Amylase value in drains after pancreatic resection as predictive factor of postoperative pancreatic fistula: results of a prospective study in 137 patients

Early Detection and Monitoring of Anastomotic Leaks via Naked Eye-Readable, Non-Electronic Macromolecular Network Sensors

Anastomotic leakage (AL) is the leaking of non-sterile gastrointestinal contents into a patient's abdominal cavity. AL is one of the most dreaded complications following gastrointestinal surgery, with mortality rates reaching up to 27%. The current diagnostic methods for anastomotic leaks are limited in sensitivity and specificity. Since the timing of detection directly impacts patient outcomes, developing new, fast, and simple methods for early leak detection is crucial. Here, a naked eye-readable, electronic-free macromolecular network drain fluid sensor is introduced for continuous monitoring and early detection of AL at the patient's bedside. The sensor array comprises three different macromolecular network sensing elements, each tailored for selectivity toward the three major digestive enzymes found in the drainage fluid during a developing AL. Upon digestion of the macromolecular network structure by the respective digestive enzymes, the sensor produces an optical shift discernible to the naked eye. The diagnostic efficacy and clinical applicability of these sensors are demonstrated using clinical samples from 32 patients, yielding a Receiver Operating Characteristic Area Under the Curve (ROC AUC) of 1.0. This work has the potential to significantly contribute to improved patient outcomes through continuous monitoring and early, low-cost, and reliable AL detection.

Early Drain Removal Versus Routine Drain Removal After Pancreaticoduodenectomy and/or Distal Pancreatectomy: A Meta-Analysis and Systematic Review

BACKGROUND

Early drain removal (EDR) has been widely accepted, but not been routinely used in patients after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP). This study aimed to evaluate the safety and benefits of EDR versus routine drain removal (RDR) after PD or DP.

METHODS

A systematic search was conducted on medical search engines from January 1, 2008 to November 1, 2023, for articles that compared EDR versus RDR after PD or DP. The primary outcome was clinically relevant postoperative pancreatic fistula (CR-POPF). Further analysis of studies including patients with low-drain fluid amylase (low-DFA) on postoperative day 1 and defining EDR timing as within 3 days was also performed.

RESULTS

Four randomized controlled trials (RCTs) and eleven non-RCTs with a total of 9465 patients were included in this analysis. For the primary outcome, the EDR group had a significantly lower rate of CR-POPF (OR 0.23; p < 0.001). For the secondary outcomes, a lower incidence was observed in delayed gastric emptying (OR 0.63, p = 0.02), Clavien-Dindo III-V complications (OR 0.48, p < 0.001), postoperative hemorrhage (OR 0.55, p = 0.02), reoperation (OR 0.57, p < 0.001), readmission (OR 0.70, p = 0.003) and length of stay (MD -2.04, p < 0.001) in EDR. Consistent outcomes were observed in the subgroup analysis of low-DFA patients and definite EDR timing, except for postoperative hemorrhage in EDR.

CONCLUSION

EDR after PD or DP is beneficial and safe, reducing the incidence of CR-POPF and other postoperative complications. Further prospective studies and RCTs are required to validate this finding.

No Drain, No Problem: Serum-Based Marker Prediction of Clinically Relevant Postoperative Pancreatic Fistula

BACKGROUND

Postoperative day (POD) 1 drain amylase concentration (DAC) is considered the most accurate predictor for the development of a clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD). Recent studies have associated drain placement with negative postoperative outcomes. This study aims to evaluate multiple biochemical markers and their associations with CR-POPF development in order to identify a reliable, non-drain dependent alternative to DAC.

METHODS

This is a review of 53 consecutive PD patients between 2021 and 2022. Albumin, C-reactive protein (CRP), C-reactive protein-to-albumin ratio (CAR), DAC, white blood cell count, and procalcitonin values were compared by CR-POPF status. The discriminatory abilities of CAR, CRP, and DAC for CR-POPF were compared using receiver operating characteristic (ROC) curves.

RESULTS

Six of 51 included patients developed a CR-POPF. Receiver operating characteristic curve analysis produced an area under the curve of .977 for POD 1 DAC (cut-off 5131.0 IU/L, sensitivity 100%, specificity 95.5%), .858 for POD 1 CRP (cut-off 52.5 mg/L, sensitivity 100%, specificity 72.7%), and 1.000 for POD 3 CAR (cut-off 99.2, sensitivity and specificity 100%). POD 3 CAR produced a positive and negative predictive value of 100%.

CONCLUSION

The CAR and CRP provide early and accurate identification of patients with post-PD CR-POPFs. These markers offer a method of safe CR-POPF detection, when the gold standard DAC is unavailable, ultimately allowing for early intervention and patient rescue.

Predictive value of drain fluid amylase level on postoperative day one after pancreatic resection for predicting postoperative pancreatic fistula

Objectives

The aim of this study was to evaluate the predictive value of the first postoperative day (POD1) drain fluid amylase in predicting pancreatic fistula formation following pancreaticoduodenectomy (PD).

Material and Methods

One-hundred and eighty-five prospective patients undergoing PD between April 2014 and April 2018 were studied retrospectively. Cut-off point to predict the development of POPF was determined by median values for drain fluid amylase of 1883 U/L. Patients were classified into two groups according to POD1 drain fluid amylase values: <1883 U/L (Group 1) and ≥1883 U/L (Group 2). Differences between the groups with clinically relevant POPF and without POPF were evaluated.

Results

The incidence of POPF was 17.2%. POD1 amylase level was the strongest predictor of POPF, with levels of higher than 1883 U/L demonstrating the best accuracy (87.5%), sensitivity (78.1%), specificity (89.5%), positive predictive value (60.9%), and negative predictive value (95.1%). One-hundred and forty-four patients (77.8%) had a POD1 drain amylase level of less than 1883 U/L, and POPF developed in only seven (3.7%) cases, whereas in patients with POD1 drain amylase level of 1883 U/L or higher (n= 41), the POPF rate was 31.4% [OR: 22.24, 95% CI (7.930-62.396), p<0.001].

Conclusion

The cut-off point of POD1 drain fluid amylase level (1883 U/L) might predict the clinically relevant POPF with adequate sensitivity and specificity rates in patients undergoing pancreatic resection.

Effect of passive versus active abdominal drainage on wound infection after pancreatectomy: A meta-analysis

Following pancreatic resection, there may be a variety of complications, including wound infection, haemorrhage, and abdominal infection. The placement of drainage channels during operation may decrease the chances of postoperative complications. However, what kind of drainage can decrease the rate of postoperative complications is still a matter of debate. The purpose of this research is to evaluate the efficacy of both active and passive drainage for post-operation wound complications. From the beginning of the database until November 2023, EMBASE, the Cochrane Library and the Pubmed database have been searched. The two authors collected 2524 related studies from 3 data bases for importation into Endnote software, and 8 finished trials were screened against the exclusion criteria. Passive drainage can decrease the incidence of superficial wound infection in postoperative patients with pancreas operation (Odds Ratio [OR], 1.30; 95% CI, 1.06-1.60 p = 0.01); No statistically significant difference was found in the incidence of deep infections among the two groups (OR, 1.51; 95% CI, 0.68-3.36 p = 0.31); No statistical significance was found for the rate of haemorrhage after active drainage on the pancreas compared with that of passive drainage (OR, 0.72; 95% CI, 0.29-1.77 p = 0.47); No statistically significant difference was found in the rate of death after operation for patients who had received a pancreas operation in active or passive drainage (OR, 0.90; 95% CI, 0.57-1.42 p = 0.65); On the basis of existing evidence, the use of passive abdominal drainage reduces postoperative surface wound infections in patients. But there were no statistically significant differences in the risk of severe complications, haemorrhage after surgery, or mortality. However, because of the limited sample size of this meta-analysis, it is necessary to have more high-quality research with a large sample size to confirm the findings.

Cattel and Blumgart Anastomosis: Comparison of Pancreatojejunostomy Techniques in Patients with Pancreatic Cancer

BACKROUND

Pancreaticojejunal anastomosis has a high risk of pancreatic leakage, which several surgical techniques have been described. Our main objective is to determine what is the association of postoperative pancreatic leakage in patients undergoing pancreaticoduodenectomy according to the pancreaticojejunal anastomosis technique used (Cattel vs Blumgart)?

MATERIAL AND METHODS

Historical cohort, all cancer patients undergoing pancreaticoduodenectomy were included. From April 2020 to May 2021, Cattel technique was used; from June 2021 to June 2022, Blumgart technique was used. All procedures were performed by a single board-certified surgical oncologist at Oncology Hospital.

