1
|
De Pastena M, Bannone E, Fontana M, Paiella S, Esposito A, Casetti L, Landoni L, Tuveri M, Pea A, Casciani F, Zamboni G, Frigerio I, Marchegiani G, Butturini G, Malleo G, Salvia R. Thirty-day prevalence and clinical impact of fluid collections at the resection margin after distal pancreatectomy: Follow-up of a multicentric randomized controlled trial. Surgery 2024; 176:189-195. [PMID: 38729888 DOI: 10.1016/j.surg.2024.03.026] [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: 10/07/2023] [Revised: 01/17/2024] [Accepted: 03/18/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Postoperative fluid collections at the resection margin of the pancreatic stump are frequent after distal pancreatectomy, yet their clinical impact is unclear. The aim of this study was to assess the 30-day prevalence of postoperative fluid collections after distal pancreatectomy and the factors associated with a clinically relevant condition. METHODS Patients enrolled in a randomized controlled trial of parenchymal transection with either reinforced, triple-row staple, or ultrasonic dissector underwent routine magnetic resonance 30 days postoperatively. Postoperative fluid collection was defined as a cyst-like lesion of at least 1 cm at the pancreatic resection margin. Postoperative fluid collections requiring any therapy were defined as clinically relevant. RESULTS A total of 133 patients were analyzed; 69 were in the triple-row staple transection arm, and 64 were in the ultrasonic dissector transection arm. The overall 30-day prevalence of postoperative fluid collections was 68% (n = 90), without any significant difference between the two trial arms. Postoperative serum hyperamylasemia was more frequent in patients with postoperative fluid collections than those without (31% vs 7%, P = .001). Among the postoperative fluid collection population, an early postoperative pancreatic fistula (odds ratio 14.9, P = .002), post pancreatectomy acute pancreatitis (odds ratio 12.7, P = .036), and postoperative fluid collection size larger than 50 mm (odds ratio 6.6, P = .046) were independently associated with a clinically relevant postoperative fluid collection. CONCLUSION Postoperative fluid collections at the resection margin are common after distal pancreatectomy and can be predicted by early assessment of postoperative serum hyperamylasemia. A preceding pancreatectomy acute pancreatitis and/or postoperative pancreatic fistula and large collections (>50 mm) were associated with a clinically relevant postoperative fluid collection, representing targets for closer follow-up or earlier therapeutic interventions.
Collapse
Affiliation(s)
- Matteo De Pastena
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy. https://twitter.com/MatteoDePastena
| | - Elisa Bannone
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy. https://twitter.com/BannoneElisa
| | - Martina Fontana
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Alessandro Esposito
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Luca Casetti
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Luca Landoni
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Massimiliano Tuveri
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Antonio Pea
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy. https://twitter.com/Totuccio1983
| | - Fabio Casciani
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Giulia Zamboni
- Section of Radiology University of Verona Hospital Trust, Verona, Italy
| | | | - Giovanni Marchegiani
- Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padua, Padua, Italy. https://twitter.com/Gio_Marchegiani
| | | | - Giuseppe Malleo
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy. https://twitter.com/gimalleo
| | - Roberto Salvia
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy.
| |
Collapse
|
2
|
Partelli S, Andreasi V, Tomajer V, Tamburrino D, Caldara R, Rigotti P, Catarinella D, Piemonti L, Falconi M. Exploring definitions of graft pancreatitis following pancreas transplantation: A scoping review. Transplant Rev (Orlando) 2024; 38:100861. [PMID: 38870826 DOI: 10.1016/j.trre.2024.100861] [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: 03/05/2024] [Revised: 05/31/2024] [Accepted: 06/03/2024] [Indexed: 06/15/2024]
Abstract
Despite the clinical relevance of graft pancreatitis (GP) after pancreas transplantation (PT), a universally accepted definition is lacking. Aim of this scoping review was to provide a systematic overview of GP definitions reported in the literature. MEDLINE, Web of Science and Embase were searched for relevant articles. Prospective/retrospective studies reporting a GP definition were included. The included series (n = 20) used four main criteria (clinical, biochemical, radiological and pathological) to define GP. Overall, 9 studies defined GP using a single criterion (n = 8 biochemical, n = 1 pathological), 7 series using two criteria (n = 3 clinical + biochemical, n = 3 biochemical + radiological, n = 1 clinical + radiological), 3 series using three criteria (n = 3 clinical + biochemical + radiological), and 1 series using four criteria. Overall, 20 definitions of GP were found. GP rate was reported by 19 series and ranged between 0% and 87%. This scoping review confirms that a universally accepted definition of GP is absent, and there is no consensus on the criteria on which it should be grounded. Future research should focus on developing a validated definition of GP.
