| | - Christoph Kuemmerli
- Swiss HPB Center Department of General and Transplant Surgery, University of Zurich, University Hospital Zurich, Switzerland
| | - Michael Linecker
- Swiss HPB Center Department of General and Transplant Surgery, University of Zurich, University Hospital Zurich, Switzerland
| | - Jochen von Spiczak
- Institute of Diagnostic and Interventional Radiology, University of Zurich, University Hospital Zurich, Switzerland
| | - Martin W Hüllner
- Department of Nuclear Medicine, University of Zurich, University Hospital Zurich, Switzerland
| | - Dimitri A Raptis
- Swiss HPB Center Department of General and Transplant Surgery, University of Zurich, University Hospital Zurich, Switzerland
| | - Henrik Petrowsky
- Swiss HPB Center Department of General and Transplant Surgery, University of Zurich, University Hospital Zurich, Switzerland
| | - Pierre-Alain Clavien
- Swiss HPB Center Department of General and Transplant Surgery, University of Zurich, University Hospital Zurich, Switzerland
| | - Hatem Alkadhi
- Institute of Diagnostic and Interventional Radiology, University of Zurich, University Hospital Zurich, Switzerland
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50
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Manou-Stathopoulou V, Korbonits M, Ackland GL. Redefining the perioperative stress response: a narrative review. Br J Anaesth 2019; 123:570-583. [PMID: 31547969 DOI: 10.1016/j.bja.2019.08.011] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 07/21/2019] [Accepted: 08/11/2019] [Indexed: 12/13/2022] Open
Abstract
The systemic stress response triggered by surgical trauma is characterised by sterile inflammation preceding metabolic and neuroendocrine dysregulation. However, the relevance of the classically described 'stress response' is now highly questionable in an era where profound physiological deconditioning is common in older, frail surgical patients. Commonly used assessment techniques do not accurately reflect hypothalamic-pituitary-adrenal axis integrity after major surgery. Clinical interpretation of plasma concentrations of cortisol, the prototypical stress hormone, is rarely accurate, because of study heterogeneity, the inherently dynamic characteristics of cortisol production, and assay variability. Before surgery, chronic psychosocial stress and common cardiorespiratory co-morbidities are clinically relevant modifiers of neuroendocrine activation to acute stress/inflammation. The frequent development of multi-morbidity after major surgery further clouds the compartmentalised, discrete model of neuroendocrine activation after initial tissue injury. Starvation, impaired mobility, and sepsis after surgery generate distinct neuroendocrine profiles that challenge the conventional model of neuroendocrine activation. Basic science studies suggest that high circulating levels of cortisol may directly cause organ injury. Conversely, randomised controlled clinical trials investigating glucocorticoid supplementation have delivered contrasting results, with some suggesting a protective effect in the perioperative period. Here, we consider many of the confounding factors that have emerged to challenge the conventional model of the surgical stress response, and suggest that a more nuanced understanding of changes in hypothalamic-pituitary-adrenal axis physiology is warranted to advance perioperative medicine. Re-examining the perioperative stress response presents opportunities for improving outcomes through enhancing the understanding of the neuroendocrine aspects of preparation for and recovery from surgery.
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Affiliation(s)
- Vasiliki Manou-Stathopoulou
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Márta Korbonits
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
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