RESULTS

24 patients (11 men and 13 women). The first 9 procedures were performed with the Cattel technique, starting from procedure 10, the Blumgart technique was used. No differences were observed regarding the consistency of the pancreas (p=0.28) or the size of the duct (p=0.51) between the two groups. Pancreatic leakage was observed in 100% with the Cattel technique and in 6.7% with the Blumgart technique (p= 0.0001). An amylase value was observed in the left drainage at 6 days > 200 U/L with the Cattel technique and < 200 U/L with Blumgart (p=0.0001). Intraoperative bleeding (Cattel 1200 ml vs. Blumgart 400 ml, p= 0.03) and 90-day mortality (Cattel 33.3% vs. Blumgart 0%, Log-Rank: 0.022) also showed a difference in favor of Blumgart technique. Blumgart technique is a protective factor for the presence of pancreatic leakage (RR 0.06, 95% CI 0.01-0.44, p=0.0001).

DISCUSSION

A lower risk of pancreatic leakage was found using the Blumgart technique, compared to the Cattel technique.

Evaluation and Recalibration of Risk-Stratified Pancreatoduodenectomy Drain Fluid Amylase Removal Criteria

BACKGROUND

Risk-stratified drain fluid amylase cutoff values for postoperative day 1 (POD1) (DFA1) and POD3 (DFA3) can guide early drain removal after pancreatoduodenectomy (PD). The aim of this study was to evaluate and recalibrate cutoff values instituted in Feb 2019 using a prospective sequential cohort.

METHODS

We performed a single-institution prospective cohort study of consecutive patients who underwent pancreatoduodenectomy following implementation of institution-specific DFA cutoffs in February 2019 through April 2022. DFA values, drain removal, and clinically relevant postoperative pancreatic fistulas (CR-POPF) were analyzed. Receiver operating characteristic (ROC) curve analysis determined optimal cutoff values.

RESULTS

In total, 267 patients, 173 (65%) low-risk and 94 (35%) high-risk, underwent 228 (85%) open and 39 (15%) robotic pancreatoduodenectomies. Seven (4%) low-risk patients and 21 (22%) high-risk patients developed CR-POPF. Drains were removed in 147 (55%) patients before/on POD3, with 1 (0.7%) CR-POPF. In low-risk patients, CR-POPF was excluded with 100% sensitivity if DFA1 < 286 (area under curve, AUC = 0.893, p = 0.001) or DFA3 < 97 (AUC = 0.856, p = 0.002). DFA1 < 137 (AUC = 0.786, p < 0.001) or DFA3 < 56 (AUC = 0.819, p < 0.001) were 100% sensitive in high-risk patients. Previously established DFA1 cutoffs of 100 (low-risk) and < 26 (high-risk) were 100% sensitive, while DFA3 cutoffs of 300 (low-risk) and 200 (high-risk) had 57% and 91% sensitivity.

CONCLUSIONS

Within a learning health system, we recalibrated post-PD drain removal thresholds to DFA1 ≤ 300 and DFA3 ≤ 100 for low-risk and DFA1 ≤ 100 and DFA3 ≤ 50 for high-risk patients. This methodology is generalizable to other centers for developing institution-specific criteria to optimize safe early drain removal.

No role for protease inhibitors as a mitigation strategy for postpancreatectomy acute pancreatitis (PPAP): Propensity score matching analysis

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.

Postoperative Day 1 Drain Amylase After Pancreatoduodenectomy: Optimal Level to Predict Pancreatic Fistula

INTRODUCTION

Drain amylase on day 1 (DA-D1) after pancreaticoduodendectomy (PD) to predict occurrence of postoperative pancreatic fistula (POPF) is controversial. In this study, we evaluate the optimal DA-D1 level to predict clinically relevant POPF (CR-POPF).

METHODS

The 2014-2020 NSQIP pancreatectomy-targeted database was queried for patients who underwent elective PD. Perioperative data was extracted to determine development of POPF and CR-POPF per International Study Group of Pancreatic Fistula guidelines. Receiver operative curve (ROC) and Youden's index were used to assess the performance and optimal cutoff for DA-D1 to predict CR-POPF. The DA-D1 value was confirmed with a multivariable logistic regression to determine hazard ratios (HR) for CR-POPF and conditional logistic regression by modified fistula risk score (mFRS) subgroups.

RESULTS

A total of 6,087 patients with complete perioperative data were included. Mean DA-D1 was 2,897 ± 8,636 U/L; median drain duration was 5 days. CR-POPF was documented in 544 (8.9%) patients. DA-D1 ROC for CR-POPF had area under the curve of 0.779 (95%CI 0.759-0.798). Youden's index for the CR-POPF ROC coordinates had 77.6% sensitivity and 66.3% specificity, corresponding to DA-D1 values ≥ 720U/L as an optimal cutoff. CR-POPF was higher for patients with DA-D1 ≥ 720U/L (HR 4.6; p = 0.001). Patients DA-D1 < 720U/L with a negligible, low, intermediate, and high mFRS had respectively 1%, 3%, 4%, and 7% rate of CR-POPF.

CONCLUSION

DA-D1 < 720U/L after elective PD is a clinically useful predictor of CR-POPF. For patients with negligible to intermediate FRS, surgeons should consider utilizing DA-D1 < 720 U/L for removal of a drain on the first postoperative day.

Serum Creatinine and Amylase in Drain to Predict Pancreatic Fistula Risk after Pancreatoduodenectomy

INTRODUCTION

The identification of patients with low risk of clinically relevant postoperative pancreatic fistula (CR-POPF) and postoperative hemorrhage (PPH) can guide drain removal after pancreatoduodenectomy (PD). However, drain fluid amylase (DFA) ≤5,000 U/L on postoperative day (POD) 1 does not robustly predict the absence of CR-POPF.

METHODS

Consecutive patients undergoing PD at Sun Yat-sen University Cancer Center between July 2018 and October 2021 were analyzed. Recursive partitioning analysis was used to classify patients into groups with different risks of CR-POPF and PPH.

RESULTS

Among 288 consecutive patients included, 99 patients (34.38%) developed CR-POPF (86 grade B and 13 grade C). Patients with CR-POPF had increased levels of preoperative creatinine (CRE) and POD1 CRE. The combination of POD1 CRE (>104 μmol/L or not) and POD1 DFA (>5,000 U/L or not) stratified patients into subgroups with the maximum difference in CR-POPF risk. The CR-POPF rates were 17.82% (36/202) in group A (POD1 CRE ≤104 μmol/L and POD1 DFA ≤5,000 U/L), 53.33% (8/15) in group B (POD1 CRE >104 μmol/L and POD1 DFA ≤5,000 U/L), and 77.46% (55/71) in group C (POD1 DFA >5,000 U/L). The PPH rates were 1.98% (4/202), 20.00% (3/15), and 19.72% (14/71) in groups A, B, and C, respectively.

CONCLUSION

Patients with POD1 DFA ≤5,000 U/L and POD1 CRE >104 μmol/L have a high risk of CR-POPF and may not benefit from early drain removal. Patients with POD1 DFA ≤5,000 U/L and POD1 CRE ≤104 μmol/L have low risk of CR-POPF and PPH.

The risk of clinically-relevant pancreatic fistula after pancreaticoduodenectomy is better predicted by a postoperative trend in drain fluid amylase compared to day 1 values in isolation

BACKGROUND

Recent studies support early drain removal after pancreaticoduodenectomy in patients with a drain fluid amylase on postoperative day 1 (DFA1) level of ≤5,000. The use of DFA1 to guide drain management is increasingly common among pancreatic surgeons; however, the benefit of checking additional drain fluid amylases beyond DFA1 is less known. We sought to determine whether a change in drain fluid amylase (ΔDFA) is a more reliable predictor of clinically relevant postoperative fistula than DFA1 alone.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Plan, pancreaticoduodenectomy patients with intraoperative drain placement, known DFA1, highest recorded drain fluid amylase value on postoperative day 2 to 5 (DFA2nd), day of drain removal, and clinically relevant postoperative fistula status were reviewed. Logistic models compared the predictive performance of DFA1 alone versus DFA1 + ΔDFA.

RESULTS

A total of 2,417 patients with an overall clinically relevant postoperative fistula rate of 12.6% were analyzed. On multivariable regression, clinical predictors for clinically relevant postoperative fistula included body mass index, steroid use, operative time, and gland texture. These variables were used to develop model 1 (DFA1 alone) and model 2 (DFA1 + ΔDFA). Model 2 outperformed model 1 in predicting the risk of clinically relevant postoperative fistula. According to model 2 predictions, the risk of clinically relevant postoperative fistula increased with any rise in drain fluid amylase, regardless of whether the DFA1 was above or below 5,000 U/L. The risk of clinically relevant postoperative fistula significantly decreased with any drop in drain fluid amylase, with an odds reduction of approximately 50% corresponding with a 70% decrease in drain fluid amylase (P < .001). A risk calculator was developed using DFA1 and a secondary DFA value in conjunction with other clinical predictors for clinically relevant postoperative fistula.

CONCLUSION

Clinically relevant postoperative fistula after pancreaticoduodenectomy is more accurately predicted by DFA1 and ΔDFA versus DFA1 in isolation. We developed a novel risk calculator to provide an individualized approach to drain management after pancreaticoduodenectomy.