Collapse
Affiliation(s)
- Stefano Partelli
- Pancreatic and Transplant Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Valentina Andreasi
- Pancreatic and Transplant Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Valentina Tomajer
- Pancreatic and Transplant Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Domenico Tamburrino
- Pancreatic and Transplant Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Rossana Caldara
- Regenerative and Transplant Medicine Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Rigotti
- Pancreatic and Transplant Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Davide Catarinella
- Regenerative and Transplant Medicine Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Piemonti
- Vita-Salute San Raffaele University, Milan, Italy; Regenerative and Transplant Medicine Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Falconi
- Pancreatic and Transplant Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
| |
Collapse
|
3
|
Xu Y, Jin C, Fu D, Yang F. External validation of fistula risk scores for postoperative pancreatic fistula after distal pancreatectomy. Surgery 2023; 174:1416-1421. [PMID: 37827899 DOI: 10.1016/j.surg.2023.09.007] [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: 05/07/2023] [Revised: 07/25/2023] [Accepted: 09/05/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Fistula risk scores such as distal fistula risk scores and DISPAIR have been recently developed to assess the risk of clinically relevant postoperative pancreatic fistula after distal pancreatectomy. This study aimed to validate these models externally using a large-scale Chinese cohort. METHODS The study enrolled adult patients who underwent distal pancreatectomy at a high-volume single center between January 2011 and December 2021. The clinically relevant postoperative pancreatic fistula was defined as grade B/C, according to the 2016 International Study Group of Pancreatic Surgery. Model performance was evaluated using the area under the curve. RESULTS Among 653 eligible patients, 126 (19.3%) suffered from clinically relevant postoperative pancreatic fistulas. Independent predictors for clinically relevant postoperative pancreatic fistulas included body mass index, diabetes mellitus, pancreatic thickness at both neck and transection sites, main pancreatic duct diameter, and soft pancreas. Clinically relevant postoperative pancreatic fistula risk increased with increasing score severity. All 3 prediction models showed acceptable discrimination, with area under the curve values of preoperative distal fistula risk score at 0.723 (95% confidence interval 0.687-0.757), intraoperative distal fistula risk score at 0.737 (95% confidence interval 0.701-0.770), and DISPAIR at 0.721 (95% confidence interval 0.685-0.755). No significant differences were found among them. CONCLUSION Distal fistula risk scores and DISPAIR are useful tools for predicting clinically relevant postoperative pancreatic fistula after distal pancreatectomy, highlighting their importance in guiding surgical approach decisions and mitigating strategies against this complication in clinical practice.
Collapse
Affiliation(s)
- Yecheng Xu
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, China
| | - Chen Jin
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, China
| | - Deliang Fu
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, China
| | - Feng Yang
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, China.
