Pancreatoenteral anastomosis or direct closure of the pancreatic remnant after a distal pancreatectomy: a single-centre experience

Pancreatic adenocarcinoma: A review of recent paradigms and advances in epidemiology, clinical diagnosis and management

Pancreatic cancer is one of the dreaded malignancies for both the patient and the clinician. The five-year survival rate of pancreatic adenocarcinoma (PDA) is as low as 2% despite multimodality treatment even in the best hands. As per the Global Cancer Observatory of the International Agency for Research in Cancer estimates of pancreatic cancer, by 2040, a 61.7% increase is expected in the total number of cases globally. With the widespread availability of next-generation sequencing, the entire genome of the tumors is being sequenced regularly, providing insight into their pathogenesis. As invasive PDA arises from pancreatic intraepithelial neoplasia and mucinous neoplasm and intraductal papillary neoplasm, screening for them can be beneficial as the disease is curable with resection at an early stage. Routine preoperative biliary drainage has no role in patients suffering from PDA with obstructive jaundice. If performed, metallic stents are preferred over plastic ones. Minimally invasive procedures are preferred to open procedures as they have less morbidity. The duct-to-mucosa technique for pancreaticojejunostomy is presently widely practiced. The role of intraperitoneal drains after surgery for PDA is controversial. Neoadjuvant chemoradiotherapy has been proven to have a significant role both in locally advanced as well as in resectable PDA. Many new regimens and drugs have been added in the arsenal of chemoradiotherapy for metastatic disease. The roles of immunotherapy and gene therapy in PDA are being investigated. This review article is intended to improve the understanding of the readers with respect to the latest updates of PDA, which may help to trigger new research ideas and make better management decisions.

Efficacy of Distal Pancreatectomy Combined With Modified DuVal Procedure in Patients With a High Risk of Postoperative Pancreatic Fistula

BACKGROUND

The incidence of postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) remains high. The present study aimed to clarify the efficacy of our modified DuVal (mDuVal) pancreatojejunostomy following DP in patients with a high risk of POPF.

METHODS

The medical records of 346 consecutive patients who underwent DP between 2006 and 2016 were retrospectively reviewed. Perioperative features were compared between 24 patients undergoing mDuVal (mDuVal group) and 322 patients undergoing standard DP (standard DP group).

RESULTS

Preoperative American Society of Anesthesiologists physical status 1 was more frequent in the standard group than in the mDuVal group (P = .02). The start of a solid diet after operation was significantly earlier in the mDuVal group than in the standard DP group (P = .01), while there were no significant differences between the groups for clinically relevant POPF, amylase concentration in the drainage fluid on postoperative day 1 and days 3-5, time to drain removal, additional intervention for POPF, overall complications, or postoperative hospital stay.

DISCUSSION

The mDuVal procedure could be an option for patients with a high risk of POPF to improve the outcomes after DP. Further investigation involving large study populations is necessary to clarify the efficacy of this procedure.

Association between intraoperative and postoperative epidural or intravenous patient-controlled analgesia and pancreatic fistula after distal pancreatectomy

PURPOSE

This study aimed to elucidate the association between postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) and clinicopathological factors and intraoperative and postoperative epidural or intravenous patient-controlled analgesia (IV-PCA).

METHODS

We reviewed data of 116 patients who underwent distal pancreatectomy at Gunma University Hospital from October 2000 to October 2019. Clinical POPF was defined as the International Study Group of Pancreatic Fistula grade B or C.

RESULTS

Intraoperative and postoperative analgesia included fentanyl-mediated IV-PCA (n = 37, 32%), fentanyl-mediated epidural analgesia (n = 39, 34%), and morphine-mediated epidural analgesia (n = 40, 34%). All patients had received analgesia. Clinical POPF occurred in 34 of the 116 (29%) DP cases. Male sex (P = 0.035) and the length of operation time (P = 0.0070) were significant risk factors of clinical POPF. Furthermore, a thick pancreas was more likely to cause clinical POPF than a thin one (P = 0.052). No statistically significant difference was found between other factors, including intraoperative and postoperative analgesia (P = 0.95), total median oral morphine equivalents (P = 0.23), and clinical POPF.

CONCLUSION

Intraoperative and postoperative epidural analgesia and IV-PCA are not associated with clinical POPF after DP. Our results suggest that morphine and fentanyl can be used as IV-PCA or epidural analgesia.