Intraoperative pancreas stump perfusion assessment during pancreaticoduodenectomy: A systematic scoping review

BACKGROUND

Post-operative pancreatic fistula (POPF) is the primary cause of morbidity following pancreaticoduodenectomy. Rates of POPF have remained high despite well known risk factors. The theory that hypoperfusion of the pancreatic stump leads to anastomotic failure has recently gained interest.

AIM

To define the published literature with regards to intraoperative pancreas perfusion assessment and its correlation with POPF.

METHODS

A systematic search of available literature was performed in November 2022. Data extracted included study characteristics, method of assessment of pancreas stump perfusion, POPF and other post-pancreatic surgery specific complications.

RESULTS

Five eligible studies comprised two prospective non-randomised studies and three case reports, total 156 patients. Four studies used indocyanine green fluorescence angiography to assess the pancreatic stump, with the remaining study assessing pancreas perfusion by visual inspection of arterial bleeding of the pancreatic stump. There was significant heterogeneity in the definition of POPF. Studies had a combined POPF rate of 12%; intraoperative perfusion assessment revealed hypoperfusion was present in 39% of patients who developed POPF. The rate of POPF was 11% in patients with no evidence of hypoperfusion and 13% in those with evidence of hypoperfusion, suggesting that not all hypoperfusion gives rise to POPF and further analysis is required to analyse if there is a clinically relevant cut off. Significant variance in practice was seen in the pancreatic stump management once hypoperfusion was identified.

CONCLUSION

The current published evidence around pancreas perfusion during pancreaticoduodenectomy is of poor quality. It does not support a causative link between hypoperfusion and POPF. Further well-designed prospective studies are required to investigate this.

Evaluation of the Value of Intraoperative Peri-Pancreatic Fluid Amylase Concentration in Predicting a Postoperative Pancreatic Fistula After Pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is a common complication after pancreaticoduodenectomy (PD) and is a cause of significant morbidity and mortality. This study aimed to assess the predictive value of the amylase concentration of fluid accumulating in the peri-pancreatic region intraoperatively or intraoperative amylase concentration (IOAC) for the development of a clinically relevant POPF after PD.

METHODS

All consecutive patients who underwent PD between April 2018 and May 2021 were prospectively included in the study. IOAC and postoperative day-three drain fluid amylase values were measured, and the incidence of clinically relevant POPF (CR-POPF) was noted. Receiver operating characteristic analysis was used to evaluate the predictive capacity of the IOAC for a CR-POPF.

RESULTS

The study included 64 patients. A clinically relevant POPF was seen in 12 (18.8%) patients. On ROC analysis, the area under the curve (AUC) was 0.912 (with 95% CI of 0.822-1.001, p<0.001), which is highly significant. A cut-off IOAC value of 236 IU/L was derived, and an IOAC above this value was shown to predict the development of a CR-POPF in the postoperative period with a sensitivity of 91.7%. The highest positive predictive value (87.5%) was obtained with a cut-off of 772 IU/L.

CONCLUSION

An IOAC is an early, simple, and sensitive predictor for the development of a clinically relevant POPF after PD and can potentially aid in managing the resulting morbidity with intraoperative and postoperative measures.

Postoperative Serum Hyperamylasemia Adds Sequential Value to the Fistula Risk Score in Predicting Pancreatic Fistula after Pancreatoduodenectomy

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.

Four-Day Robotic Whipple: Early Discharge after Robotic Pancreatoduodenectomy

BACKGROUND

The authors aimed to assess the safety of an enhanced recovery after surgery (ERAS) and early discharge pathway in a robotic pancreatoduodenectomy (PD) program and compared outcomes with an open PD control cohort to identify the synergistic effects of robotic surgery and an ERAS pathway on lengths of stay (LOS).

STUDY DESIGN

Consecutive patients undergoing open or robotic PD from a single surgeon between March 2020 and July 2022 were identified. Logistic regression models were used for adjusted analyses of postoperative outcomes.

RESULTS

There were 134 consecutive PD patients, of which 40 (30%) were performed robotically. Pancreatic adenocarcinoma was the most common indication in both open (56%) and robotic (55%, p = 0.51) groups, with a similar proportion of them being borderline resectable or locally advanced tumors (78% vs 82% in robotic group, p = 0.82). The LOS was significantly shorter in the robotic PD group (median, 5 [IQR 4 to 7] days) when compared with the open PD group (median, 6 [IQR 5 to 8] days, p < 0.001). LOS of 4 days or fewer were observed in 40% of the robotic PD group compared with only 3% of patients in the open PD group (p < 0.001). There was no difference in the overall readmission rate (10% vs 12% in the robotic PD group, p = 0.61). On multivariable logistic regression, robotic PD was independently associated with higher odds of LOS of 4 days or fewer (odds ratio 22.4, p = 0.001) when compared with open PD.

CONCLUSIONS

An ERAS and early discharge pathway could be safely implemented in a robotic PD program. Patients undergoing robotic PD have significantly shorter length of stay without increased complication or readmission rate compared with open PD, with 40% of patients undergoing robotic PD achieving a LOS of 4 days or fewer.

ALTERNATIVE FISTULA RISK SCORE AND FIRST POSTOPERATIVE DAY DRAIN FLUID AMYLASE AS PREDICTORS OF PANCREATIC FISTULA AFTER PANCREATICODUODENECTOMY

BACKGROUND

The high morbidity and mortality rates of pancreaticoduodenectomy are mainly associated with pancreaticojejunal anastomosis, the most fragile and susceptible to complications such as clinically relevant postoperative pancreatic fistula.

AIMS

The alternative fistula risk score and the first postoperative day drain fluid amylase are predictors of the occurrence of clinically relevant postoperative pancreatic fistula. No consensus has been reached on which of the scores is a better predictor; moreover, their combined predictive power remains unclear. To the best of our knowledge, this association had not yet been studied.

METHODS

This study assessed the predictive effect of alternative fistula risk score and/or drain fluid amylase on clinically relevant postoperative pancreatic fistula in a retrospective cohort of 58 patients following pancreaticoduodenectomy. The Shapiro-Wilk and Mann-Whitney tests were applied for assessing the distribution of the samples and for comparing the medians, respectively. The receiver operating characteristics curve and the confusion matrix were used to analyze the predictive models.

RESULTS

The alternative fistula risk score values were not statistically different between patients in the clinically relevant postoperative pancreatic fistula and non- clinically relevant postoperative pancreatic fistula groups (Mann-Whitney U test 59.5, p=0.12). The drain fluid amylase values were statistically different between clinically relevant postoperative pancreatic fistula and non- clinically relevant postoperative pancreatic fistula groups (Mann-Whitney U test 27, p=0.004). The alternative fistula risk score and drain fluid amylase were independently less predictive for clinically relevant postoperative pancreatic fistula, compared to combined alternative fistula risk score + drain fluid amylase.

CONCLUSION

The combined model involving alternative fistula risk score >20% + drain fluid amylase=5,000 U/L was the most effective predictor of clinically relevant postoperative pancreatic fistula occurrence following pancreaticoduodenectomy.

Distal Pancreatectomy Fistula Risk Score (D-FRS): Development and International Validation

OBJECTIVE

To develop 2 distinct preoperative and intraoperative risk scores to predict postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) to improve preventive and mitigation strategies, respectively.

BACKGROUND

POPF remains the most common complication after DP. Despite several known risk factors, an adequate risk model has not been developed yet.

METHODS

Two prediction risk scores were designed using data of patients undergoing DP in 2 Italian centers (2014-2016) utilizing multivariable logistic regression. The preoperative score (calculated before surgery) aims to facilitate preventive strategies and the intraoperative score (calculated at the end of surgery) aims to facilitate mitigation strategies. Internal validation was achieved using bootstrapping. These data were pooled with data from 5 centers from the United States and the Netherlands (2007-2016) to assess discrimination and calibration in an internal-external validation procedure.

RESULTS

Overall, 1336 patients after DP were included, of whom 291 (22%) developed POPF. The preoperative distal fistula risk score (preoperative D-FRS) included 2 variables: pancreatic neck thickness [odds ratio: 1.14; 95% confidence interval (CI): 1.11-1.17 per mm increase] and pancreatic duct diameter (OR: 1.46; 95% CI: 1.32-1.65 per mm increase). The model performed well with an area under the receiver operating characteristic curve of 0.83 (95% CI: 0.78-0.88) and 0.73 (95% CI: 0.70-0.76) upon internal-external validation. Three risk groups were identified: low risk (<10%), intermediate risk (10%-25%), and high risk (>25%) for POPF with 238 (18%), 684 (51%), and 414 (31%) patients, respectively. The intraoperative risk score (intraoperative D-FRS) added body mass index, pancreatic texture, and operative time as variables with an area under the receiver operating characteristic curve of 0.80 (95% CI: 0.74-0.85).

CONCLUSIONS

The preoperative and the intraoperative D-FRS are the first validated risk scores for POPF after DP and are readily available at: http://www.pancreascalculator.com . The 3 distinct risk groups allow for personalized treatment and benchmarking.

