Prevention and treatment of complications in pancreatic cancer surgery

Comparison of endoscopic ultrasound-guided drainage and percutaneous catheter drainage of postoperative fluid collection after pancreaticoduodenectomy

Backgrounds/Aims

Postoperative fluid collection is a common complication of pancreatic resection without clear management guidelines. This study aimed to compare outcomes of endoscopic ultrasound (EUS)-guided trans-gastric drainage and percutaneous catheter drainage (PCD) in patients who experienced this adverse event after pancreaticoduodenectomy (PD).

Methods

Demographic and clinical data and intervention outcomes of 53 patients who underwent drainage procedure (EUS-guided, n = 32; PCD, n = 21) for fluid collection after PD between January 2015 and June 2019 in our tertiary referral center were retrospectively analyzed.

Results

Prior to drainage, 83.0% had leukocytosis and 92.5% presented with one or more of the following signs or symptoms: fever (69.8%), abdominal pain (69.8%), and nausea/vomiting (17.0%). Within 8 weeks of drainage, 77.4% showed a diameter decrease of more than 50% (87.5% in EUS vs. 66.7% in PCD, p = 0.09). Post-procedural intravenous antibiotics were used for an average of 8.1 ± 4.3 days and 12.4 ± 7.4 days for EUS group and PCD group, respectively (p = 0.01). The EUS group had a shorter post-procedural hospital stay than the PCD group (9.8 ± 1.1 vs. 15.8 ± 2.2 days, p < 0.01). However, the two groups showed no statistically significant difference in technical or clinical success rate, reintervention rate, or adverse event rate.

Conclusions

EUS-guided drainage and PCD are both safe and effective methods for managing fluid collection after PD. However, EUS-guided drainage can shorten hospital stay and duration of intravenous antibiotics use.

Factors associated with unplanned transfers among cancer patients at a freestanding acute rehabilitation facility

BACKGROUND

Cancer patients undergoing inpatient rehabilitation often have high risk of complications leading to unplanned transfer to acute care. Prior studies have identified factors associated with these transfers but have been limited to examining factors that pertain to initial admission to rehabilitation and were not conducted in a freestanding inpatient rehabilitation facility.

OBJECTIVE

The study aimed to include these prerehabilitation factors in addition to factors upon initial assessment in rehabilitation. It was hypothesized that specific factors from each of these periods would be associated with unplanned transfer to acute care.

DESIGN

Retrospective cohort study.

SETTING

Freestanding academic inpatient rehabilitation facility affiliated with an academic tertiary care facility with a comprehensive cancer center.

PATIENTS

Retrospective review of 330 specific encounters unique to 250 patients from March 2017 to September 2018.

MAIN OUTCOME MEASURES

The outcome measure was unplanned transfer to acute care. A binary logistic regression model was used to examine the relationship between factors from oncologic history, acute care course, and factors upon admission to rehabilitation to unplanned transfer to acute care.

RESULTS

From 330 encounters, there were 111 unplanned transfers (34%). Unplanned transfer to acute care was independently associated with gastrointestinal malignancy (odds ratio [OR] 4.4, p = .01), 6-minute walk test less than 90 m (OR 4.6, p = .003), and prior unplanned transfer (OR 3.5, p = .007).

CONCLUSIONS

The study suggests that oncologic and functional prerehabilitation markers are associated with an increased likelihood of unplanned transfer during inpatient cancer rehabilitation. These findings will provide a framework for creating predictive tools for unplanned transfers in cancer rehabilitation patients.

The prognostic value of Presepsin for postoperative complications following pancreatic resection: A prospective study

Background

Presepsin is involved in binding lipopolysaccharides and previous studies have confirmed its value as a marker for early diagnosis and prediction of severity in sepsis. Comparable studies assessing the predictive potential regarding postoperative complications and mortality following pancreatic resection are lacking.

Methods

This prospective study included 70 patients undergoing pancreatic resection from December 2017 until May 2019. Presepsin was measured preoperatively, on postoperative day 1, 3 and 8 (POD1/3/8) and correlated with the clinical course and mortality.

Results

Severe complications (Clavien-Dindo ≥3a) occurred in 28 patients (40%), postoperative pancreatic fistula (POPF) grade B/C occurred in 20 patients (28.6%), infectious complications in 28 (40%), and four patients (5.7%) died during hospital stay. Presepsin levels at any timepoint did not correlate with further development of postoperative complications or in-hospital mortality whereas CRP levels on postoperative day (POD) 3 were significantly associated with clinically relevant POPF (AUC 0.664, 95%CI 0.528–0.800; p = 0.033). Preoperative Presepsin levels as well as Presepsin on POD1 were significantly elevated in patients with malignant compared to benign underlying disease (299pg/ml vs. 174pg/ml and 693.5pg/ml vs. 294pg/ml; p = 0.009 and 0.013, respectively).

Conclusion

In our cohort, Presepsin was not eligible to predict the postoperative course following pancreatic resection. However, Presepsin levels were significantly elevated in patients with malignant disease, this finding warrants further investigation.

Comparison between two different reconstruction techniques after pancreatic head resection. Technical feasibility and clinical benefits

BACKGROUND

The study aim was to evaluate if diverting drainage of bile and pancreatic secretions with an isolated Roux loop technique helps to decrease the rate of postoperative morbidity and mortality, in particular postoperative pancreatic fistula (POPF).