Management of the pancreatic transection plane after left (distal) pancreatectomy: Expert consensus guidelines by the International Study Group of Pancreatic Surgery (ISGPS)

BACKGROUND

The aim was to evaluate the various operative techniques and outcomes used to manage the pancreatic transection plane (or stump) during a left (distal) pancreatectomy and to develop expert consensus guidelines.

METHODS

Evidence-based, clinically relevant questions were discussed and then were circulated among members of the International Study Group of Pancreatic Surgery. After agreement on the questions and statements, voting in a 9-point Likert scale was used to gauge the level of objective support for each.

RESULTS

Studies using the International Study Group of Pancreatic Surgery definition of postoperative pancreatic fistula including 16 randomized trials were reviewed to generate a series of statements set into 14 domains. There was strong consensus in the following statements: there was no difference in the postoperative pancreatic fistula rate after left pancreatectomy between the handsewn and stapler techniques; a stapling technique could not be used in all cases of left pancreatectomy; the use of an energy-based tissue sealant or a chemical sealant device or combinations of these did not impact the postoperative pancreatic fistula rate; there was no difference in the postoperative pancreatic fistula rate between the open, laparoscopic, or robotic approaches; and there are 1 or more clinically important, patient-related risk factors associated with the postoperative pancreatic fistula rate. There was weak or conditional agreement on the use of prophylactic somatostatin analogs, stents, stump closure, stump anastomosis, and the role of abdominal drains.

CONCLUSION

Areas of strong consensus suggests a change in clinical practice and priority setting. Eight domains with lower agreement will require novel approaches and large multicenter studies to determine future key areas of practice.

Prevention and treatment of pancreatic fistula after pancreatic body and tail resection: current status and future directions

Postoperative pancreatic fistula (POPF) is the most common and critical complication after pancreatic body and tail resection. How to effectively reduce the occurrence of pancreatic fistula and conduct timely treatment thereafter is an urgent clinical issue to be solved. Recent research standardized the definition of pancreatic fistula and stressed the correlation between POPF classification and patient prognosis. According to the literature, identification of the risk factors for pancreatic fistula contributed to lowering the rate of the complication. Appropriate management of the pancreatic stump and perioperative treatment are of great significance to reduce the rate of POPF in clinical practice. After the occurrence of POPF, the treatment of choice should be determined according to the classification of the pancreatic fistula. However, despite the progress and promising treatment approaches, POPF remains to be a clinical issue that warrants further studies in the future.

Surgical techniques and postoperative management to prevent postoperative pancreatic fistula after pancreatic surgery

Postoperative pancreatic fistula (POPF) is one of the most severe complications after pancreatic surgeries. POPF develops as a consequence of pancreatic juice leakage from a surgically exfoliated surface and/or anastomotic stump, which sometimes cause intraperitoneal abscesses and subsequent lethal hemorrhage. In recent years, various surgical and perioperative attempts have been examined to reduce the incidence of POPF. We reviewed several well-designed studies addressing POPF-related factors, such as reconstruction methods, anastomotic techniques, stent usage, prophylactic intra-abdominal drainage, and somatostatin analogs, after pancreaticoduodenectomy and distal pancreatectomy, and we assessed the current status of POPF. In addition, we also discussed the current status of POPF in minimally invasive surgeries, laparoscopic surgeries, and robotic surgeries.

The rate of postoperative pancreatic fistula after distal pancreatectomy is independent of the pancreatic stump closure technique - A retrospective analysis of 284 cases

BACKGROUND

Many techniques have been developed to prevent postoperative pancreatic fistula (POPF) after distal pancreatectomy, but POPF rates remain high. The aim of our study was to analyze POPF occurrence after closure of the pancreatic remnant by different operative techniques.

METHODS

Between 2006 and 2017, 284 patients underwent distal pancreatectomy in our institution. For subgroup analysis the patients were divided into hand-sewn (n = 201) and stapler closure (n = 52) groups. The hand-sewn closure was performed in three different ways (fishmouth-technique, n = 27; interrupted transpancreatic U-suture technique, n = 77; common interrupted suture, n = 97). All other techniques were summarized in a separate group (n = 31). Results were gained by analysis of our prospective pancreatic database.

RESULTS

The median age was 63 (range 23-88) years. 74 of 284 patients (26%) were operated with spleen preservation (similar rates in subgroups). ASA-classes, median BMI as well as frequencies of malignant diseases, chronic pancreatitis, alcohol and nicotine abuse were also comparable in the subgroups. Neither the rates of overall POPF (fishmouth-technique 30%, common interrupted suture 40%, stapler closure 33% and interrupted U-suture 38%) nor the rates of POPF grades B and C showed significant differences in the subgroups. However is shown to be associated with pancreatic function and parenchymal texture.

