Isolated Roux-en-Y pancreaticojejunostomy versus conventional pancreaticojejunostomy after pancreaticoduodenectomy: a systematic review and meta-analysis

Big data and RCT's in surgical oncology: Impact on improving hepatopancreatobiliary cancer surgical care on the global stage

Randomized controlled clinical trials (RCTs) are at the heart of "evidence-based" medicine. Conducting well-designed RCTs for surgical procedures is often challenged by inadequate recruitment accrual, blinding, or standardization of the surgical procedure, as well as lack of funding and evolution of the treatment strategy during the many years over which such trials are conducted. In addition, most clinical trials are performed in academic high-volume centers with highly selected patients, which may not necessarily reflect a "real-world" practice setting. Large databases provide easy and inexpensive access to data on a large and diverse patient population at a variety of treatment centers. Furthermore, large database studies provide the opportunity to answer questions that would be impossible or very arduous to answer using RCTs, including questions regarding health policy efficacy, trends in surgical practice, access to health care, the impact of hospital volume, and adherence to practice guidelines, as well as research questions regarding rare disease, infrequent surgical outcomes, and specific subpopulations. Prospective data registries may also allow for quality benchmarking and auditing. There are several high-quality RCTs providing evidence to support current practices in hepatopancreatobiliary (HPB) oncology. Evidence from big data bridges the gap in several instances where RCTs are lacking. In this article, we review the evidence from RCTs and big data in HPB oncology identify the existing lacunae, and discuss the future directions of research in HPB oncology.

Prospective Study Correlating External Biliary Stenting and Pancreatic Fistula Following Pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is the most common complication of pancreaticoduodenectomy (PD). Sometimes POPF is associated with biliary fistula (BF) or "mixed" fistula. The purpose of this study is to assess whether the severity of the fistulae, when present, is decreased with an external biliary stent in place.

METHODS

In this single-center study, we assessed patients who underwent elective PD from January 2014 to December 2017. Patients were divided into two groups: standard PD (ST-PD) vs. PD with external biliary stent (PD-BS). Demographic, preoperative, intraoperative, and postoperative variables were analyzed, including complications according to the Clavien-Dindo classification, and those specific to pancreatic surgeries, and mortality rates within 90 days of operation.

RESULTS

A total of 128 patients were included (65 in ST-PD group and 63 in PD-BS group). Postoperative complications occurred in 61.7% of patients (32.8%, Clavien-Dindo ≥ III) and were more common among patients in the PD-BS group (44.4% vs. 23.1%; p = 0.03). POPF was also more common among patients in the PD-BS group (39.7% vs. 18.5%; p = 0.008). No statistically significant differences were found for any other complications.

CONCLUSION

Based on the results of our study, placement of a transanastomotic external biliary stent does not reduce the rate of pancreatic or biliary fistulae, or their severity; in fact, POPF is more likely when biliary exteriorization is present.

TRIAL REGISTRATION

NCT04654299.

[Actual issues of pancreatic tumor surgery]

OBJECTIVE

To analyze the features of diagnosis and treatment of pancreatic tumors.

MATERIAL AND METHODS

This report is based on the results of 389 surgeries for different pancreatic neoplasms performed in the abdominal surgery department of the Vishnevsky Center of Surgery between 2016 and 2020.

RESULTS

Most serous cystic adenomas don't require surgical treatment. At the same time, mucinous cystic neoplasms should be exsiced. Intraductal papillary mucinous neoplasms type I and III should be surgically treated in organ-sparing fashion. Minimally invasive enucleation is desirable for solid pseudopapillary neoplasm. There is a high risk of post-pancreatecomy pancreatitis and fistula in patients with pancreatic neuroendocrine tumors. Pancreatic fistula and hemorrhage occurred in 23% and 17% of cases after pancreaticoduodenectomy (n=211), respectively.