METHODS

A prospectively maintained database between 2006 and 2018 was reviewed. Patients who underwent primary elective pancreaticoduodenectomy were included. Two types of reconstruction methods were compared: single loop (SJL) reconstruction (28 patients) and isolated Roux-en-Y (DJL) reconstruction (36 patients). Demographic characteristics and perioperative results were compared between the two groups.

RESULTS

This study includes 64 patients. The average duration of surgery was 308 mins; it was longer for DJL (P<0.0001). Major postoperative complications were seen in 24 patients (9 in SJL; 15 in DJL) without statistically significant difference. The most frequent complication that occurred was PJ anastomosis failure (4 in SJL; 6 in DJL). The choice of postoperative complication management was not related to surgical reconstruction technique (P=0.389). Length of hospital stay in DJL was significantly longer than in SJL (P=0.04).

CONCLUSIONS

No significant advantage of one technique over the other was found. In our opinion, surgeons should choose the approach with which they have the most experience and ease.

Imaging of post-operative pancreas and complications after pancreatic adenocarcinoma resection

Pancreatic ductal adenocarcinoma is one of the leading causes of cancer-related deaths. With surgical resection being the only definitive treatment, improvements in technique has led to an increase in number of candidates undergoing resection by inclusion of borderline resectable disease patients to the clearly resectable group. Post-operative complications associated with pancreaticoduodenectomy and distal pancreatectomy include delayed gastric emptying, anastomotic failures, fistula formation, strictures, abscess, infarction, etc. The utility of dual-phase CT with multiplanar reconstruction and 3D rendering is increasingly recognized as a tool for the assessment of complications associated with vascular resection and reconstruction such as hemorrhage, pseudoaneurysm, vascular thrombosis, and ischemia. Prompt recognition of the complications and distinction from benign post-operative findings such as hepatic steatosis and mesenteric fat necrosis on imaging plays a key role in helping decrease the morbidity and mortality associated with surgery. We discuss, with case examples, some of such common and uncommon findings on imaging to familiarize the abdominal radiologists evaluating post-operative imaging in both acute and chronic post-operative settings.

Pancreaticoduodenectomy for nonampullary duodenal lesions: indications and results

BACKGROUND

Pancreaticoduodenectomy (PD) is a complex procedure, associated with a definite risk of mortality and 30-50% risk of complications. For nonampullary duodenal lesions, PD can carry a higher morbidity as they are more commonly associated with a soft pancreas and narrow-calibre main pancreatic ducts. It is therefore paramount that the risks and benefits of surgery are considered carefully in this group of patients. A preoperative histological diagnosis for duodenal lesions is normally achieved by endoscopic biopsy. In this study, we aim to assess the outcome of PD in patients with nonampullary duodenal lesions and correlate the preoperative endoscopic histology work-up with the definitive postoperative pathology.

MATERIALS AND METHODS

We reviewed a prospectively collected PD database from January 2007 to December 2013. Demographic and clinical data were included. Preoperative endoscopic histology was compared with final specimen histology to assess concordance.

RESULTS

Forty patients (55% women, mean age 69.4 years, range 45-83 years) underwent PD for duodenal lesions over a 7-year time period. The most common presenting symptom was epigastric pain (32.5%), followed by anaemia (20%). Overall, the complication rate was 55%, with the most frequent adverse event being pancreatic fistula in 13/40 (32.5%). The perioperative mortality was 2/40 (5%). Duodenal adenocarcinoma (65%) was the most common postoperative histological diagnosis. The mean tumour size was 36 mm (range 5-103 mm) and a median of 13 nodes were harvested. The median length of stay was 15 days (range 7-66 days). Overall, 12/40 patients (30%) had a preoperative diagnosis of high-grade dysplasia. The postoperative specimen in this subgroup of patients was reviewed carefully and only 3/12 (25%) patients had high-grade dysplasia in the resection specimen. In the remaining patients, 3/12 (25%) had adenocarcinoma in the resection specimen and 6/12 patients (50%) had low-grade dysplasia.

CONCLUSION

PD carries a high mortality and morbidity, especially for duodenal lesions. We recommend a careful endoscopic review after the index case with a high-definition optical evaluation of duodenal lesions. This, in addition to an experienced histological assessment of the index biopsy material, forms an essential prerequisite in aiding the multidisciplinary team in the decision-making process with respect to triage of these lesions to conservative management, surveillance, endoscopic resection or finally surgical resection.

Clinical outcomes of pancreaticoduodenectomy in octogenarians: a surgeon's experience from 2007 to 2015

BACKGROUND

As the number of elderly people in our population increases, there will be a greater number of octogenarians who will need pancreaticoduodenectomy as the only curative option for periampullary malignancies. This study evaluated clinical outcomes of pancreaticoduodenectomy in octogenarians, in comparison to younger patients.

METHODS

A retrospective review was conducted of 216 consecutive patients who underwent pancreaticoduodenectomy from January 2007 to April 2015. A two-sided Fisher's exact statistical analysis was used to compare pre-operative comorbidities, intra-operative factors, surgical pathology, and post-operative complication rates between non-octogenarians and octogenarians.

RESULTS

One hundred and eighty three non-octogenarians and 33 octogenarians underwent pancreaticoduodenectomy. Of patients with periampullary adenocarcinoma, octogenarians were more likely to present with advanced disease state (P=0.01). The two cohorts had similar ASA scores (P=0.62); however, octogenarians were more likely to have coronary artery disease (P=0.03). The length of operation was shorter in octogenarians (P=0.002). Mortality rates (P=0.49) and overall postoperative complication rates (P=1.0) were similar in two cohorts; however octogenarians had a higher incidence of pulmonary embolism (P=0.02).