CONCLUSION

In our experience the technique of pancreatic stump closure after distal resection did not influence postoperative pancreatic fistula rate. As a consequence patient specific reasons rather than surgical techniques may be responsible for POPF formation after distal pancreatectomy.

How to close the pancreatic stump and the role of sealants

Postoperative pancreatic fistula (POPF) is the most common and also the most threatening complication following distal pancreatectomy. For this reason, morbidity and mortality of this operation remain still high. Over the last two decades, many different studies have been performed aiming to reduce the rate and the severity of POPF. However, effective treatments to prevent or avoid clinically relevant pancreatic fistula are still unclear. In this review, we discuss the current evidence on such a relevant topic.

Simplicity and Safety: Minimized Pancreatic Fistula Rate after Distal Pancreatectomy through Pancreas Stump Sutured Fish-Mouth Closure

Pancreatic stump leak after distal pancreatectomy (DP) is a major determinant for impaired postoperative recovery. Factors influencing pancreatic fistula (PF) occurrence remain of interest. Prospectively collected data from an academic surgical oncology practice were examined for predictors of PF. Seventy-five of 294 pancreatectomy patients underwent DP (26%). There were 33 men and 42 women, with a median age of 61 years (range: 18–85 years). Underlying conditions included cancer (60%) and benign processes (40%). Resections were comprising open DP (64%), laparoscopic DP (21%), and open multivisceral resections (15%). Of 21 cases with postoperative complications (28%, no death), six were PFs (8%, 2 grade A and 4 grade B). The median length of stay was six days (4–24). The PF rate was 2.0 per cent in 50 patients after sutured fish-mouth closures, but 20 per cent in cases using other techniques including stapling ( P = 0.007); no other variable was linked to PF occurrence. Length of stay was linked to complications, resection extent, malignancy, and transfusions (all at P < 0.02), but not to PF. PF rate after DP in this experience is unaffected by splenic vessel resection but seems to be minimized through a sutured fish-mouth closure technique.

Pancreatic stump closure techniques and pancreatic fistula formation after distal pancreatectomy: Meta-analysis and single-center experience

Background

Pancreatic fistula/PF is the most frequent and feared complication after distal pancreatectomy/DP. However, the safest technique of pancreatic stump closure remains an ongoing debate. Here, we aimed to compare the safety of different pancreatic stump closure techniques for preventing PF during DP.

Methods

We performed a PRISMA-based meta-analysis of all relevant studies that compared at least two techniques of stump closure during DP with regard to PF rates/PFR. We further performed a retrospective analysis of our institutional PFR in correlation with stump closure techniques.

Results

8301 studies were initially identified. From these, ten randomized controlled trials/RCTs, eleven prospective and 59 retrospective studies were eligible. Stapler closure (26%vs.31%, OR:0.73, p = 0.02), combination of stapler and suture (30%vs.33%, OR:0.70, p = 0.05), or stump anastomosis (14%vs.28%, OR:0.51, p = 0.02) were associated with lower PFR than suture closure alone. Spleen preservation/splenectomy, or laparoscopic/open DP, TachoSil^®, fibrin-like glue-application, or bioabsorbable-stapler-reinforcements (Seamguard^®) did not influence PFR after DP. In contrast, autologous patches (falciform ligament/seromuscular patches) resulted in lower PFR than no patch application (21.9%vs.25,8%, OR:0.60, p = 0.006). In our institution, the major three techniques of stump closure resulted in comparable PFR (suture:27%, stapler:29%, or combination:24%). However, selective suturing/clipping of the main pancreatic duct during pancreatic stump closure prevented severe PF (p = 0.02).

Conclusion

After DP, stapler closure, pancreatic anastomosis, or falciform/seromuscular patches lead to lower PFR than suture closure alone. However, the differences are rather small, and further RCTs are needed to test these effects. Selective closure of the main pancreatic duct during stump closure may prevent severe PF.

Predictors of 30-day readmission following pancreatic surgery: A retrospective review

BACKGROUND

Pancreatectomies have been identified as procedures with an increased risk of readmission. In surgical patients, readmissions within 30 days of discharge are usually procedure-related. We sought to determine predictors of 30-day readmission following pancreatic resections in a large healthcare system.