| |
Collapse
|
4
|
Bannone E, Marchegiani G, Vollmer C, Perri G, Procida G, Corvino G, Peressotti S, Vacca PG, Salvia R, Bassi C. Postoperative Serum Hyperamylasemia Adds Sequential Value to the Fistula Risk Score in Predicting Pancreatic Fistula after Pancreatoduodenectomy. Ann Surg 2023; 278:e293-e301. [PMID: 35876366 DOI: 10.1097/sla.0000000000005629] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate whether postoperative serum hyperamylasemia (POH), with drain fluid amylase (DFA) and C-reactive protein (CRP), improves the Fistula Risk Score (FRS) accuracy in assessing the risk of a postoperative pancreatic fistula (POPF). SUMMARY BACKGROUND DATA The FRS predicts POPF occurrence using intraoperative predictors with good accuracy but intrinsic limits. METHODS Outcomes of patients who underwent pancreaticoduodenectomies between 2016 and 2021 were evaluated across FRS-risk zones and POH occurrence. POH consists of serum amylase activity greater than the upper limit of normal (52 U/l), persisting within the first 48 hours postoperatively (postoperative day -POD- 1 and 2). RESULTS Out of 905 pancreaticoduodenectomies, some FRS elements, namely soft pancreatic texture (odds ratio (OR) 11.6), pancreatic duct diameter (OR 0.80), high-risk pathologic diagnosis (OR 1.54), but not higher blood loss (OR 0.99), were associated with POH. POH was an independent predictor of POPF, which occurred in 46.8% of POH cases ( P <0.001). Once POH occurs, POPF incidence rises from 3.8% to 42.9%, 22.9% to 41.7%, and 48.9% to 59.2% in patients intraoperatively classified at low, moderate and high FRS risk, respectively. The predictive ability of multivariable models adding POD 1 drain fluid amylase, POD 1-2 POH and POD 3 C-reactive protein to the FRS showed progressively and significantly higher accuracy (AUC FRS=0.82, AUC FRS-DFA=0.85, AUC FRS-DFA-POH=0.87, AUC FRS-DFA-POH-CRP=0.90, DeLong always P <0.05). CONCLUSIONS POPF risk assessment should follow a dynamic process. The stepwise retrieval of early, postoperative biological markers improves clinical risk stratification by increasing the granularity of POPF risk estimates and affords a possible therapeutic window before the actual morbidity of POPF occurs.
Collapse
Affiliation(s)
- Elisa Bannone
- 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
| | - Charles Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Giampaolo Perri
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppa Procida
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Gaetano Corvino
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Sara Peressotti
- 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
| | - 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
| |
Collapse
|
5
|
Post-Pancreatectomy Acute Pancreatitis-The New Criteria Fail to Recognize Significant Presentations. J Gastrointest Surg 2023; 27:363-372. [PMID: 36449249 PMCID: PMC9974691 DOI: 10.1007/s11605-022-05533-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 11/13/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Post-pancreatectomy acute pancreatitis (PPAP) is a newly described clinical entity defined as elevated serum amylase sustained ≥ 48 h postoperatively, radiological findings consistent with acute pancreatitis, and associated clinically relevant features. This study aimed to investigate the incidence of PPAP and the rate of major complications after pancreatoduodenectomy (PD) in patients with only transiently elevated serum amylase. METHODS A retrospective single-center observational study was conducted including consecutive patients ≥ 18 years of age undergoing PD at Karolinska University Hospital, between 2008 and 2020. Serum amylase on postoperative day (POD) 1 and 2 and records from computer tomography were analyzed and correlated with postoperative major complications by logistic regressions. RESULTS Of some 1078 patients that underwent PD, 284 exhibited sustained elevated serum amylase (according to PPAP criteria) and 183 transiently elevated serum amylase on either POD1 or POD2. Of the patients with sustained elevated levels, 43% (n = 123) developed major complications, but only 6.3% (n = 18) showed findings consistent with acute pancreatitis on imaging. Of the 183 cases that exhibited only transiently elevated serum amylase on either POD1 or POD2, 32% (n = 58) developed major complications. CONCLUSION Sustained hyperamylasemia was observed in 26% of patients after PD, and an additional 17% of patients had a transient elevation of serum amylase postoperatively. Acute pancreatitis after PD may be underdiagnosed, partly by overlooking transiently elevated serum amylase and partly by requiring imaging that potentially fails to recognize mild but complication-prone acute pancreatitis.
Collapse
|
6
|
Brajcich BC, Platoff RM, Thompson VM, Hall B, Ko CY, Pitt HA. Hyperamylasemia grade versus drain fluid amylase: which better predicts pancreatectomy outcomes? HPB (Oxford) 2022; 24:1252-1260. [PMID: 35034836 DOI: 10.1016/j.hpb.2021.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 11/30/2021] [Accepted: 12/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The clinical importance of postoperative hyperamylasemia (POHA) grade is unknown. Our objectives were to evaluate the association of POHA grade with clinically relevant postoperative pancreatic fistula (CR-POPF) and compare its prognostic utility against postoperative day 1 drain fluid amylase (DFA-1). METHODS Patients who underwent pancreatectomy from January 2019 through March 2020 were identified in the ACS NSQIP pancreatectomy-targeted dataset. POHA grade was assigned using post-operative serum amylase and clinical sequelae. The primary outcome was CR-POPF within 30 days. The association of POHA grade with CR-POPF was assessed using multivariable logistic regression, and c-statistics were used to compare POHA grade versus DFA-1. RESULTS POHA occurred in 520 patients at 98 hospitals, including 261 (50.2%) with grade A, 234 (45.0%) with grade B, and 25 (4.8%) with grade C POHA. CR-POPFs were increased among patients with grade B (66.2%, OR 9.28 [5.84-14.73]) and C (68.0%, OR 10.50 [3.77-29.26]) versus grade A POHA (19.2%). POHA-inclusive models better predicted CR-POPF than those with DFA-1 alone (p < 0.002) and models with both predictors outperformed POHA alone (p = 0.039). CONCLUSION POHA grade represents a measure of post-pancreatectomy outcomes that predicts CR-POPF and outperforms DFA-1 but must be aligned with new international definitions.