Current Perioperative Care in Pancreatoduodenectomy: A Step-by-Step Surgical Roadmap from First Visit to Discharge

Pancreaticoduodenectomy (PD) is a mainstay in the management of periampullary tumors. Treatment algorithms increasingly employ a multimodal strategy, which includes neoadjuvant and adjuvant therapies. However, the successful treatment of a patient is contingent on the execution of a complex operation, whereby minimizing postoperative complications and optimizing a fast and complete recovery are crucial to the overall success. In this setting, risk reduction and benchmarking the quality of care are essential frameworks through which modern perioperative PD care must be delivered. The postoperative course is primarily influenced by pancreatic fistulas, but other patient- and hospital-associated factors, such as frailty and the ability to rescue from complications, also affect the outcomes. A comprehensive understanding of the factors influencing surgical outcomes allows the clinician to risk stratify the patient, thereby facilitating a frank discussion of the morbidity and mortality of PD. Further, such an understanding allows the clinician to practice based on the most up-to-date evidence. This review intends to provide clinicians with a roadmap to the perioperative PD pathway. We review key considerations in the pre-, intra-, and post-operative periods.

Drain fluid and serum amylase concentration ratio is the most reliable indicator for predicting postoperative pancreatic fistula after distal pancreatectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is a major complication of pancreatic surgery. Drain fluid amylase concentration (DAC) is considered a predictive indicator of POPF. However, other indicators related to postoperative drain fluid amylase status exist, and the most reliable indicator for predicting POPF remains unclear. The object of this study is to identify the single most accurate indicator related to drain fluid amylase status of POPF after distal pancreatectomy (DP).

METHODS

This single-institution retrospective study included 122 patients who underwent DP. The study was conducted between 2010 and 2022 at Gifu University Hospital. We statistically analyzed DAC, drain fluid amylase amount (DAA) calculated by multiplying DAC and daily drainage volume, and drain and serum amylase concentration ratio (DSACR) to assess the correlation with POPF.

RESULTS

Based on the definition and grading of the International Study Group of Pancreatic Fistula, 24.6 (%) of the 122 patients had Grades B and C POPF. The result of the receiver operating characteristic (ROC) curve for predicting POPF after DP, DSACR had the highest area under curve(AUC) value among DAC, DAA, and DSACR both POD1 and POD3. The cutoff value of DSACR on POD1 was 17 (AUC 0.69, sensitivity 80.0%, specificity 58.2%, and accuracy 63.6%). The cutoff value of DSACR on POD3 was 22 (AUC 0.77, sensitivity 77.7%, specificity 73.3%, and accuracy 73.6%). Overall, DSACR on POD3 had the highest AUC value. Furthermore, a multivariate logistic regression analysis revealed that pancreatic texture (soft; odds ratio [OR] 9.22; 95% confidence interval [CI] 2.22-44.19; p < 0.01) and DSACR on POD3 (> 22; OR 8.76; 95% CI 2.78-31.59; p < 0.001) were independently associated with POPF after DP.

CONCLUSIONS

DSACR is the most reliable indicator of drain fluid amylase status for predicting POPF after DP.

Adjusting Drain Fluid Amylase for Drain Volume Does Not Improve Pancreatic Fistula Prediction

INTRODUCTION

Drain fluid amylase (DFA) levels have been used to predict clinically relevant postoperative pancreatic fistula (CR-POPF) and guide postoperative drain management. Optimal DFA cutoff thresholds vary between studies, thereby prompting investigation of an alternative assessment technique. As DFA measurements could, in theory, be distorted by variations in ascites fluid production, we hypothesized that adjusting DFA for volume corrected drain fluid amylase (vDFA) would improve CR-POPF predictive models.

METHODS

A single-institution retrospective cohort study of patients, who underwent pancreatoduodenectomies (PD) and distal pancreatectomies (DP) between 2013 and 2019, was performed. DFAs and vDFAs were measured on postoperative day (POD) 3. Clinicopathologic variables were compared between cohorts by univariable and multivariable analyses and Receiver operating characteristic (ROC) curves.

RESULTS

Patients developing a CR-POPF were more likely to be male and have elevated DFA, vDFA, and body mass index (BMI). vDFA use did not contribute to a superior CR-POPF predictive model compared to DFA-a finding consistent on subanalysis of surgery type PD versus DP. In CR-POPF predictive models, DFA, vDFA, and male sex significantly improved CR-POPF predictive models when considering both surgery subtypes, while only DFA and vDFA significantly improved models when cohorts were segregated by surgery type.

CONCLUSIONS

Postoperative DFA remains a preferred method of predicting CR-POPF as the proposed vDFA assessment technique only adds complexity without increased discriminability.

The Choice of the Most Appropriate Suture Threads for Pancreatic Anastomoses on the Basis of Their Mechanical Characteristics

The choice of the most appropriate suture threads for pancreatic anastomoses may play an important role in reducing the incidence of post-operative pancreatic fistula (POPF). The literature on this topic is still not conclusive. The aim of this study was to analyze the mechanical characteristics of suture materials to find the best suture threads for pancreatic anastomoses. A single-axial electromagnetic actuation machine was used to obtain the stress–deformation relationship curves and to measure both the ultimate tensile strength (UTS) and the Young’s modulus at the 0–3% deformation range (E0–3) of four different suture materials (Poliglecaprone 25, Polydioxanone, Polyglactin 910, and Polypropylene) at baseline and after incubation in saline solution, bile, and pancreatic juice for 1, 3, and 7 days. Polydioxanone and Polypropylene showed stable values of UTS and E0–3 in all conditions. Polyglactin 910 presented significant UTS and E0–3 variations between different time intervals in all types of liquids analyzed. Poliglecaprone 25 lost half of its strength in all biological liquids analyzed but maintained low E0–3 values, which could reduce the risk of lacerations of soft tissues. These results suggest that Polydioxanone and Poliglecaprone 25 could be the best suture materials to use for pancreatic anastomoses. In vivo experiments will be organized to obtain further confirmations of this in vitro evidence.

Positive drain fluid culture on postoperative day 1 predicts clinically relevant pancreatic fistula in early drain removal with higher drain fluid amylase after pancreaticoduodenectomy

BACKGROUND

This study aimed to clarify the risk factors of clinically relevant pancreatic fistula after early drain removal with higher drain fluid amylase after pancreaticoduodenectomy. Clinical evaluation of early drain removal with a higher drain fluid amylase after pancreaticoduodenectomy has been controversial. The safety and effectiveness have not been sufficiently examined.

METHODS

Between 2015 and 2020, prophylactic surgical drains were prospectively removed on postoperative day 4 regardless of drain fluid amylase level in 364 study-eligible patients who underwent pancreaticoduodenectomy. Patients were classified according to drain fluid amylase on postoperative day 1: 281 patients with drain fluid amylase <4,000 U/L, and 83 patients with drain fluid amylase ≥4,000 U/L.

RESULTS

Clinically relevant pancreatic fistula occurred in 40 of 364 enrolled patients (11.0%). In the entire cohort, male, positive postoperative day 1 drain fluid culture, and postoperative day 1 drain fluid amylase ≥4,000 U/L were independent risk factors for clinically relevant pancreatic fistula after early drain removal. When stratifying by 4,000 U/L of postoperative day 1 drain fluid amylase, the rate of clinically relevant pancreatic fistula in postoperative day 1 drain fluid amylase <4,000 U/L was significantly lower than that in postoperative day 1 drain fluid amylase ≥4,000 U/L (4% vs 35%, P < .001) after early drain removal. Moreover, in postoperative day 1 drain fluid amylase <4,000 U/L, positive postoperative day 1 drain fluid culture did not develop clinically relevant pancreatic fistula after early drain removal. However, in postoperative day 1 drain fluid amylase ≥4,000 U/L, multivariate analysis clarified that positive postoperative day 1 drain fluid culture was the only independent risk factor of clinically relevant pancreatic fistula after early drain removal (odds ratio 26.27, 95% confidence interval 5.59-123.56, P = .001).

CONCLUSION

Positive drain fluid culture on postoperative day 1 might predict clinically relevant pancreatic fistula in early drain removal with a higher drain fluid amylase.

Early and Sustained Elevation in Serum Pancreatic Amylase Activity: A Novel Predictor of Morbidity After Pancreatic Surgery

OBJECTIVE

To characterize early postoperative serum pancreatic amylase (spAMY) trends after pancreatic resections.

SUMMARY BACKGROUND DATA

A postoperative spAMY elevation is a common finding but uncertainties remain about its meaning and prognostic implications.

METHODS

Analysis of patients who consecutively underwent pancreatectomy from 2016 to 2019. spAMY activity was assessed from postoperative day (POD) 0 to 3. Different patterns of spAMY have been identified based on the spAMY standard range (10-52 U/l).