METHODS

We retrospectively collected information from the records of 383 patients who underwent pancreatic resections from 2004-2013. To find the predictors of readmission in the 30 days after discharge, we performed a univariate screen of possible variables using the Fisher's exact test for categorical variables and the Mann-Whitney U test for continuous variables. Multivariate analysis was used to determine the independent factors.

RESULTS

Fifty-eight (15.1%) patients were readmitted within 30 days of discharge. Of the patients readmitted, the most common diagnoses at readmission were sepsis (17.2%), and dehydration (8.6%). Multivariate logistic regression found that the development of intra-abdominal fluid collections (OR = 5.32, P < 0.0001), new thromboembolic events (OR = 4.08, P = 0.016), and pre-operative BMI (OR = 1.06, P = 0.040) were independent risk factors of readmission within 30 days of discharge.

CONCLUSION

Our data demonstrate that factors predictive of 30-day readmission are a combination of patient characteristics and the development of post-operative complications. Targeted interventions may be used to reduce the risk of readmission.

Bovine Serum Albumin-Glutaraldehyde Sealed Fish-Mouth Closure of the Pancreatic Remnant during Distal Pancreatectomy

Introduction. Postoperative pancreatic fistula formation remains the major complication after distal pancreatectomy. At our institution, we have recently developed a novel bovine serum albumin-glutaraldehyde sealed hand sutured fish-mouth closure technique of the pancreatic remnant during distal pancreatectomy. The aim of this study was to analyze the impact of this approach with regard to technical feasibility and overall postoperative outcome. Patients and Methods. 32 patients who underwent a bovine serum albumin-glutaraldehyde sealed hand sutured fish-mouth closure of the pancreatic remnant during distal pancreatectomy between 2012 and 2014 at our institution were analyzed for clinically relevant postoperative pancreatic fistula formation (Grades B and C according to ISGPF definition) and overall postoperative morbidity. Results. Three out of 32 patients (9.4%) developed Grade B pancreatic fistula, which could be treated conservatively. No Grade C pancreatic fistulas were observed. Postpancreatectomy hemorrhage occurred in 1 patient (3.1%). Overall postoperative complications > Clavien II were observed in 5 patients (15.6%). There was no postoperative mortality. Conclusion. The performance of a bovine serum albumin-glutaraldehyde sealed hand sutured fish-mouth closure of the pancreatic remnant was shown to be technically feasible and may lead to a significant decrease of postoperative pancreatic fistula formation after distal pancreatectomy.

A Review of Techniques for Closure of the Pancreatic Remnant following Distal Pancreatectomy

The prevalence of pancreatic diseases needing surgical intervention is continuously rising. Distal pancreatectomy is performed in the case of pathologies affecting the left side of the pancreas. More and more sophisticated surgical techniques have appeared and an increasing number of published articles discuss the possibilities for closure of the pancreatic remnant. However, the optimum solution is still under debate, as none of the examined techniques have been proven superior in reducing the incidence of the most common surgical complication, the formation of a postoperative pancreatic fistula (PF). Fistula rates have been stationary at 20-30% in the past decades despite the apparent advancement of medicine. This review presents a survey of the relevant articles examining different closure strategies and risk factors to reduce fistula formation rate. International medical publication database search and assessment was carried out to include the findings of studies investigating the efficacy of pancreatic remnant closure techniques to gain a clearer view on the complexity of pancreas fistulas. Emphasis is on indications for surgery, risk factors for postoperative fistula formation and strategies to seal the pancreatic remnant to avoid leakage. Findings suggest that careful patient selection, meticulous surgical techniques are equally important to reduce fistula rates. Ideal closure of the pancreatic remnant is still to be developed, as none of the widespread techniques (hand-sewn suture or staple closure) proved to be statistically significantly superior. Additional closure and covering methods (seromuscular patch, falciform ligament patch, pancreatico-enteric anastomosis, reinforced staplers, fibrin glue etc.) can have profitable effect but strong evidences are yet to come due to small case numbers. The recent introduction of standardized classification of PFs and future prospective randomized trials are more likely to be susceptible to determine if any of the standard or experimental closure techniques is more beneficial than the others.

Fluid collection after distal pancreatectomy: a frequent finding

BACKGROUND

Fluid collections (FC) at the resection margin of the pancreatic stump after distal pancreatectomy (DP) are common radiological findings in follow-up scans. No recommendations exist regarding the management of such findings. The aim was to characterise incidence, risk factors, clinical impact and therapy of FC.