CONCLUSIONS

Our data demonstrates that octogenarians can undergo pancreaticoduodenectomy with outcomes similar to those in younger patients. Thus, patients should not be denied a curative surgical option for periampullary malignancy based on advanced age alone.

A Novel Technique for Managing Pancreaticojejunal Anastomotic Leak after Pancreaticoduodenectomy

Pancreaticoduodenectomy (Whipple's procedure) remains the only definitive treatment option for tumors of the periampullary region. The most common and life-threatening complications following the procedure are pancreatic anastomotic leakage and subsequent fistula formation. When these complications occur, treatment strategy depends on the severity of anastomotic leakage, with patients with severe leakages requiring reoperation. The optimal surgical method used for reoperation is selected from among different options such as wide drainage, definitive demolition of the pancreaticojejunal anastomosis and performing a new one, or completion pancreatectomy. Here we present a novel, simple technique to manage severe pancreatic leakage via ligamentum teres hepatis patch.

Preventive effects of ulinastatin on complications related to pancreaticoduodenectomy: A Consort-prospective, randomized, double-blind, placebo-controlled trial

Postoperative pancreatic fistula (POPF) is one of the most common major complications after pancreaticoduodenectomy (PD). Ulinastatin is an intrinsic trypsin inhibitor and mainly used to treat acute pancreatitis, chronic recurrent pancreatitis, and acute circulatory failure. The study aims to investigate the efficacy of ulinastatin on pancreatic fistula and other complications after PD. This prospective, randomized, double-blind, placebo-controlled trial was conducted in West China Hospital of Sichuan University from December 2012 to December 2014. A total of 106 consecutive patients undergoing PD were randomly assigned to receive ulinastatin or placebo during and after the surgery for 5 days. Baseline clinical characteristics and outcomes of patients were recorded and analyzed. Ninety-two patients including 42 in the ulinastatin group and 50 in the placebo group were available for outcome assessment. The POPF rates were comparable between ulinastatin group (43%) and placebo group (26%), whereas the severe pancreatic fistula rate (grade B + C) was significantly less in ulinastatin group than that in placebo group (7% vs 24%, P = 0.045). For patients with small pancreatic duct diameter (≤3 mm), ulinastatin could significantly reduce the risk of POPF (P = 0.022). Ulinastatin had protective effects for patients undergoing PD on the prevention of severe postoperative pancreatic fistula.

[Treatment of postoperative impairment of gastrointestinal motility, cholangitis and pancreatitis]

Although the mortality associated with major hepatopancreaticobiliary surgery has continuously decreased during the last decades, the morbidity of these procedures remains high. Functional disturbances of normal gastrointestinal motility as well as inflammation and infections of surgically treated organs are frequent complications resulting in considerably prolonged lengths of stay in hospital and increased healthcare costs. This review article highlights the therapeutic approaches and recent developments in the treatment of delayed gastric emptying, prolonged postoperative ileus, postoperative cholangitis and pancreatitis after hepatopancreaticobiliary surgery. Current practice is discussed on the basis of recent results in basic and clinical research, review articles, meta-analyses and guidelines.

Enclosed passive infraversion lavage-drainage system (EPILDS): a novel safe technique for local management of early stage bile leakage and pancreatic fistula Post Pancreatoduodenectomy

This study's objective was to test the new drainage apparatus called enclosed passive infraversion lavage-drainage system (EPILDS) in the treatment of bile leakage and pancreatic fistula Post Pancreatoduodenectomys. The EPILDS device has a design of a siphon. The inlet bag that contains the rinse liquid is put lower than the abdominal lacuna to be washed but higher than the outlet bag. The hydrostatic pressure difference between the inlet and outlet bags constitutes the driving force of the flow. The three-way cock valves are installed in the inlet and outlet tubes to facilitate the washing of occluded tubes. Two side by side Penrose drainage tubes were placed during the operation. One tube passed through the posterior side of pancreatico-jejunal and biliary-jejunal anastomoses, right paracolic gutter, and exited through an opening made in the right lower abdomen. Second tube came from the smaller sac, went through the anterior side of pancreatico-jejunal and biliary-jejunal anastomoses, and exited through an opening made in the left upper abdomen. Using this system, we successfully treated two patients. Both inlet and outlet volumes were observed to verify that the outlet exceeds the inlet volume. In conclusion, EPILDS has a simple and practical design. It changes the active washing process into a passive one, in which the input is controlled by the exiting fluid. This is the effective and safe system for treatment of severe bile leakage and pancreatic fistula at the early postoperative stage.

A comparative analysis of postoperative pancreatic fistulas after surgery with and without hyperthermic intraperitoneal chemoperfusion

BACKGROUND

Postoperative pancreatic fistulas (POPFs) are potentially morbid complications that often require therapeutic interventions. Distal pancreatectomy performed during cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemoperfusion (HIPEC) puts patients at risk for POPF. The authors hypothesized that POPFs are more severe after CRS/HIPEC than after pancreatectomy alone.