Collapse
Affiliation(s)
- Brian C Brajcich
- American College of Surgeons, Chicago, IL, USA; Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, IL, USA
| | | | | | - Bruce Hall
- American College of Surgeons, Chicago, IL, USA; Department of Surgery, Washington University in Saint Louis School of Medicine, and BJC Healthcare, St Louis, MO USA
| | - Clifford Y Ko
- American College of Surgeons, Chicago, IL, USA; Department of Surgery, University of California Los Angeles School of Medicine, Los Angeles, CA, USA; The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, United Kingdom
| | - Henry A Pitt
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Ikenaga N, Nakata K, Fujita N, Abe T, Ideno N, Ishigami K, Nakamura M. Clinical significance of postpancreatectomy acute pancreatitis defined by the International Study Group for Pancreatic Surgery. Ann Gastroenterol Surg 2022; 6:842-850. [PMID: 36338587 PMCID: PMC9628230 DOI: 10.1002/ags3.12587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/21/2022] [Indexed: 11/10/2022] Open
Abstract
Aim The International Study Group for Pancreatic Surgery (ISGPS) developed a structured definition of postpancreatectomy acute pancreatitis (PPAP) in 2021. This study aimed to evaluate the clinical significance of PPAP as defined by the ISGPS criteria. Methods We evaluated the medical records and postoperative computed tomography (CT) findings of 247 patients who underwent pancreaticoduodenectomy. Postoperative hyperamylasemia (POH) was defined as an elevation in serum amylase levels over the upper baseline limit (≥133 U/L) on postoperative days 1 and 3. PPAP was defined as acute pancreatitis satisfying the following three requirements: POH, clinically relevant deterioration, and radiologic features consistent with acute pancreatitis. Results Postoperative hyperamylasemia and PPAP were prevalent in 9.7% (24/247) and 3.6% (9/247) of the patients, respectively. PPAP grade B occurred in eight patients, seven of whom experienced Clavien–Dindo grade IIIA complications, including postoperative pancreatic fistula (POPF) and extended periods of postoperative hospitalization. PPAP grade C occurred in one patient, who died from the exacerbation of underlying interstitial pneumonia following the POPF occurrence. Acute pancreatitis determined by CT was observed in 15.3% (38/247) of the patients who underwent pancreaticoduodenectomy and was strongly associated with severe morbidity (P < .0001) and longer postoperative hospitalization (P < .0001). POH preceded acute pancreatitis on CT in only 23.7% (9/38) of those cases, resulting in a low incidence rate of PPAP. Conclusion Post‐pancreatectomy acute pancreatitis is a major postoperative complication of pancreatic resection; however, based on the current ISGPS criteria, its prevalence is low. Defining PPAP promotes universal evaluation and understanding of this new concept.