METHOD

Data of 209 patients who underwent DP between 07/2009 and 06/2011 were prospectively collected and analysed, regarding follow-up CT or MRI scan findings of FC at the resection margin. FC was defined as a cyst-like lesion >1 cm in diameter.

RESULTS

A follow-up with at least two cross-sectional images was available in 159/209 patients. In the first postoperative control, 68 patients showed an FC (43%). FC size was classified as <5 cm (n = 38 pat.), 5-10 cm (n = 24 pat.) and >10 cm (n = 6 pat.). 20 patients (30%) showed clinical symptoms. Six patients (9%) required specific treatment, all other FC showed spontaneous regression. No correlation with stump closure techniques or preceding postoperative pancreatic fistula was found (4/68 patients, 6%). Multivariate analysis revealed standard resections as the only significant factor for FC.

CONCLUSIONS

FCs at the resection margin after DP are frequent and harmless findings. Therapeutic interventions are required in only 9% of all FC patients.

Successful surgical internal drainage of postoperative pancreatic pseudocyst through pancreaticojejunostomy with distal pancreatectomy: a case report

Pancreatic pseudocyst is usually treated by percutaneous external drainage, endoscopic internal or external drainage, or surgical internal drainage such as cystogastrostomy. Surgical external drainage is an option if these procedures fail. We describe a case of a 70-year-old man with a pancreatic body pseudocyst that developed postoperatively. It was improved by endoscopic external drainage, and the stent was changed to an internal stent. However, surgery was required as the pseudocyst grew again. A direct approach to the pseudocyst was not possible because of severe adhesion. A distal pancreatectomy with pancreaticojejunostomy was performed, and an external pancreatic stent tube was inserted from the cut end into the duodenum to drain the pseudocyst. One month later, the pseudocyst disappeared, and the stent was removed.

PolysorbR (an absorbable lactomer) staples, a safe closure technique for distal pancreatic resection

AIM: To investigate twenty-year experience evaluated the use of the Polysorb^R (an absorbable lactomer) staples for distal pancreatic resection.

METHODS: The data on 150 patients [92 men, 58 women, mean age 52 (24-72) years] who underwent distal pancreatectomy (DP) in the last 20 years were collected prospectively from an electronic database. The diagnosis was confirmed by endoscopic retrograde cholangiopancreatography, sonography, computed tomography and/or magnetic resonance imaging. The indications for DP were focal pancreatic necrosis, spontaneous pancreatic fistulas, abscesses, pseudocysts, segmental chronic obstructive pancreatitis in the tail, traumatic disruption, and benign (cystadenomas, insulinomas, or glucagonomas) or malignant tumours. The distal resections were performed without splenectomy in 29 of the 150 patients (19%). In the event of splenectomy, the splenic artery and vein were individually ligated, the TA-55 Auto Suture stapler, loaded with Premium Polysorb^R 55 staples (5.5 mm), was placed across the gland, and the trigger was pulled, the action of which produced two staggered absorbable suture lines. The gland distal to the stapler was then amputated with a scalpel on the TA-55 stapler and the two rows of staples were left in the proximal pancreatic stump. After the distal resection, a drainage tube was inserted into the pancreatic bed.

RESULTS: The average duration of the operation was 150 min (range: 90-210 min) and no transfusion was indicated during the operation. After DP in one patient a type B fistula was diagnosed, which was treated successfully by conservative treatment comprising of 12-d octreotide medication (3 × 0.1 mg/d) and jejunal feeding. The incidence of postoperative pancreatic fistula was therefore 0.6%. Another 2 patients suffered postoperative pancreatitis, which was also conservatively treated. Reoperations were performed in 2 patients on the first or second postoperative day, necessitated by bleeding from the retroperitoneal region. The morbidity was 3.3% (5 patients), but no mortality occurred in the postoperative period. Overall, the postoperative period was uneventful without any complications (pancreatic fistula, abscess, bleeding or wound infection) in 145 patients. The length of the postoperative stay ranged between 8 and 16 d. For the 145 patients who had no any postoperative complications, the hospital stay was 8 or 9 d. No mortality occurred in the follow-up period (6 or 12 mo postoperatively); but 6 mo after surgery one patient suffered a pseudocyst following recurrent pancreatitis and was treated with cystojejunostomy.

CONCLUSION: Our clinical results demonstrated that the application of absorbable lactomer staples for distal pancreatic resection is a safe alternative to the standard closure technique.