METHODS

Clinicopathologic and perioperative details, including POPF by International Study Group of Pancreatic Fistula criteria (ISGPF), and oncologic outcomes for patients undergoing distal pancreatectomy during CRS/HIPEC for peritoneal carcinomatosis of appendiceal (n = 31) or colorectal (n = 23) origin (HIPEC group) were compared with those for patients undergoing minimally invasive or open distal pancreatectomy without HIPEC (n = 66) for locally resectable pancreatic adenocarcinoma (non-HIPEC group).

RESULTS

The incidence of POPF was similar between the HIPEC and non-HIPEC groups (26 %). The severity of POPF according to the ISGPF criteria was significantly worse in the HIPEC group. The HIPEC patients had 13 grade B fistulas and 1 grade C fistula compared with 12 grade A fistulas and 4 grade B fistulas in the non-HIPEC group. The HIPEC patients with POPF did not differ in the extent of their CRS, peritoneal cancer index, length of hospital stay, or other postoperative complications from the the HIPEC patients without POPF. The HIPEC patients with colorectal carcinomatosis who experienced POPF had higher disease recurrence in the first year after CRS/HIPEC than those without POPF.

CONCLUSION

The findings showed that POPFs are more severe when distal pancreatectomy is combined with CRS/HIPEC. Moreover, selective use of distal pancreatectomy is important during CRS/HIPEC because POPFs may increase early disease recurrence for patients with colorectal carcinomatosis.

Natural history of intra-abdominal fluid collections following pancreatic surgery

BACKGROUND

Little data are available for non-abscess abdominal fluid collections (AFCs) after pancreatic surgery and their clinical implications. We sought to analyze the natural history of such collections in a population of patients subject to routine postoperative imaging.

METHODS

From 1995 to 2011, 709 patients underwent pancreatic resections and routine postoperative monitoring with abdominal ultrasound according to a unit protocol. AFCs were classified as asymptomatic (no interventional treatment), symptomatic (need for percutaneous drainage of sterile, amylase-poor fluid), and pancreatic fistula (drainage of amylase-rich fluid).

RESULTS

Ninety-seven of 149 AFCs (65 %) were asymptomatic and resolved spontaneously after a median follow-up of 22 days (interquartile range, 9-52 days). Among 52 (35 %) AFCs requiring percutaneous drainage, there were 20 pancreatic fistulas and 32 symptomatic collections. A stepwise logistic regression model identified three factors associated with the need for interventional treatment, i.e., body mass index ≥25 (odds ratio, 3.23; 95 % confidence interval (CI), 1.32 to 7.91), pancreatic fistula (odds ratio, 2.93; 95 % CI, 1.20 to 7.17), and biliary fistula (odds ratio, 3.92; 95 % CI, 1.35 to 11.31).

CONCLUSIONS

One fourth of patients develop various types of non-abscess AFCs after pancreatic surgery. Around half of them are asymptomatic and resolve spontaneously.

Postoperative pancreatic fistula

Postoperative pancreatic fistula is an important complication after pancreatic resection. The frequency of its incidence varies between 3% after pancreatic head resections and up to 30% following distal pancreatectomy. In recent years, the international definition of pancreatic fistula has been standardised according to the approach of the International Study Group on Pancreatic Fistula (ISGPF). Consequently, results from different studies have become comparable and the historically reported fistula rates can be evaluated more critically. The present review summarises the currently available data on incidence, risk factors, fistula-associated complications and management of postoperative pancreatic fistula.

Risk factors for pancreatic leak after distal pancreatectomy

INTRODUCTION

Pancreatic leak (PL) remains a major cause of postoperative morbidity in patients undergoing pancreatic resection. We sought to evaluate the incidence of and identify risk factors for the development of PL in patients undergoing distal pancreatectomy (DP) at a single high-volume institution.

METHODS

All patients who underwent primary open DP (excluding completion pancreatectomy and debridement) between January 1, 1984 and July 1, 2006 were identified, and their medical records were reviewed. chi and multivariable logistic regression analyses were performed to identify risk factors for PL.

RESULTS

In a cohort of 704 patients undergoing primary DP, the indications for DP were benign pancreatic neoplasm (34%), malignant pancreatic neoplasm (31%), other neoplasm (15%), chronic pancreatitis (14%), pseudocyst (3%), and trauma (3%). The pancreatic remnant was sutured alone in 83%, stapled alone in 5%, and both stapled and sutured in 9% of cases. Ligation of the pancreatic duct was performed in 22% of cases. Perioperative mortality was <1%, but overall morbidity was 33%, most commonly PL (12% clinically significant, 21% biochemical). Multivariable logistic regression analysis revealed that neither the method of closure of the pancreatic remnant (P = 0.41) nor ligation of the pancreatic duct (P > 0.05) affected the risk of clinically significant PL.

CONCLUSIONS

This largest reported series of DP demonstrates that this procedure can be performed with low mortality but still carries a substantial risk of morbidity, particularly PL. In contrast to some previous studies, this analysis found that surgical management of the pancreatic remnant has no effect on the incidence of clinically significant PL.

[Pancreatic carcinoma]

Aggressive tumor biology is the main characteristic of pancreatic cancer, in Germany the fourth leading cause of cancer death for females and the fifth leading cause for males. Due to late occurrence of symptoms and aggressive tumor growth, pancreatic cancer has equal incidence and mortality. Most malignant pancreatic tumours are ductal adenocarcinomas (85%). Surgical resection is the main therapeutic modality for pancreatic cancer, even though only a fraction of patients can undergo complete resection. Prognosis of pancreatic cancer remains poor even in completely resected patients; however, multimodal regimes might improve prognosis. Additionally, advances in surgical technique and perioperative management have reduced operative mortality and morbidity, especially in high-volume centers.