RESULTS

Three patterns were identified: (#1) spAMY values always < the lower limit of normal/within the reference range /a single increase in spAMY > upper limit of normal at any POD; (#2) Sustained increase in spAMY activity on POD 0 + 1; (#3) Sustained increase in spAMY activity including POD 1 + 2. Shifting through spAMY patterns was associated with increase morbidity (21% in #1 to 68% in #3 at POD 7; log rank < 0.001). Almost all severe complications (at least Clavien-Dindo ≥3) occurred in patients with pattern #3 (15% vs 3% vs 5% in #1 and #2 at POD 7, P = 0.006), without difference considering >3-times or >the spAMY normal limit ( P = 0.85). POPF (9% in #1 vs 48% in #3, P < 0.001) progressively increased across patterns. Pre-operative diabetes (OR 0.19), neoadjuvant therapy (OR 0.22), pancreatic texture (OR 8.8), duct size (OR 0.78), and final histology (OR 2.2) were independent predictors of pattern #3.

CONCLUSIONS

A sustained increase in spAMY activity including POD 1 + 2 (#3) represents an early postoperative predictor of overall and severe early morbidity. An early and dynamic evaluation of spAMY could crucially impact the subsequent clinical course with relevant prognostic implications.

Preoperative Hypoalbuminemia as a Predictor of Severe Postoperative Complications in Patients Undergoing Whipple Pancreatoduodenectomy

Background

Pancreaticoduodenectomy (PD) known as Whipple procedure is still one of the most complex abdominal surgeries used for treatment of periampullary tumors. PD is often followed with postoperative complications (pancreatic, biliar or intestinal fistula, haemorrhage, intraabdominal abscess, delayed gastric empting. Severe postoperative complications (SPC) can be reason for reoperation and reason of bad outcome of treatment and life treathening condition.

Objective

To investigate predicitive value of preoperative hypoalbuminemia for severe postoperative complications (SPC) in patients who have undergone Whipple pancreaticoduodenetomy (PD). However, no similiar study has been ever reported from our country until now.

Methods

In this retrospective-prospective study, 100 patients who have had Whipple pancreaticoduodenectomy for malignant periampullary tumors at the Department for Surgery of University Clinic Center Tuzla, Bosnia and Herzegovina were enrolled, from january of 2009 to decembre of 2021. All patients were preoperatively analysed according to serum albumine levels and presensce of hypolabuminemia (serum albumine levels <32g/l). Serum albumine biochemical test were done 1-2 days preoperatively. Clavien Dindo classification was used for determination patients with SPC. Patients who did not have SPC belonged to (I-II) Clavien Dindo group of patients while those who had SPC belonged to( III-V) Clavien Dindo group of patients.

Results

Out of 100 patients who have undergone pancreaticoduodenetomy, in 55 (55%) patients postoperative complications were noticed. Mortality rate was 18 (18%) and reoperation has been done in 20 cases (20%). SPC were noticed in 19 patients and most often were: delayed gastric emptying (20%), pancreatic fistula (13%) and intraabdominal collections (9%). Hypoalbuminemic patients had a significantly higher rate of severe postoperative complications ( p<0.05). Using hypoalbuminemia-SPC correlation analaysis, there is confirmed statistically significant correlation between hypoalbuminemia and SPC (ρ= 0.236; p<0.05).

Conclusion

Preoperative hypoalbuminemia can be used as predictor and prognostic factor for severe postoperative complications after Whipple pancreaticoduodenectomy. Identification and optimization of serum albumin level prior to Whipple pancreatoduodenectomy may improve surgical outcomes.

LATE POSTPANCREATICODUODENECTOMY HEMORRHAGE: INCIDENCE, RISK FACTORS, MANAGEMENT AND OUTCOME

ABSTRACT

Background:Postpancreaticoduodenectomy (PD) hemorrhage (PPH) is a life-threatening complication after PD. The main objective of this study was to evaluate incidence and factors associated with late PPH as well as the management strategy and outcomes. Methods: Between May 2017 and March 2020, clinical data from 192 patients undergoing PD were collected prospectively in the CHIRPAN Database (NCT02871336) and retrospectively analyzed. In our institution, all patients scheduled for a PD are routinely admitted for monitoring and management in intensive/intermediate care unit (ICU/IMC). Results: The incidence of late PPH was 17% (32 of 192), whereas the 90-day mortality rate of late PPH was 19% (6 of 32). Late PPH was associated with 90-day mortality (P = 0.001). Using multivariate analysis, independent risk factors for late PPH were postoperative sepsis (P = 0.036), and on day 3, creatinine (P = 0.025), drain fluid amylase concentration (P = 0.023), lipase concentration (P < 0.001), and C-reactive protein (CRP) concentration (P < 0.001). We developed two predictive scores for PPH occurrence, the PANCRHEMO scores. Score 1 was associated with 68.8% sensitivity, 85.6% specificity, 48.8% predictive positive value, 93.2% negative predictive value, and an area under the receiver operating characteristic curves of 0.841. Score 2 was associated with 81.2% sensitivity, 76.9% specificity, 41.3% predictive positive value, 95.3% negative predictive value, and an area under the receiver operating characteristic curve of 0.859. Conclusions: Routine ICU/IMC monitoring might contribute to a better management of these complications. Some predicting factors such as postoperative sepsis and biological markers on day 3 should help physicians to determine patients requiring a prolonged ICU/IMC monitoring.

Progression from biochemical leak to pancreatic fistula after distal pancreatectomy. Don't cry over spilt amylase

BACKGROUND

Postoperative pancreatic fistula (POPF) is a frequent complication after distal pancreatectomy (DP), but its upgrading from biochemical leak (BL) still represents an unexplored phenomenon. This study aims at identifying risk factors of the clinical evolution from BL to grade-B POPF after DP.

METHODS

Patients who underwent DP between 2015 and 2019 and who developed either BL (n = 89,56%) or BL upgraded to late B fistula (LB) after postoperative day 5 (n = 71,44%) were included. Preoperative, surgical, postoperative predictors were compared between the two groups.

RESULTS

Patients with LB were significantly older (61 vs 56 years, P < 0.025) and received neoadjuvant chemotherapy more frequently (22.5% vs 8.5%,P = 0.017). Extended lymphadenectomy (52.8% vs 31.0%,P = 0.006), longer operative times (OT) (307 vs 250 min,P = 0.002), greater estimated blood loss (250 vs 150 ml, P = 0.021), and the appearance of purulent fluid in surgical drains (58.4% vs 21.1%; P < 0.001) were more frequently observed in LB group. Only purulent fluid in surgical drains and longer OT were confirmed as independent predictors of BL clinical progression.

CONCLUSIONS

Purulent fluid from surgical drains should be suspicious of BL upgrading. Frail patients undergoing longer interventions may represent key targets of mitigation strategies to minimize the magnitude of an incipient fistula and its increase in morbidity.

Hyperamylasemia grade versus drain fluid amylase: which better predicts pancreatectomy outcomes?

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.

Novel Calculator to Estimate the Risk of Clinically Relevant Postoperative Pancreatic Fistula Following Distal Pancreatectomy

BACKGROUND

Drain management algorithms are based on studies that predict clinically relevant postoperative pancreatic fistula (CR-POPF) using drain fluid amylase level on POD1 (DFA1). These studies are focused on pancreaticoduodenectomy which is inherently different than distal pancreatectomy. Moreover, the change of DFA between POD1 and POD3 (ΔDFA) is underutilized despite its importance in predicting CR-POPF. We sought to generate a calculator that estimates the risk of CR-POPF following distal pancreatectomy.

METHODS

The 2014-2018 pancreas-targeted ACS-NSQIP database was used to identify patients who underwent elective distal pancreatectomy. Models to predict CR-POPF were constructed using DFA1 with/without ΔDFA. The fittest model was used to construct a calculator.

RESULTS

Out of 12,042 distal pancreatectomies, 692 patients met the study's inclusion criteria. The risk of CR-POPF was 15.9% in the included cohort versus 14.8% in the excluded one (P = 0.421). The predictors of the CR-POPF were age, operative time, DFA1, and ΔDFA. Adding ΔDFA decreased the Akaike's information criterion of the model (507.7 vs 544.7)-indicating a significantly better model fit-and improved the cross-validated area under the curve from 0.731 to 0.791. An easy-to-use calculator was created for surgeons to estimate the risk of CR-POPF based on the abovementioned variables. A sensitivity/specificity table was created at various cutoffs to direct clinical decision-making with respect to early drain removal.

CONCLUSIONS

This study highlights the importance of ΔDFA, in addition to DFA1, in predicting CR-POPF. The provided calculator will facilitate predicting CR-POPF and postoperative drain management following distal pancreatectomy.

Can trainees safely perform pancreatoenteric anastomosis? A systematic review, meta-analysis, and risk-adjusted analysis of postoperative pancreatic fistula

BACKGROUND

The complexity of pancreaticoduodenectomy and fear of morbidity, particularly postoperative pancreatic fistula, can be a barrier to surgical trainees gaining operative experience. This meta-analysis sought to compare the postoperative pancreatic fistula rate after pancreatoenteric anastomosis by trainees or established surgeons.