Collapse
Affiliation(s)
- Naoki Ikenaga
- Departments of Surgery and Oncology, Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Kohei Nakata
- Departments of Surgery and Oncology, Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Nobuhiro Fujita
- Department of Clinical Radiology, Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Toshiya Abe
- Departments of Surgery and Oncology, Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Noboru Ideno
- Departments of Surgery and Oncology, Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Kousei Ishigami
- Department of Clinical Radiology, Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Masafumi Nakamura
- Departments of Surgery and Oncology, Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| |
Collapse
|
9
|
Bannone E, Marchegiani G, Perri G, Procida G, Vacca PG, Cattelani A, Salvia R, Bassi C. Postoperative serum hyperamylasemia (POH) predicts additional morbidity after pancreatoduodenectomy: It is not all about pancreatic fistula. Surgery 2022; 172:715-722. [PMID: 35636983 DOI: 10.1016/j.surg.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/16/2022] [Accepted: 04/07/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The association between postoperative serum hyperamylasaemia (POH) and morbidity has been hypothesized but rarely explored once occurring with or without (POH-exclusive) a combined postoperative pancreatic fistula (POPF). METHODS Analysis of patients who consecutively underwent pancreaticoduodenectomy from 2016 to 2020. POH was defined as serum amylase activity greater than the institutional upper limit of normal (52 U/L), persisting within the first 48 hours postoperatively (postoperative day [POD] 1 and 2). RESULTS Among 852 patients, 15.8% developed POH-exclusive. Compared with patients without POH or POPF (64.3%), they showed a significantly higher postoperative burden (Clavien-Dindo ≥II: 52.6% vs 30.8%) with increased rates of bacteraemia (12.6% vs 6%), pleural effusion (13.3% vs 5.3%), postpancreatectomy haemorrhage (13.3% vs 7.5%), postpancreatectomy acute pancreatitis (PPAP) (10.3% vs 0%), and organ site infections (18.5% vs 10.9%; all P < .05). A total of 13.8% experienced POH with POPF leading to the worse outcome. The combined occurrence of POH with POPF led to a shorter median time to morbidity (3 PODs, 95% confidence interval [CI] 2.2-3.7 vs 6 PODs, 95% CI 4.2-8; P < .001) than patients experiencing POPF-exclusive (5.9%). In all, 46.6% of POH patients developed POPF. Body mass index (BMI) (odds ratio [OR] 1.1), male sex (OR 2.1), increased drain fluid amylase on POD 1 (OR 1.001), and increased C-reactive protein (OR 1.01) were independent risk factors for POPF once POH has occurred. CONCLUSION POH has relevant postoperative clinical implications, independently from POPF occurrence. Developing POH with POPF leads to an earlier onset of higher postoperative burdens. Once POH is diagnosed, risk factors for additional POPF could identify patients who may benefit from additional surveillance, specific drains protocols, and preventive strategies.
Collapse
Affiliation(s)
- Elisa Bannone
- 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
| | - Giampaolo Perri
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppa Procida
- 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
| | - 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.
| |
Collapse
|
10
|
Marchegiani G, Barreto SG, Bannone E, Sarr M, Vollmer CM, Connor S, Falconi M, Besselink MG, Salvia R, Wolfgang CL, Zyromski NJ, Yeo CJ, Adham M, Siriwardena AK, Takaori K, Hilal MA, Loos M, Probst P, Hackert T, Strobel O, Busch ORC, Lillemoe KD, Miao Y, Halloran CM, Werner J, Friess H, Izbicki JR, Bockhorn M, Vashist YK, Conlon K, Passas I, Gianotti L, Del Chiaro M, Schulick RD, Montorsi M, Oláh A, Fusai GK, Serrablo A, Zerbi A, Fingerhut A, Andersson R, Padbury R, Dervenis C, Neoptolemos JP, Bassi C, Büchler MW, Shrikhande SV. Postpancreatectomy Acute Pancreatitis (PPAP): Definition and Grading From the International Study Group for Pancreatic Surgery (ISGPS). Ann Surg 2022; 275:663-672. [PMID: 34596077 DOI: 10.1097/sla.0000000000005226] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The ISGPS aimed to develop a universally accepted definition for PPAP for standardized reporting and outcome comparison. BACKGROUND PPAP is an increasingly recognized complication after partial pancreatic resections, but its incidence and clinical impact, and even its existence are variable because an internationally accepted consensus definition and grading system are lacking. METHODS The ISGPS developed a consensus definition and grading of PPAP with its members after an evidence review and after a series of discussions and multiple revisions from April 2020 to May 2021. RESULTS We defined PPAP as an acute inflammatory condition of the pancreatic remnant beginning within the first 3 postoperative days after a partial pancreatic resection. The diagnosis requires (1) a sustained postoperative serum hyperamylasemia (POH) greater than the institutional upper limit of normal for at least the first 48 hours postoperatively, (2) associated with clinically relevant features, and (3) radiologic alterations consistent with PPAP. Three different PPAP grades were defined based on the clinical impact: (1) grade postoperative hyperamylasemia, biochemical changes only; (2) grade B, mild or moderate complications; and (3) grade C, severe life-threatening complications. DISCUSSIONS The present definition and grading scale of PPAP, based on biochemical, radiologic, and clinical criteria, are instrumental for a better understanding of PPAP and the spectrum of postoperative complications related to this emerging entity. The current terminology will serve as a reference point for standard assessment and lend itself to developing specific treatments and prevention strategies.