[Endoscopic management of postoperative pancreatic collections]

INTRODUCTION

Treatment of pancreatic postoperative collections are usually managed with a multidisciplinary team. Different managements are possible: abstention, external drainage, endoscopic treatment or surgery.

METHODS

We report on a case series of five patients with a postoperative pancreatic collection, endoscopically managed. Patients underwent all a CT scan associated or not with endoscopic ultrasonography.

RESULTS

An endoscopic cystenterosotomy was performed in all the cases, with two double pig tail stents sometimes associated with nasocystic drainage for clearing the cyst lumen and with transpapillary drainage in one case. All the procedures were successful and patients healed in all the cases with the disappearance of the radiological image within a 33 days to three months range with one complication due to superinfection of the drained cyst, endoscopically managed with a nasocystic catheter.

CONCLUSION

Therapeutic endoscopy, with a multidisciplinary approach, is a promising way to manage postoperative pancreatic collections.

The challenge of pancreatic anastomosis

BACKGROUND AND AIMS

Significant progress in surgical technique and perioperative management has substantially reduced the mortality rate of pancreatic surgery. However, morbidity remains considerably high, even in expert hands and leakage from the pancreatic stump still accounts for the majority of surgical complications after pancreatic head resection. For that reason, management of the pancreatic remnant after partial pancreatoduodenectomy remains a challenge. This review will focus on technique, pitfalls, and complication management of pancreaticoenteric anastomoses.

MATERIALS AND METHODS

A medline search for surgical guidelines, prospective randomized controlled trials, systematic metaanalysis, and clinical reports was performed with regard to surgical technique and complication management of pancreatic anastomoses.

RESULTS

Pancreaticojejunostomy appears to be most widely performed, but pancreaticogastrostomy is a reasonable alternative. Postoperative treatment with octreotide can be recommended only for patients with soft pancreatic tissue, and neither stents of the pancreatic duct nor drainages have proven to effectively reduce anastomotic complications. Gastroparesis remains the most common complication after pancreatic surgery and should be treated conservatively. However, it may be a symptom of other local complications, such as anastomotic leakage, pancreatic fistula or abscess. All septic complications may finally result in late postoperative hemorrhage, which requires immediate diagnostic workup and therapy. Today, interventional radiology has emerged as a standard tool in the management of local septic complications and bleeding. Therefore, relaparotomy has become less frequent and salvage pancreatectomy is now a rare procedure in case of local complications.

CONCLUSION

The surgeon's experience with one or the other technique of pancreatic anastomosis appears to be more important than the technique itself.

Sentinel bleeding after pancreaticoduodenectomy: a disregarded sign

INTRODUCTION

Delayed massive hemorrhage induced by pancreatic fistula after pancreaticoduodenectomy is a rare but life-threatening complication. The purpose of this study was to analyze the clinical course of patients with late hemorrhage, with or without sentinel bleeding, to better define treatment options in the future.

MATERIAL AND METHODS

From April 1998 to December 2006, 189 pancreaticoduodenectomies were performed. Eleven patients, including two patients referred from other hospitals, were treated with delayed massive hemorrhage occurring 5 days or more after pancreaticoduodenectomy. Sentinel bleeding was defined as minor blood loss via surgical drains or the gastrointestinal tract with an asymptomatic interval until development of hemorrhagic shock. The clinical data of patients with bleeding episodes were analyzed retrospectively.

RESULTS

Eight of the 11 patients had sentinel bleeding, and seven of them had it at least 6 h before acute deterioration. Seven out of 11 patients died, five out of eight with sentinel bleeding. No differences could be detected between patients with or without sentinel bleeding before delayed massive hemorrhage. The only difference found was that non-surviving patients were significantly older than surviving patients. Delayed massive hemorrhage is a common cause of death after pancreaticoduodenostomy complicated by pancreatic fistula formation. The observation of sentinel bleeding should lead to emergency angiography and dependent from the result to emergency relaparotomy to increase the likelihood of survival.

Surgery insight: surgical management of pancreatic cancer

Pancreatic ductal adenocarcinoma is a common malignancy of the gastrointestinal tract. The number of new cases diagnosed and the number of deaths each year are almost identical, demonstrating the particularly dismal prognosis for patients affected by this disease. Despite recent advances in the field of medical and radiation oncology, and the introduction of neoadjuvant and adjuvant regimens, surgery remains the single most important modality for the treatment of pancreatic ductal adenocarcinoma. Surgery for pancreatic cancer is widely viewed as a complex procedure associated with considerable perioperative morbidity and mortality. Many aspects of surgery for pancreatic cancer, such as the extent of resection, the value of vascular resection, the use of laparoscopy, and the importance of treatment at high-volume centers, are currently under debate. This Review describes the current status of surgical treatment for pancreatic ductal adenocarcinoma, and highlights the new developments in this field.

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

BACKGROUND

The correlation of the amylase value in drains (AVD) with the development of pancreatic fistula (PF) is still unclear.

AIM

The purpose of this study was to identify within the first postoperative day (POD1) the predictive role of different risks factors, including AVD, in the development of PF.

PATIENTS AND METHODS

We prospectively investigated 137 patients who underwent major pancreatic resections. PF was defined and graded in accordance with the International Study Group on PF.