METHODS

A systematic review of the literature was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, with differences in postoperative pancreatic fistula rates after pancreatoenteric anastomosis between trainee-led versus consultant/attending surgeons pooled using meta-analysis. Variation in rates of postoperative pancreatic fistula was further explored using risk-adjusted outcomes using published risk scores and cumulative sum control chart analysis in a retrospective cohort.

RESULTS

Across 14 cohorts included in the meta-analysis, trainees tended toward a lower but nonsignificant rate of all postoperative pancreatic fistula (odds ratio: 0.77, P = .45) and clinically relevant postoperative pancreatic fistula (odds ratio: 0.69, P = .37). However, there was evidence of case selection, with trainees being less likely to operate on patients with a pancreatic duct width <3 mm (odds ratio: 0.45, P = .05). Similarly, analysis of a retrospective cohort (N = 756 cases) found patients operated by trainees to have significantly lower predicted all postoperative pancreatic fistula (median: 20 vs 26%, P < .001) and clinically relevant postoperative pancreatic fistula (7 vs 9%, P = .020) rates than consultant/attending surgeons, based on preoperative risk scores. After adjusting for this on multivariable analysis, the risks of all postoperative pancreatic fistula (odds ratio: 1.18, P = .604) and clinically relevant postoperative pancreatic fistula (odds ratio: 0.85, P = .693) remained similar after pancreatoenteric anastomosis by trainees or consultant/attending surgeons.

CONCLUSION

Pancreatoenteric anastomosis, when performed by trainees, is associated with acceptable outcomes. There is evidence of case selection among patients undergoing surgery by trainees; hence, risk adjustment provides a critical tool for the objective evaluation of performance.

Is routine CT scan after pancreaticoduodenectomy a useful tool in the early detection of complications? A single center retrospective analysis

PURPOSE

The clinical impact of routine CT imaging after pancreaticoduodenectomy (PD) has not been properly investigated. The aim of this study was to investigate the role of routine CT scan after PD for the detection of postoperative complications.

METHODS

Prospectively collected data of consecutive patients undergoing PD and receiving routine postoperative CT imaging were retrospectively analyzed. The primary endpoint was accuracy of CT imaging in identifying major complications. The secondary endpoint was identification of preoperative and intraoperative factors associated with severe complications. A subgroup analysis of CT scan accuracy in identifying severe complications in patients stratified by fistula risk score (FRS) and presence of early clinical alterations was also performed.

RESULTS

A total of 145 patients were included. Routine CT scan had low specificity (Sp = 0.36) and high sensitivity (Sn = 0.98) for predicting major complications, with an accuracy of 0.57. At multivariate logistic regression analysis, only fistula moderate-high FRS (p = 0.029) was independently associated with severe complications. In patients with negligible-low FRS, CT scan showed a Sp of 0.63 and a Sn of 1.0 with an accuracy of 0.69. In patients with moderate-high FRS, CT scan had a Sp of 0.19, a Sn of 0.97 and an accuracy of 0.5. In the 20 (14%) patients with negligible-low FRS and no clinical alterations, no deaths or readmissions occurred regardless of CT findings, while one severe complication occurred in the positive CT scan group. In all other groups, no deaths or readmissions occurred in case of negative CT, with only one severe complication in the moderate-high FRS group with clinical alterations. In case of positive CT, the rate of severe complications was 47% in case of negligible-low FRS and clinical alterations, 40% in case of moderate-high FRS with no clinical alterations, and 45% in case of moderate-high FRS and clinical alterations.

CONCLUSIONS

Routine postoperative CT scan after PD should not be performed in patients with negligible-low FRS and no clinical alterations. In all other patients, a negative CT scan appears to be highly accurate in identifying patients who will have an uneventful course and who could benefit from early discharge.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Postoperative serum hyperamylasemia (POH) predicts additional morbidity after pancreatoduodenectomy: It is not all about pancreatic fistula

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.

Validations of new cut-offs for surgical drains management and use of computerized tomography scan after pancreatoduodenectomy: The DALCUT trial

BACKGROUND

Postoperative pancreatic fistula (POPF) is the most fearful complication after pancreatic surgery and can lead to severe postoperative complications such as surgical site infections, sepsis and bleeding. A previous study which identified cut-offs of drains amylase levels (DALs) determined on postoperative day (POD) 1 and POD3, was able to significantly predict POPF, abdominal collections and biliary fistulas, when related to specific findings detected at the abdominal computerized tomography (CT) scan routinely performed on POD3.

AIM

To validate the cut-offs of DALs in POD1 and POD3, established during the previous study, to assess the risk of clinically relevant POPF and confirm the usefulness of abdominal CT scan on POD3 in patients at increased risk of abdominal collection.

METHODS

The DALCUT trial is an interventional prospective study. All patients who will undergo pancreatoduodenectomy (PD) for periampullary neoplasms will be considered eligible. All patients will receive clinical staging and, if eligible for surgery, will undergo routine preoperative evaluation. After the PD, daily DALs will be evaluated from POD1. Drains removal and possible requirement of abdominal CT scans in POD3 will be managed on the basis of the outcome of DALs in the first three postoperative days.

RESULTS

This prospective study could validate the role of DALs in the management of surgical drains and in assessing the risk or relevant complications after PD. Drains could be removed in POD3 in case of POD1 DALs < 666 U/L and POD3 DALs < 207 U/L. In case of POD3 DALs ≥ 252, abdominal CT scan will be performed in POD3 to identify abdominal collections ≥ 5 cm. In this latter category of patients, drains could be maintained beyond POD3.

CONCLUSION

The results of this trial will contribute to a better knowledge of POPF and management of surgical drains.

Postpancreatectomy Acute Pancreatitis (PPAP): Definition and Grading From the International Study Group for Pancreatic Surgery (ISGPS)

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.

Early biochemical predictors of clinically relevant pancreatic fistula after distal pancreatectomy: a role for serum amylase and C-reactive protein

BACKGROUND

Recent evidence suggests that pancreatic inflammation plays a pivotal role in the occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy but few data are available for distal pancreatectomy (DP). The aim of this study was to evaluate the impact of early biochemical markers on the occurrence of CR-POPF after DP.

METHODS

Clinical and laboratory data for 432 consecutive DP patients were reviewed. Serum amylase was evaluated on postoperative day (POD) 1, and drain fluid amylase (DFA) and C-reactive protein (CRP) were evaluated on POD 2 and 3. Receiver operator characteristic (ROC) curves were performed for all biochemical markers and an area under the curve (AUC) was computed. Multivariable regression analyses to identify the factors associated with CR-POPF and severe postoperative morbidity (Clavien-Dindo grade ≥ 3) were performed.

RESULTS

At 90 days after surgery, CR-POPF occurred in 155 (36%) patients, severe complications in 66 (15%) patients. ROC curve analyses showed that DFA on POD2 had the largest AUC (0.753, p < 0.001), followed by serum amylase on POD 1 (0.651, p < 0.001), serum CRP on POD3 (0.644, p < 0.001), and CRP change between POD 2 and POD 3 (0.644, p < 0.001). Multivariable analysis identified male gender (OR 2.29, 95% CI 1.36-3.86; p = 0.002), DFA ≥ 1500 U/L on POD2 (OR 4.63, 95% CI 2.72-7.89; p < 0.001), serum amylase ≥ 100 U/L on POD 1 (OR 1.72, 95% CI 1.01-2.93; p = 0.046), and CRP increase by at least 25 mg/L on POD 3 compared to the previous day (OR 1.89, 95% CI 1.11-3.21; p = 0.019) as independent predictors of CR-POPF, yielding a valid regression model (AUC 0.765, 95% CI 0.714-0.816, p < 0.001).

CONCLUSIONS

Postoperative serum amylase and CRP trajectory represent useful early biochemical markers for CR-POPF in addition to DFA. Our findings suggest that these laboratory tests should be incorporated into clinical practice to aid postoperative patient and drain management.

Development and validation of risk prediction nomogram for pancreatic fistula and risk-stratified strategy for drainage management after pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is the major complication following pancreaticoduodenectomy (PD). We sought to develop and validate a risk prediction model for POPF after PD with the aim of determining personal risk probability and proposing a novel strategy for intraoperative placement and/or early-removal of prophylactic drainage.

METHODS

Data from 993 patients undergoing PD from January 2012 to December 2016 were retrospectively analyzed. Patients were randomly assigned to either training cohort or validation cohort. A nomogram was formulated based on the results from multivariable regression model for prediction of POPF. Internal and external validation were carried out with calibration plot respectively.