Systematic review and meta-analysis comparing three techniques for pancreatic remnant closure following distal pancreatectomy

BACKGROUND

Established closure techniques for the pancreatic remnant after distal pancreatectomy include stapler, suture and anastomotic closure. However, controversy remains regarding the ideal technique; therefore, the aim of this study was to compare closure techniques and risk of postoperative pancreatic fistula (POPF).

METHODS

A systematic review was carried out according to PRISMA guidelines for studies published before January 2014 that compared at least two closure techniques for the pancreatic remnant in distal pancreatectomy. A random-effects model was constructed using weighted odds ratios (ORs).

RESULTS

Thirty-seven eligible studies matched the inclusion criteria and 5252 patients who underwent distal pancreatectomy were included. The primary outcome measure, the POPF rate, ranged 0 from to 70 per cent. Meta-analysis of the 31 studies comparing stapler versus suture closure showed that the stapler technique had a significantly lower rate of POPF, with a combined OR of 0.77 (95 per cent c.i. 0.61 to 0.98; P = 0.031). Anastomotic closure was associated with a significantly lower POPF rate than suture closure (OR 0.55, 0.31 to 0.98; P = 0.042). Combined stapler and suture closure had significantly lower POPF rates than suture closure alone, but no significant difference compared with stapler closure alone.

CONCLUSION

The use of stapler closure or anastomotic closure for the pancreatic remnant after distal pancreatectomy significantly reduces POPF rates compared with suture closure. The combination of stapler and suture closure shows superiority over suture closure alone.

Is Roux-Y binding pancreaticojejunal anastomosis feasible for patients undergoing left pancreatectomy? Results from a prospective randomized trial

Background. After pancreaticoduodenectomy, the Finnish binding pancreaticojejunal anastomosis (FBPJ) seems to reduce the risk for pancreatic fistula (POPF). Our aim was to investigate whether FBPJ is feasible and prevents the risk for POPF even after left pancreatectomy (LP). Patients and Methods. 47 consecutive patients underwent LP. 27 patients were recruited on the basis of CT and, of these, 16 patients were randomized on the basis of findings during surgery (transection line must be left of portal vein, as 2-3 cm pancreatic mobilization is required for FBPJ) to receive either Roux-Y FBPJ or hand-sewn closure of the pancreatic remnant. Results. Only 34% (16/47) of the patients met the randomization criteria. Clinically significant POPF rate was higher in FBPJ group (60%) compared to thand-sewn closure group (13%; P < 0.05). POPF rate in FBPJ group was higher even when compared to all patients with hand-sewn closure (60% versus 37%; P < 0.05). Overall, FBPJ was technically feasible for only 28% of patients. Conclusion. FBPJ cannot be recommended for the routine closure of the pancreatic remnant after LP, as it was not technically achievable in 72% of the cases. Moreover, the technique does not seem to reduce the risk for POPF compared to the hand-sewn closure.

Rapid postoperative reduction in prognostic nutrition index is associated with the development of pancreatic fistula following distal pancreatectomy

BACKGROUNDS

Despite recent advances in surgical techniques and devices for pancreatic remnant closure, postoperative pancreatic fistula (POPF) still remains one of the common complications after distal pancreatectomy (DP). Identification of risk factors for POPF may lead to the development of new strategies to prevent this ominous complication.

METHODS

We retrospectively reviewed data on 44 patients undergoing DP with the use of a stapler to identify risk factors for POPF. Study variables included preoperative prognostic nutritional index (PNI) and reduction rate of PNI on postoperative day (POD) 7.

RESULTS

POPF occurred in 23 patients (52%), of which 13 (56%) were grade B or C. Univariate analyses comparing patients with POPF and those without POPF showed significant differences in body mass index (P = 0.0102), pancreatic thickness (P = 0.0134), white blood cell count on POD7 (P = 0.0432), C-reactive protein level on POD7 (P = 0.0123), and PNI reduction rate (P = 0.0471). A multivariate analysis revealed pancreatic thickness (P = 0.0121) and PNI reduction rate (P = 0.0165) to be significant factors for POPF. Furthermore, the PNI reduction rate was significantly higher in patients with clinically relevant (grade B/C) POPF than in those with no or grade A POPF (P = 0.0257). In most patients, the massive postoperative PNI reduction preceded the diagnosis of clinically relevant POPF.

CONCLUSIONS

These findings suggest that rapid postoperative reduction in PNI is associated with the development of POPF.