RESULTS

We considered 101 pancreaticoduodenectomies and 36 distal resections. The overall incidence of PF (A, B, and C grades) was 19.7% and it was 14.8% after pancreaticoduodenectomy and 33.3% after distal resection. All PF occurred in "soft" remnant pancreas. The PF developed in patients with a POD1 median AVD of 10,000 U/L, whereas patients without PF had a median AVD of 1222 U/L (P < 0.001). We established a cut-off of 5000 U/L POD1 AVD for univariate and multivariate analysis. The area under the receiver operating characteristic (ROC) curve was 0.922 (P < 0.001). The predicting risk factors selected in the univariate setting were "soft" pancreas (P = 0.005; odds ratio [OR]: 1.54; 95% CI: 1.32-1.79) and AVD (P < 0.001; OR: 5.66; 95% CI: 3.6-8.7; positive predictive value 59%; negative predictive value 98%), whereas in multivariate analysis the predicting risk factor was the POD1 AVD (P < 0.001; OR: 68.4; 95% CI: 14.8-315). Only 2 PFs were detected with AVD <5000 U/L and both were in pancreatogastric anastomosis (P = 0.053).

CONCLUSIONS

AVD in POD1 > or =5000 U/L is the only significant predictive factor of PF development.

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

BACKGROUND

The correlation of the amylase value in drains (AVD) with the development of pancreatic fistula (PF) is still unclear.

AIM

The purpose of this study was to identify within the first postoperative day (POD1) the predictive role of different risks factors, including AVD, in the development of PF.

PATIENTS AND METHODS

We prospectively investigated 137 patients who underwent major pancreatic resections. PF was defined and graded in accordance with the International Study Group on PF.

RESULTS

We considered 101 pancreaticoduodenectomies and 36 distal resections. The overall incidence of PF (A, B, and C grades) was 19.7% and it was 14.8% after pancreaticoduodenectomy and 33.3% after distal resection. All PF occurred in "soft" remnant pancreas. The PF developed in patients with a POD1 median AVD of 10,000 U/L, whereas patients without PF had a median AVD of 1222 U/L (P < 0.001). We established a cut-off of 5000 U/L POD1 AVD for univariate and multivariate analysis. The area under the receiver operating characteristic (ROC) curve was 0.922 (P < 0.001). The predicting risk factors selected in the univariate setting were "soft" pancreas (P = 0.005; odds ratio [OR]: 1.54; 95% CI: 1.32-1.79) and AVD (P < 0.001; OR: 5.66; 95% CI: 3.6-8.7; positive predictive value 59%; negative predictive value 98%), whereas in multivariate analysis the predicting risk factor was the POD1 AVD (P < 0.001; OR: 68.4; 95% CI: 14.8-315). Only 2 PFs were detected with AVD <5000 U/L and both were in pancreatogastric anastomosis (P = 0.053).

CONCLUSIONS

AVD in POD1 > or =5000 U/L is the only significant predictive factor of PF development.

The efficacy of the prophylactic use of octreotide after a pancreaticoduodenectomy

This study was performed to analyze the efficacy of the prophylactic use of octreotide (Novartis, Stein, Switzerland) for pancreatic fistula following a pancreaticoduodenectomy. The medical records of 190 patients who underwent a pancreaticoduodenectomy at the Samsung Medical Center in Seoul, Korea between January 2000 and December 2002 were reviewed. Patients were divided into either the octreotide (n = 81) or control group (n = 109). The octreotide group received subcutaneous injections of 100 microg of octreotide every 12 hours for more than five days after surgery. The control group was not treated with octreotide. The criterion of pancreatic fistula was the drainage of the amylase rich fluid, over 500 U/mL in the three days after surgery. The morbidity and mortality rates were 32.1% and 1.2% in the octreotide group and 31.2% and 0% in the control group, respectively. Pancreatic fistula was the second most common complication (8.4%). In the univariate analysis, octreotide was ineffective in reducing pancreatic fistula (p = 0.26). However, in the multivariate regression analysis, combined gastrectomy (p = 0.018), cellular origin of the disease (p = 0.049), and use of octreotide (p = 0.044) were the risk factors that increased the frequency of pancreatic fistula. Therefore, the routine use of octreotide after a pancreaticoduodenectomy should be avoided until a worldwide consensus is established.

Quality of Life and Functional Long-Term Outcome After Partial Pancreatoduodenectomy: Pancreatogastrostomy Versus Pancreatojejunostomy

BACKGROUND

To determine the effects of pancreatogastrostomy (PG) versus pancreatojejunostomy (PJ) as types of reconstruction after partial pancreatoduodenectomy on postoperative quality of life and long-term gastrointestinal morbidity, the outcomes of 104 patients (PG, n = 63; PJ, n = 41) were evaluated.

METHODS

To compare the two groups, the European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire (QLQ-PAN 26) standard and an additional self-developed questionnaire were used. The mean time after surgery was 6.4 +/- 3.4 years.

RESULTS

In the PG group, there was a significant reduction of gastric acid reflux, gastroduodenal ulcers, and pain compared with before surgery. However, a significant increase in steatorrhea, intolerance toward larger meals, and aversion against certain foods were observed. In the PJ group, no significant change of preoperative symptoms was present except for jaundice. The incidence of diabetes mellitus and the need for pancreatic enzyme substitution had increased significantly but similarly in both groups. The global quality of life was identical in both groups of patients.