RESULTS

POPF occurred in 162 (16.3%) patients. The final pre-/intra-operative prediction model included alanine transaminase level [odds ratio (OR) 1.00, 95% confidence interval (CI): 1.00-1.00, P=0.023], combined portal-superior mesenteric vein resection (OR 0.22, 95% CI: 0.05-0.95, P=0.043), pancreatic duct diameter (OR 1.48, 95% CI: 1.11-1.96, P=0.007), intraoperative colloid infusion (OR 1.00, 95% CI: 1.00-1.00, P=0.001), pathology (OR 1.71, 95% CI: 1.09-2.66, P=0.018). The area under the curve (AUC) was 0.667 in the training cohort and 0.621 in the validation cohort. The final postoperative prediction model included pancreatic duct diameter (OR 1.58, 95% CI: 1.14-2.19, P=0.006), intraoperative colloid infusion (OR 2.52, 95% CI: 1.26-5.06, P=0.009), drainage fluid amylase on postoperative day 3 (POD3) (OR 4.70, 95% CI: 3.30-6.70, P<0.001), and neutrophil count on POD3 (OR 2.83, 95% CI: 1.63-4.93, P<0.001). The AUC was 0.809 in the training cohort and 0.797 in the validation cohort. Based on these variables, two nomogram prediction models were developed respectively. The calibration plot of the two models showed a good correlation between the expected risk and the actual risk in the low-risk range. Our risk-stratified strategy for drain management according to nomograms may be beneficial for 34.5% of patients.

CONCLUSIONS

Our study formulated and validated two nomogram models for predicting POPF that performed particularly well in the low-risk range. This tool may allow surgeons to propose a risk stratified strategy for intraoperative drain placement and early drain removal, which may be beneficial for a substantial proportion of patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Which is the best predictor of clinically relevant pancreatic fistula after pancreatectomy: drain fluid concentration or total amount of amylase?

AIM

Drain fluid amylase concentration (DFAC) has been reported as a predictor of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatectomy. However, the clinical significance of measuring the total drain fluid amylase amount (DFAA) considering the daily drainage volume of CR-POPF remains unclear.

METHODS

Data from 216 consecutive patients who underwent pancreaticoduodenectomy (PD) (n = 126) or distal pancreatectomy (DP) (n = 90) between August 2014 and November 2020 were reviewed. All drains were closed but not suctioned. DFAA was calculated by multiplying the DFAC and daily drainage fluid volume. DFAC and DFAA were recorded on d 1 and 3 after pancreatectomy. The cutoff value of CR-POPF was determined using the receiver operating characteristic curve.

RESULTS

CR-POPF was found in 75 patients (35%) (PD: 30%, DP: 41%, P = .111); the mortality rate was zero. The cutoff value of DFAC-day 1 was 1757 U/L (sensitivity [SE]: 84%, specificity [SP]: 62%, and accuracy [AC]: 69%). The cutoff value of DFAA-day 1 was 139 U (SE: 71%, SP: 72%, and AC: 71%). The cutoff value of DFAC-day 3 was 1044 U/L (SE: 73%, SP: 79%, and AC: 78%). The cutoff value of DFAA-day 3 was 21 U (SE: 68%, SP: 72%, and AC: 70%). Multivariate analysis indicated that a nondilated pancreatic duct and high DFAC-day 3 were independently associated with CR-POPF after PD, indicating that a prolonged operative duration, massive blood loss, and high DFAC-day 3 are independently associated with CR-POPF after DP.

CONCLUSION

DFAC is more reliable than DFAA for predicting CR-POPF after both PD and DP.

Abdominal drain amylase on the first day after pancreatectomy: a predictive factor for pancreatic fistula

OBJECTIVE

To analyze abdominal drain on the first postoperative day and evaluate its predictive nature for the diagnosis of Pancreatic Fistula exclusion, seeking to establish a cutoff point from which lower values demonstrate safety in excluding the possibility of this complication.

METHODS

From August 2017 to June 2020, data from 48 patients undergoing pancreatic resection were collected and analyzed from a prospective cohort. The patients were divided into two groups, one group consisting of patients who did not develop PF (Group A), and the other composed of patients who developed PF (Group B). The receiver operation characteristic curve was constructed, and cutoff points were evaluated by calculating sensitivity and specificity.

RESULTS

Group A brought 30 patients together (62.5%) and Group B brought 18 patients together (37.5%). The 444 U/L value was the most satisfactory cutoff point for the receiver operation characteristic curve (CI 0.690-0.941), with a sensitivity of 94.4% and a specificity of 60%, thus being able to select 18 of 30 patients who did not succumb to PF.

CONCLUSIONS

Abdominal drain on the first postoperative day can be used as a predictive factor in the diagnosis of PF exclusion (CI 0.690-0.941), with the value of 444 U/L being the best performance cutoff point.

Amylase Is Not a Useful Indicator for Leakage Detection Following Sleeve Gastrectomy: A Prospective Study

Introduction. Gastric leak after laparoscopic sleeve gastrectomy (LSG) is a severe complication that may lead to sepsis and even death. Early diagnosis and treatment are critical. The aims of this prospective study are to establish normal amylase levels and investigate elevated amylase levels, especially in the drain, for detecting anastomotic leakage following LSG. Material and Methods. One hundred sixty-one patients who underwent LSG during 1 year at Rambam Health Care Campus were included prospectively in the study. Demographic and medical background, peri- and postoperative complications, and laboratory data including amylase levels in blood, urine, and drain were evaluated. Univariate and multivariate analyses were performed to examine independent variables that can predict increases in amylase values. Results. Thirty-five (21.8%) patients had high levels of amylase in blood, urine, and/or drain and 126 (78.2%) normal values of amylase until discharge. No significant differences were found in operation duration, length of hospitalization, or occurrence of complications. One patient had a staple-line leak diagnosed in the third postoperative day that was treated conservatively with endoscopic approach. His amylase levels in the blood and drain were normal, with only a slight hyperamylasuria. Conclusions. High amylase levels after LSG does not necessarily indicate a major complication such as staple-line leak, and in the vast majority of cases, it seems to have no clinical relevancy. Therefore, it should not automatically lead to a full investigation in the absence of further clinical signs. It is suggested that there is no clinical justification to test amylase routinely after LSG.

Postoperative day 1 combination of serum C-reactive protein and drain amylase values predicts risks of clinically relevant pancreatic fistula. The "90-1000" score

BACKGROUND

Several scoring systems predict risks of clinically relevant postoperative pancreatic fistula after pancreatectomy, but none have emerged as the gold standard. This study aimed to evaluate the accuracy of postoperative day 1 drain amylase and serum C-reactive protein levels in predicting clinically relevant postoperative pancreatic fistula compared with intraoperative pancreatic characteristics.

METHODS

Patients who underwent pancreatectomy between 2017 and 2019 were included prospectively. Cutoff values were determined using receiver operating characteristic curves, and a score combining postoperative day 1 drain amylase and serum C-reactive protein was tested in a multivariate logistic regression model to evaluate clinically relevant postoperative pancreatic fistula risk.

RESULTS

A total of 274 pancreatic resections (182 pancreaticoduodenectomies and 92 distal pancreatectomies) were included. The pancreatic gland texture was "soft" in 47.8% (n = 131), and 55.8% (n = 153) had a small size main pancreatic duct (≤3 mm). Clinically relevant postoperative pancreatic fistula occurred in 58 patients (21.2%). Drain amylase ≥1,000 UI/L and serum C-reactive protein ≥90 mg/L were identified as the optimal cutoffs to predict clinically relevant postoperative pancreatic fistula. On multivariate analysis these cutoffs were independent predictors of clinically relevant postoperative pancreatic fistula after both pancreaticoduodenectomies (drain amylase: P < .001, serum C-reactive protein: P = .006) and distal pancreatectomies (drain amylase: P = .009, serum C-reactive protein: P = .001). The postoperative day 1 "90-1000" model, a 2-value score relying on these cutoffs, significantly (P < .001) outperformed intraoperative pancreatic parenchymal characteristics in predicting clinically relevant postoperative pancreatic fistula after both pancreaticoduodenectomies and distal pancreatectomies. A postoperative day 1 "90-1000" score = 0 had a negative predictive value of 97% and 94%, respectively, after pancreaticoduodenectomy and distal pancreatectomies.

CONCLUSION

A combined score relying on postoperative day 1 values of drain amylase and serum C-reactive protein levels was accurate in predicting risks of clinically relevant postoperative pancreatic fistula after pancreatectomy.

Redefining the Role of Drain Amylase Value for a Risk-Based Drain Management after Pancreaticoduodenectomy: Early Drain Removal Still Is Beneficial

BACKGROUND

The application of postoperative pancreatic fistula (POPF) risk stratification and mitigation strategies requires an update of the protocol for an early drain removal after pancreaticoduodenectomy (PD). The aim of the study is to highlight the unreliability of a single drain fluid amylase (DFA) cutoff-based protocol in the setting of a risk-based drain management.

METHODS

The role of postoperative day one (POD1) DFA in predicting POPF was explored in the setting of both selective drain placement and early drain removal protocols. Receiver operating characteristics (ROC) curves were used to assess the POPF diagnostic performance in terms of negative predictive value (NPV) of several POD1 DFA cutoffs in different clinical scenarios according to POPF risk and mitigation strategies.