CONCLUSION

The choice of surgical strategy for pancreatic tumors is a quite complex problem. Technical features of surgeries require special experience. Surgical treatment of patients with pancreatic tumors should be carried out in specialized pancreatic centers.

Impact of gastric resection and enteric anastomotic configuration on delayed gastric emptying after pancreaticoduodenectomy: a network meta-analysis of randomized trials

Introduction

Delayed gastric emptying (DGE) is frequent after pancreaticoduodenectomy (PD). Several RCTs have explored operative strategies to minimize DGE, however, the optimal combination of gastric resection approach, anastomotic route, configuration and the use of enteroenterostomy remains unclear.

Methods

MEDLINE, Embase and CENTRAL databases were systematically searched for RCTs comparing gastric resection (classic Whipple, pylorus-resecting, pylorus-preserving), anastomotic route (antecolic, retrocolic), configuration (loop gastroenterostomy/Billroth II, Roux-en-Y), and use of enteroenterostomy (Braun). A random-effects, Bayesian network meta-analysis with non-informative priors was conducted to determine the optimal combination of approaches to PD for minimizing DGE.

Results

Twenty-four RCTs, including 2526 patients and 14 approaches were included. There was some heterogeneity, although inconsistency was low. The overall incidence of DGE was 25.6 per cent (647 patients). Pylorus-resecting, antecolic, Billroth II with Braun enteroenterostomy was associated with the lowest rates of DGE and ranked the best in 35 per cent of comparisons. Classic Whipple, retrocolic, Billroth II with Braun ranked the worst for DGE in 32 per cent of comparisons. Pairwise meta-analysis of retrocolic versus antecolic route for gastrojejunostomy found increased risk of DGE with the retrocolic route (odds ratio 2.10, 95 per cent credibility interval (cr.i.) 0.92 to 4.70). Pairwise meta-analysis of enteroenterostomy found a trend towards lower DGE rates when this was used (odds ratio 1.90, 95 per cent cr.i. 0.92 to 3.90). Having a Braun enteroenterostomy ranked the best in 96 per cent of comparisons.

Conclusion

Based on existing RCT evidence, a pylorus-resecting, antecolic, Billroth II with Braun enteroenterostomy seems to be associated with the lowest rates of DGE.

Preregistration

PROSPERO submitted 23 December 2020. CRD42021227637

[Prevention of pancreatic fistula after pancreatoduodenectomy]

OBJECTIVE

Prospective randomized investigation of the efficiency of somatostatin analogues and glucocorticoids in pancreatic fistula prevention after pancreatoduodenectomy by using.

MATERIAL AND METHODS

In period from December 2018 till March 2020 78 patients underwent pancreatoduodenectomy for pancreatobilliary tumors in department of abdominal surgery of National Medical Research Center of Surgery named after A.V. Vishnevsky. Intraoperative frozen section investigation of pancreatic functioning acinar structures (FAS) was held for all patients. 38 patients had more than 40% of FAC and were related with high risk of pancreatic fistula (PF), while 40 patients with less than 40% FAC were included in low risk of PF group. In both groups patients were randomized to main and control subgroups. In main subgroup of high risk group patients combination of somatostatin analogues and glucocorticoids was used, while in control subgroup patients received only somatostatin analogue. In low risk of PF group patients of main subgroup preventively got somatostatin analogue, while control group patients had no specific prophylaxis of PF. To assess the effect of drug prophylaxis on the development of pancreatic fistula we used logistic regression models with the inclusion of the drug use factor as an independent variable.

RESULTS

25 patients were included in main subgroup of high risk group. Clinically relevant pancreatic fistula (CRPF) developed in 14 (56%) cases. From 13 patients of control subgroup CRPF developed in 5 (38%) cases. In main subgroup of low risk group 18 patients were included and 3 (16%) of them had CRPF. In control subgroup were 22 patients and there were no cases of CRPF.