CONCLUSIONS

This analysis demonstrates that the global quality of life was not affected by the type of reconstruction after partial pancreatoduodenectomy. Patients who underwent PG had a significant reduction of gastric reflux, pain, and abdominal discomfort compared with before surgery. Patients in both groups showed an impaired exocrine and endocrine pancreatic function of a similar extent.

Complications of pancreatic surgery

Pancreatic resection is the only treatment option that can lead to a meaningful prolonged survival in pancreatic cancer and, in some instances, perhaps a potential chance for cure. With the advent of organ and function preserving procedures, its use in the treatment of chronic pancreatitis and other less common benign diseases of the pancreas is increasing. Furthermore, over the past two decades, with technical advances and centralization of care, pancreatic surgery has evolved into a safe procedure with mortality rates of <5%. However, postoperative morbidity rates are still substantial. This article reviews the more common procedure-related complications, their prevention and their treatment.

Current standards of surgery for pancreatic cancer

Background

Pancreatic cancer carries a dismal prognosis but there has been a vast increase in evidence on its management in the past decade.

Methods

An electronic and manual search was performed for articles on the surgical treatment of pancreatic cancer published in the past 10 years.

Results

Six major areas of advancement were identified. Groups at high risk of developing pancreatic cancer, notably those with chronic pancreatitis and hereditary pancreatitis, have been defined, raising the need for secondary screening. Methods of staging pancreatic cancer for resection have greatly improved but accuracy is still only 85–90 per cent. Pylorus-preserving partial pancreatoduodenectomy without extended lymphadenectomy is the simplest procedure; it does not compromise long-term survival. Adjuvant chemotherapy significantly improves long-term survival. Patients who are free from major co-morbidity have better palliation by surgery (with a double bypass) than by endoscopy. High-volume centres improve the results of surgery for all outcome measures including long-term survival.

Conclusion

The surgical management of pancreatic cancer has undergone a significant change in the past decade. It has moved away from no active treatment. The standard of care can now be defined as potentially curative resection in a specialist centre followed by adjuvant systemic chemotherapy.

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Octreotide Does Not Prevent Postoperative Pancreatic Fistula or Mortality following Pancreaticoduodenectomy

The role of octreotide in preventing pancreatic fistula following pancreaticoduodenectomy (PD) remains controversial. The purpose of our study was to report our experience with octreotide in 266 patients undergoing PD from 1995 to 2002. There were 150 males and 116 females. Patients were divided into two groups. Group 1 did not receive octreotide ( N = 61). Group 2 received octreotide (N = 205). The average patient age was 66.2 years in the control group and 63.6 years in the octreotide group. One hundred fifty patients were male and 116 were female. Thirty-day mortality for both groups was 1.9 per cent. The incidence of pancreatic fistula was 12 per cent. Fistula occurrence in the octreotide group was 13 per cent and in the no-octreotide group 8 per cent ( P = 0.34). Common complications in the no-octreotide group were pancreatic leak (10%), pancreatic fistula (8%), and delayed gastric emptying (8%). Common complications in the octreotide group were pancreatic leak (18%), pancreatic fistula (13%), intra-abdominal abscess (7%), and arrhythmia or myocardial infarction (7%). The only statistically different variable was the incidence of arrhythmia or myocardial infarction ( P = 0.026). Octreotide did not reduce pancreatic fistula, other complications, or mortality. Octreotide may contribute cardiac morbidity. Octreotide cannot be recommended to prevent mortality or postoperative complications after PD.

Review article: chemotherapy for pancreatic cancer

Pancreatic cancer is a common, highly lethal disease that is rising in incidence. Chemotherapy based on 5-fluorouracil (5-FU) has been shown to prolong survival in advanced pancreatic cancer. Gemcitabine improves major symptoms and survival outcomes compared with bolus 5-FU. Many novel small molecules are being widely and actively researched. These compounds are based on classical mechanisms of action as well as biological therapies targeting novel cellular survival pathways, and include fluoropyrimidines, nucleoside cytidine analogues, platinum analogues, topoisomerase-inhibitors, antimicrotubule agents, proteasome inhibitors, vitamin D analogues, arachidonic acid pathway inhibitors, histone deacytylator inhibitors, farnesyltransferase inhibitors and epidermal growth factor receptor therapies. Adjuvant chemotherapy has also demonstrated the best survival outcomes following resection compared to other adjuvant or neo-adjuvant strategies such as radiation-based treatments. These benefits are superimposed on the dramatic increase in resectability rates and reduction in post-operative mortality achieved by centralisation of treatment in high-volume speciality centres. Newer 'small-molecule' drugs as well as the latest 'large-molecule' biological agents hold considerable promise for the future. Real advances are anticipated over the next five years but are dependent on large randomised controlled trials for success.