RESULTS

The areas under the curve (AUCs) for POD1-DFA were 0.815 for intermediate risk and pancreaticojejunostomy (PJ) (best cutoff 1000 IU/L, NPV 92.9%), 0.712 for intermediate risk and PJ with external stent (best cutoff 1000 IU/L, NPV 88.8%), and 0.574 for high risk and external stent (best cutoff 250 IU/L, NPV 93.7%). Independent predictors of POPF were body mass index, pancreatic texture, and early drain removal, whereas POD1 DFA was not.

CONCLUSION

In the era of risk stratification and mitigation strategies, selective early drain removal still is associated with a reduced rate of POPF. However, a single protocol based on POD1-DFA is not suitable for all clinical scenarios after PD.

A Surface Plasmon Resonance Plastic Optical Fiber Biosensor for the Detection of Pancreatic Amylase in Surgically-Placed Drain Effluent

Postoperative pancreatic fistula (POPF), the major driver of morbidity and mortality following pancreatectomy, is caused by an abnormal communication between the pancreatic ductal epithelium and another epithelial surface containing pancreas-derived, enzyme-rich fluid. There is a strong correlation between the amylase content in surgically-placed drains early in the postoperative course and the development of POPF. A simple and cheap method to determine the amylase content from the drain effluent has been eagerly advocated. Here, we developed an amylase optical biosensor, based on a surface plasmon resonance (SPR) plastic optical fiber (POF), metallized with a 60 nm layer of gold and interrogated with white light. The sensor was made specific by coupling it with an anti-amylase antibody. Each surface derivatization step was optimized and studied by XPS, contact angle, and fluorescence. The POF-biosensor was tested for its response to amylase in diluted drain effluents. The volume of sample required was 50 µL and the measurement time was 8 min. The POF-biosensor showed selectivity for amylase, a calibration curve log-linear in the range of 0.8-25.8 U/L and a limit of detection (LOD) of ~0.5 U/L. In preliminary tests, the POF-biosensor allowed for the measurement of the amylase content of diluted surgically-placed drain effluents with an accuracy of >92% with respect to the gold standard. The POF-biosensor allows for reliable measurement and could be implemented to allow for a rapid bedside assessment of amylase value in drains following pancreatectomy.

The value of serum amylase and drain fluid amylase to predict postoperative pancreatic fistula after pancreatoduodenectomy: a retrospective cohort study

Purpose

Serum and drain amylase have been identified as important predictors of postoperative pancreatic fistula (POPF) and might be useful to guide postoperative drain management after pancreatoduodenectomy. We aimed to determine and compare the value of serum amylase and drain fluid amylase to predict postoperative pancreatic fistula after pancreatoduodenectomy.

Methods

This retrospective cohort study included patients after pancreatoduodenectomy from 2012 to 2019. The primary endpoint of our study was grade B/C POPF. Serum amylase on postoperative day 1 (SA-1) and drain fluid amylase on postoperative day 2 (DFA-2) were analyzed.

Results

A total of 92 of 437 patients (21.1%) developed a grade B/C POPF. SA-1 was higher in patients who developed a grade B/C POPF (336 U/L vs. 97 U/L, p<0.001). Similarly, DFA-2 was higher in patients who developed a grade B/C POPF (1764 U/L vs. 78 U/L, p<0.001). SA-1 and DFA-2 had similar predictive accuracy (AUC: 0.82 vs. 0.85, respectively, p=0.329). Patients with SA-1<100 U/L (n=178) had a risk of 2.2% of developing grade B/C POPF, compared to 38.2% in patients with SA-1 >100 U/L (n=207). Patients with DFA-2<100 U/L (n=141) had a risk of 0% of developing grade B/C POPF, compared to 36.2% in patients with DFA-2>100 U/L (n=196). SA-1 and DFA-2 were strongly associated at a cut-off of 100 U/L (p<0.001, 89% concordance rate).

Conclusion

Postoperative serum and drain amylase values below 100 U/L both effectively rule out POPF after pancreatoduodenectomy. The advantage of serum amylase measurement is that it can be used in patients who are managed without surgical drains.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-021-02192-y.

Decision points in pancreatoduodenectomy: Insights from the contemporary experts on prevention, mitigation, and management of postoperative pancreatic fistula

BACKGROUND

Despite abundant, high-level scientific evidence, there is no consensus regarding the prevention, mitigation, and management of clinically relevant pancreatic fistula after pancreatoduodenectomy. The aim of the present investigation is three-fold: (1) to analyze the multiple decision-making points for pancreatico-enteric anastomotic creation and fistula mitigation and management after pancreatoduodenectomy, (2) to reveal the practice of contemporary experts, and (3) to indicate avenues for future research to reduce the burden of clinically relevant pancreatic fistula.

METHODS

A 109-item questionnaire was sent to a panel of international pancreatic surgery experts, recognized for their clinical and scientific authority. Their practice habits and thought processes regarding clinically relevant pancreatic fistula risk assessment, anastomotic construction, application of technical adjuncts, and mitigation strategies, as well as postoperative management, was explored. Sixteen clinical vignettes were presented to reveal their certain approaches to unique situations-both common and uncommon.

RESULTS

Sixty experts, with a cumulative 48,860 pancreatoduodenectomies, completed the questionnaire. Their median pancreatectomy/pancreatoduodenectomy case volume was 1,200 and 705 procedures, respectively, with a median career duration of 22 years and 200 indexed publications. Although pancreatico-jejunostomy reconstruction with transperitoneal drainage is the standard operative approach for most authorities, uncertainty emerges regarding the employment of objective risk stratification and adaptation of practice to risk. Concrete suggestions are offered to inform decision-making in intimidating circumstances. Early drain removal is frequently embraced, while a step-up approach is unanimously invoked to treat severe clinically relevant pancreatic fistula.

CONCLUSION

A comprehensive conceptual framework of 4 sequential phases of decision-making is proposed-risk assessment, anastomotic technique, mitigation strategy employment, and postoperative management. Basic science studies and outcome analyses are proposed for improvement.

Predictors and Outcomes of Pancreatic Fistula Following Pancreaticoduodenectomy: a Dual Center Experience

Fistula following leaked pancreatico-enteric anastomosis is a common, potentially lethal complication of pancreaticoduodenectomy (PD). Early assessment and prediction of its occurrence can improve postoperative outcomes. Various perioperative factors were analyzed for its contribution to clinically relevant postoperative pancreatic fistula (crPOPF). Also, the difference in clinical outcomes of patients with and without fistula was studied. Sixty-seven patients undergoing PD for malignancies were analyzed during 3-year period in a dual-institutional study. Various preoperative, intraoperative, and postoperative factors were assessed. The incidence and severity of POPF and its association with the development of other post-PD complications were observed. Patients with and without POPF were divided into groups and compared with univariate and multivariate analyses, to identify significant contributing factors. Clinically relevant POPF was present in 20.9% cases. crPOPF contributed to delayed gastric emptying, albeit insignificant (p = 0.403), but was significantly associated with increased incidence of post-pancreatectomy hemorrhagic (p = 0.005) and infectious complications (p = 0.013). Soft pancreas (p = 0.024), intraoperative blood loss (p = 0.045), blood transfusion (p = 0.024), and fistula risk score (p = 0.001) were significant predictors of crPOPF. First postoperative day (POD1) drain fluid amylase (DFA) values at cut-off of 1336 U/L (AUC = 0.871; p < 0.001) significantly predicted crPOPF with good sensitivity and specificity. POD1 DFA was only factor significant on multivariate analysis (p = 0.014). There was no significant difference in overall survival between groups. crPOPF results in significant post-pancreatectomy hemorrhagic and septic complications, along with increased mortality. It can be accurately predicted by several preoperative and intraoperative factors. POD1 DFA can independently predict crPOPF development.

Clinical relevant pancreatic fistula after pancreatoduodenectomy: when negative amylase levels tell the truth

Drain Amylase level are routinely determined to diagnose pancreatic fistula after Pancreatocoduodenectomy. Consensus is lacking regarding the cut-off value of amylase to diagnosis clinically relevant postoperative pancreatic fistulae (POPF). The present study proposes a model based on Amylase Value in the Drain (AVD) measured in the first three postoperative days to predict a POPF. Amylase cut-offs were selected from a previous published systematic review and the accuracy were validated in a multicentre database from 12 centres in 2 countries. The present study defined POPF the 2016 ISGPS criteria (3 times the upper limit of normal serum amylase). A learning machine method was used to correlate AVD with the diagnosis of POPF. Overall, 454 (27%) of 1638 patients developed POPF. Machine learning excluded a clinically relevant postoperative pancreatic fistulae with an AUC of 0.962 (95% CI 0.940-0.984) in the first five postoperative days. An AVD at a cut-off of 270 U/L in 2 days in the first three postoperative days excluded a POPF with an AUC of 0.869 (CI 0.81-0.90, p < 0.0001). A single AVD in the first three postoperative days may not exclude POPF after pancreatoduodenectomy. The levels should be monitored until day 3 and have two negative values before removing the drain. In the group with a positive level, the drain should be kept in and AVD monitored until postoperative day five.