Collapse
Affiliation(s)
- Giovanni Marchegiani
- Department of Surgery, The Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Savio George Barreto
- Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Bedford Park, Adelaide, South Australia, Australia
| | - Elisa Bannone
- Department of Surgery, The Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Michael Sarr
- Mayo Clinic Department of General Surgery, Rochester, NY
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Saxon Connor
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, "Vita-Salute" University, Milan, Italy
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Roberto Salvia
- Department of Surgery, The Pancreas Institute, Verona University Hospital, Verona, Italy
| | | | - Nicholas J Zyromski
- Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
| | - Charles J Yeo
- Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - Mustapha Adham
- Digestive Surgery Department, Lyon Civil Hospital, Lyon, France
| | | | - Kyoichi Takaori
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Martin Loos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Olivier R C Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Yi Miao
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, PR China
| | - Christopher M Halloran
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Jens Werner
- Department of General, Visceral, and Transplantation Surgery, Ludwig Maximilians-University, Munich, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Yogesh K Vashist
- Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland
| | - Kevin Conlon
- Department of Surgery, AGIA OLGA Hospital, Athens, Greece
| | - Ioannis Passas
- School of Medicine and Surgery, Milano - Bicocca University, and Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Luca Gianotti
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Marco Del Chiaro
- Department of Surgery, Humanitas University and Research Hospital IRCCS, Milan, Italy
| | | | - Marco Montorsi
- Department of HPB Surgery and Liver Transplant, Royal Free Hospital NHS Foundation Trust, London, UK
| | - Attila Oláh
- Department of Surgery, Miguel Servet University Hospital, Paseo Isabel la Catolica, Zaragoza, Spain
| | | | - Alejandro Serrablo
- Department of Surgery, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Alessandro Zerbi
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Abe Fingerhut
- Department of Gastrointestinal and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | | | - Robert Padbury
- Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Bedford Park, Adelaide, South Australia, Australia
| | | | - John P Neoptolemos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Claudio Bassi
- Department of Surgery, The Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Shailesh V Shrikhande
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| |
Collapse
|
11
|
SSAT GI Surgery Debate: Hepatobiliary and Pancreas: Is Post-Pancreatectomy Acute Pancreatitis a Relevant Clinical Entity? J Gastrointest Surg 2022; 26:60-63. [PMID: 34741252 DOI: 10.1007/s11605-021-05194-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/23/2021] [Indexed: 01/31/2023]
|
12
|
Abstract
Current evidence shows that robotic pancreatoduodenectomy (RPD) is feasible with a safety profile equivalent to either open pancreatoduodenectomy (OPD) or laparoscopic pancreatoduodenectomy (LPD). However, major intraoperative bleeding can occur and emergency conversion to OPD may be required. RPD reduces the risk of emergency conversion when compared to LPD. The learning curve of RPD ranges from 20 to 40 procedures, but proficiency is reached only after 250 operations. Once proficiency is achieved, the results of RPD may be superior to those of OPD. As for now, RPD is at least equivalent to OPD and LPD with respect to incidence and severity of POPF, incidence and severity of post-operative complications, and post-operative mortality. A minimal annual number of 20 procedures per center is recommended. In pancreatic cancer (versus OPD), RPD is associated with similar rates of R0 resections, but higher number of examined lymph nodes, lower blood loss, and lower need of blood transfusions. Multivariable analysis shows that RPD could improve patient survival. Data from selected centers show that vein resection and reconstruction is feasible during RPD, but at the price of high conversion rates and frequent use of small tangential resections. The true Achilles heel of RPD is higher operative costs that limit wider implementation of the procedure and accumulation of a large experience at most single centers. In conclusion, when proficiency is achieved, RPD may be superior to OPD with respect to CR-POPF and oncologic outcomes. Achievement of proficiency requires commitment, dedication, and truly high volumes.
Collapse
|