Islet autotransplantation after left pancreatectomy for non-enucleable insulinoma

Insulinoma is a rare, almost always benign endocrine tumor of the pancreas, clinically characterized by hyperinsulinemic, hypoglycemic episodes. Surgical excision is the therapy of choice, which may lead to postpancreatectomy diabetes mellitus in the case of extensive pancreatic resection. We present the cases and the metabolic follow up of two patients, 81 and 73 years old, with insulinoma localized close to the main duct in the pancreatic neck. Both patients underwent an 80% left pancreatectomy, avoiding a pancreatico-enteric anastomosis. In order to prevent postpancreatectomy diabetes, the islets from the tumor-free part of the resected pancreas were isolated and injected via a right colic vein into the portal system. After a follow up of 6 and 3 years respectively, both patients remained insulin-independent without any dietary restrictions. Fasting and glucagon-stimulated C-peptide-levels and glycosylated hemoglobin remained within normal range. There were no signs of recurrent insulinoma. Liver biopsy performed in one patient at 1 year after autotransplantation, showed intact, insulin-producing islets within the portal spaces. In conclusion, autologous islet transplantation can preserve the insulin secretory reserve after extended left pancreatectomy for the treatment of benign tumors in the pancreatic neck.

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Morbidity and mortality associated with pancreatogastrostomy and pancreatojejunostomy following partial pancreatoduodenectomy

BACKGROUND

The pancreatic anastomosis is still the Achilles heel in partial pancreatoduodenectomy (PPD).

METHODS

This study describes retrospectively a series of 441 patients who underwent standard or extended PPD and reconstruction by either pancreatogastrostomy or pancreatojejunostomy over a period of 13 years (1988-2000).

RESULTS

Reconstruction of the pancreatic remnant was achieved by pancreatogastrostomy in 250 patients (56.7 per cent) and by pancreatojejunostomy in 191 patients (43.3 per cent). The leakage rate of the pancreatic anastomosis was 2.8 per cent after pancreatogastrostomy versus 12.6 per cent after pancreatojejunostomy (P < 0.001), whereas other surgical complications (bile leakage, haemorrhage, pancreatitis) were identical in the two groups. The leakage rate after standard PPD with or without vascular reconstruction was 2.0 per cent (four of 205 patients) after pancreatogastrostomy and 11.5 per cent (18 of 156) after pancreatojejunostomy (P < 0.001); following extended PPD it was 6.7 per cent (three of 45) after pancreatogastrostomy and 17.1 per cent (six of 35) after pancreatojejunostomy. The mortality rate due to leakage was 1.6 per cent (four of 250 patients) after pancreatogastrostomy versus 5.2 per cent (ten of 191) after pancreatojejunostomy (P = 0.037).

CONCLUSION

Pancreatogastrostomy is a safe and reliable method of reconstruction after PPD that may be associated with a lower leakage and mortality rate than pancreatojejunostomy.

Vascular complications associated with pancreaticoduodenectomy adversely affect clinical outcome

BACKGROUND

Early survival after pancreaticoduodenectomy has improved, but its morbidity remains high. The purpose of this study is to determine how the intra-operative (OR) occurrence of major vascular complications affects the outcome of pancreaticoduodenectomy.

METHODS

The medical records of 180 consecutive patients having pancreaticoduodenectomy from 1991 to 2001 were reviewed. Vascular complications were defined as "an unanticipated injury or thrombosis of a major vessel necessitating intervention." Age, sex, type of pancreaticoduodenectomy, tumor size, estimated blood loss, OR time, time in intensive care, post-OR hospitalization, and survival were compared.

RESULTS

Eighteen vascular complications were identified. Differences in age, sex, and type of resection between patients with or without vascular complications were not significant. OR time, estimated blood loss, blood transfusions, tumor size, time in intensive care, and post-OR hospitalization were all significantly greater in patients with vascular complications. Median survival for patients with vascular complications was significantly shorter than for patients without vascular complications. Thirty-day mortality was greater in patients with vascular complications.

CONCLUSION

Vascular complications significantly affect the outcome of pancreaticoduodenectomy increasing OR time, estimated blood loss, blood transfusion requirements, time in intensive care, post-OR hospitalization, and mortality.

Timing and extent of surgical intervention in patients from hereditary pancreatic cancer kindreds

Our knowledge of the molecular and genetic etiology of hereditary pancreatic cancer has expanded considerably and is steadily increasing. However, there are only a few hard data available regarding the clinical and surgical management of these patients. Surgery is currently performed when we detect dysplastic changes in the pancreas or when cancer is suspected. Of the available diagnostic modalities, endoscopic ultrasonography has proven so far to be the most useful for detecting dysplastic changes in the pancreases of patients from hereditary pancreatic cancer kindreds. It seems reasonable, once dysplasia has been diagnosed in a high-risk patient, to proceed to total pancreatectomy. The multifocal nature of dysplastic lesions precludes any type of operation that would leave behind pancreatic tissue. Currently, prophylactic whole-organ resection in the absence of premalignant lesions cannot be recommended since we do not know the exact risk for the development of cancer.

Complications of pancreatic cancer resection

Pancreatic cancer is a common cause of cancer death in the developed world. Currently, resection is the only chance of long-term survival. The post-operative mortality in nonspecialist centres often exceeds 20% but is around 6% or less in specialist centres. The overall complication rate even in specialist centres is 18-54%. An analysis of eleven large series of pancreatic resections shows an incidence of common complications of 10.4% for fistula, 9.9% for delayed gastric emptying, 4.8% for bleeding, 4.8% for wound infection and 3.8% for intra-abdominal abscess. The median hospital stay is 13-18 days in different series. The re-operation rate varies from 4 to 9% with a mortality rate of 23 to 67%. Major complications are a significant factor in post-operative mortality, especially if they require re-operation. The use of octreotide or somatostatin to prevent complications is supported by several multicentre, double-blind, randomized controlled trials. The best way to improve outcome is to concentrate pancreatic cancer care in regional specialist centres.