CONCLUSION

In our series combination of somatostatin analogue and glucocorticoid didn't show efficiency in prevention of CRPF in high risk patients, although difference between subgroups wasn't statistically significant (p=0.34). In low risk group patients prophylactic use of somatostatin analogue also didn't show decline of CRPF incidence and the difference between subgroups also wasn't statistically significant (p=0.46).

Delayed gastric emptying following pancreatoduodenectomy: a Roux-en-Y gastrojejunostomy vs Billroth II gastrojejunostomy randomized study

INTRODUCTION

delayed gastric emptying (DGE) is the most common complication after pancreaticoduodenectomy (PD) and it occurs in 50% of cases.

OBJECTIVES

the endpoint was to determine if there were any differences in the incidence of DGE between Roux-en-Y gastrojejunostomy (ReY) and Billroth II gastrojejunostomy (BII) in PD with pancreaticogastrostomy (PG).

METHODS

this was a case-control prospective randomized study of all PD cases between 2013 and 2016. Sixty-four patients were included, 32 in each group. An intention-to-treat statistical analysis was performed.

RESULTS

no significant differences were found with regard to morbidity and mortality or hospital stay. DGE was present in 25% of the patients in the BII group in comparison to 15.6% in the ReY group, which was not statistically significant (p = 0.35). There was a higher percentage of patients with primary DGE in the BII group, 12.5% versus 6.2%, but this was not statistically significant (p = 0.53). No difference in DGE severity was observed. Male gender (OR 8.38 [1.1; 129]), abdominal complications (OR 15 [1.7; 396.9]), pre-operative malnutrition (OR 99.7 [3.3, 11,126]) and hemorrhage (OR 9.4 [1.37, 107.94]) were the main risk factors for DGE according to the multivariate analysis.

CONCLUSIONS

there were no significant differences in the incidence or severity of DGE between BII or ReY after PD with PG.

National survey on Pancreatic Surgery Units

INTRODUCTION

The technical, human, scientific and treatment characteristics of the Units that manage complex pathologies have not been studied in depth.

METHODS

Multi-institutional descriptive study (survey) developed jointly by the Hepatobiliary-Pancreatic Division of the Spanish Association of Surgeons and the Spanish Chapter of the IHPBA (International Hepatopancreatobiliary Association) on the characteristics of the Units where pancreatic surgery is performed in Spain.

RESULTS

82 surveys were sent. 69 medical centers responded (84%), belonging to 16 autonomous regions of Spain. The total population of these regions was 23,183,262 (50% of the Spanish population). The average number of beds per hospital was 673. The unit that performs pancreatic surgery is a Hepatobiliary-Pancreatic Surgery Unit or HPB and Liver Transplant Surgery Unit in 56 hospitals (77%). The average number of surgeons is 4.5 per Unit. Fifty-five Units (80%) lack specific anesthetists. The number of pancreatectomies performed during 2017 at the hospitals surveyed was 1,315 pancreaticoduodenectomies (PD), 566 distal pancreatectomies (DP) and 178 total pancreaticoduodenectomies (TPD). The mean per hospital was 19.1 PD, 8.2 DP and 2.6 TPD. PD was usually performed using a classic approach, with pancreatojejunostomy, single-loop technique, antecolic gastrojejunostomy and using two drain tubes. Only 7 Units performed PD laparoscopically and only 13 units did not perform laparoscopic DP.

CONCLUSIONS

This survey provides updated information about the majority of the Units where pancreatic surgery is performed in Spain and could also serve as a starting point for prospective multicenter studies.

Dual loop (Roux en Y) reconstruction with isolated gastric limb reduces delayed gastric emptying after pancreatico-duodenectomy

BACKGROUND

Single loop reconstruction (SLR) was routine in our institution for patients undergoing pancreatico-duodenectomy (PD). Roux-en Y reconstruction with an isolated gastric limb (RIGL) recently became the reconstruction of choice.

AIM

To evaluate the impact of RIGL on incidence and severity of delayed gastric emptying (DGE).

METHODS

This is a single institution, retrospective analysis of patients undergoing PD. All patients undergoing PD from July 2010 through December 2016 were included in the study. Outcome of RIGL were compared to SLR. Primary measure of outcome included incidence and severity of DGE. Secondary measures of outcome were overall complications and postoperative mortality.

RESULTS

One hundred and seventy-nine patients were included in the study. Fifty-two had RIGL, 127 had SLR. Overall complication rate was 40.2%, patients in the RIGL group experienced lower rates of DGE (15.4% vs 59.1%, P = 0.001). Other patient related outcomes were also significantly reduced: day of nasogastric tube removal (3 vs 5, P < 0.001), regain of normal diet (8 vs 9, P < 0.001). On multivariate analysis RIGL was associated independently with reduced rates of DGE (P < 0.001, OR 0.14)

CONCLUSION

The current study shows that RIGL reduces the rate of DGE after PD. Further prospective randomized controlled trials are required to affirm the current data.

A modified single-loop reconstruction after pancreaticoduodenectomy reduces severity of postoperative pancreatic fistula in high-risk patients

BACKGROUND

Double-loop (DL) reconstruction after pancreaticoduodenectomy (PD), diverting pancreatic from biliary secretions, has been reported to reduce rates and severity of postoperative pancreatic fistula (POPF) compared to single loop (SL) reconstruction at the price of prolonged operative duration. This study investigated the feasibility of a new reconstruction method combining the advantages of DL with the simplicity of SL in patients with high-risk pancreas.

METHODS

A modified single-loop (mSL) reconstruction was used in patients undergoing PD with a soft pancreatic remnant and a pancreatic duct smaller than 3 mm (n = 50). The loop between the pancreatic and the biliary anastomoses was left longer and a side-to-side jejunojejunal anastomosis was performed between them at the lowest point to promote isolated flow of pancreatic and biliary secretions. Rate and severity of POPF, mortality, duration of surgery, and POPF-associated morbidity were compared to those of 50 matched patients with SL and 25 patients with DL reconstruction.

RESULTS

Duration of surgery was 57 min longer for DL, but equal for mSL and SL. The POPF rate did not differ between the three groups. The severity of POPF was more pronounced in the SL group (62% grade C: p = 0.011). Mortality and major morbidity were lower and hospital stay shorter in the mSL and DL groups compared to the SL group.

CONCLUSIONS

The new mSL reconstruction was safer than conventional SL and faster to perform than DL reconstruction in patients with a high-risk pancreas. It did not influence the rate of POPF, but reduced its severity, leading to less major morbidity and mortality.

[Evidence-based supportive measures to secure pancreatic anastomoses]

BACKGROUND

Pancreatic anastomosis is the Achilles heel of pancreatic surgery. Despite substantial progress in surgical techniques the rate of postoperative pancreatic fistulas remains very high. For this reason various supportive measures to secure pancreatic anastomoses are of continuing interest.

OBJECTIVE

This review presents the newest evidence-based data on supportive measures designed to secure a pancreatic anastomosis.

MATERIAL AND METHODS

The most recent meta-analyses, randomized controlled trials and the largest retrospective studies on the role of pancreatic duct stenting, double loop reconstruction, autologous patches and drainage in pancreaticoduodenectomy were taken into account. The value of somatostatin analogues, perioperative nutrition and fluid management is critically discussed.

RESULTS

The existing body of evidence on supportive measures is insufficient and remains controversial. The use of somatostatin analogues, drainages and restrictive perioperative fluid management has proven effective. In contrast, routine stenting of the pancreatic duct cannot be recommended. Other approaches, such as double loop reconstruction and use of autologous patches lack sufficient evidence.

CONCLUSION

Meticulous surgical technique and surgeon experience remain the cornerstones of performing a safe pancreatic anastomosis; however, some additional supportive measures seem to have significant potential and should be further investigated in large and well-designed prospective clinical trials.