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Uijterwijk BA, Lemmers DHL, Bolm L, Luyer M, Koh YX, Mazzola M, Webber L, Kazemier G, Bannone E, Ramaekers M, Ielpo B, Wellner U, Koek S, Giani A, Besselink MG, Abu Hilal M. Long-term Outcomes After Laparoscopic, Robotic, and Open Pancreatoduodenectomy for Distal Cholangiocarcinoma: An International Propensity Score-matched Cohort Study. Ann Surg 2023; 278:e570-e579. [PMID: 36730852 DOI: 10.1097/sla.0000000000005743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE This study aimed to compare surgical and oncological outcomes after minimally invasive pancreatoduodenectomy (MIPD) versus open pancreatoduodenectomy (OPD) for distal cholangiocarcinoma (dCCA). BACKGROUND A dCCA might be a good indication for MIPD, as it is often diagnosed as primary resectable disease. However, multicenter series on MIPD for dCCA are lacking. METHODS This is an international multicenter propensity score-matched cohort study including patients after MIPD or OPD for dCCA in 8 centers from 5 countries (2010-2021). Primary outcomes included overall survival (OS) and disease-free interval (DFI). Secondary outcomes included perioperative and postoperative complications and predictors for OS or DFI. Subgroup analyses included robotic pancreatoduodenectomy (RPD) and laparoscopic pancreatoduodenectomy (LPD). RESULTS Overall, 478 patients after pancreatoduodenectomy for dCCA were included of which 97 after MIPD (37 RPD, 60 LPD) and 381 after OPD. MIPD was associated with less blood loss (300 vs 420 mL, P =0.025), longer operation time (453 vs 340 min; P <0.001), and less surgical site infections (7.8% vs 19.3%; P =0.042) compared with OPD. The median OS (30 vs 25 mo) and DFI (29 vs 18) for MIPD did not differ significantly between MIPD and OPD. Tumor stage (Hazard ratio: 2.939, P <0.001) and administration of adjuvant chemotherapy (Hazard ratio: 0.640, P =0.033) were individual predictors for OS. RPD was associated with a higher lymph node yield (18.0 vs 13.5; P =0.008) and less major morbidity (Clavien-Dindo 3b-5; 8.1% vs 32.1%; P =0.005) compared with LPD. DISCUSSION Both surgical and oncological outcomes of MIPD for dCCA are acceptable as compared with OPD. Surgical outcomes seem to favor RPD as compared with LPD but more data are needed. Randomized controlled trials should be performed to confirm these findings.
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Affiliation(s)
- Bas A Uijterwijk
- Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, The Netherlands
| | - Daniël H L Lemmers
- Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, The Netherlands
| | - Louisa Bolm
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
| | - Misha Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Ye Xin Koh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Michele Mazzola
- Division of Oncologic and Mini-invasive General Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Laurence Webber
- Department of Surgery, Fiona Stanley Hospital, Perth, Australia
| | - Geert Kazemier
- Cancer Center Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Elisa Bannone
- Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
| | - Mark Ramaekers
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Benedetto Ielpo
- Hepatobiliary and Pancreatic Surgery Unit, Hospital del Mar, Universitat Pompeu Fabra, Barcelona, Spain
| | - Ulrich Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany
| | - Sharnice Koek
- Department of Surgery, Fiona Stanley Hospital, Perth, Australia
| | - Alessandro Giani
- Division of Oncologic and Mini-invasive General Surgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, The Netherlands
| | - Mohammed Abu Hilal
- Department of Surgery, Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy
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Stool Elastase as an Independent Prognostic Factor in Patients with Pancreatic Head Cancer. J Clin Med 2022; 11:jcm11133718. [PMID: 35807003 PMCID: PMC9267127 DOI: 10.3390/jcm11133718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 06/22/2022] [Accepted: 06/25/2022] [Indexed: 12/13/2022] Open
Abstract
(1) Background: Patients with pancreatic exocrine insufficiency (PEI) have an increased risk of malnutrition, which in turn increases morbidity and mortality and is frequent in pancreatic head cancer. This study aimed to analyze the utility of PEI measured using the stool elastase (SE) level to predict the prognosis of patients with pancreatic head cancer. (2) Methods: Patients who underwent pancreaticoduodenectomy for pancreatic cancer at our institution between 2011 and 2015 were included. Only patients with data on preoperative SE levels were analyzed. Patients were classified into low and high SE groups based on preoperative SE levels (low < 100 µg/g < high). (3) Results: The median preoperative SE level was 67.2 µg/g, and 84 of 143 (58.7%) patients were included in the low SE group. The two groups had significantly different overall survival (OS) and disease-free survival (DFS), and the low SE group had a worse prognosis. In multivariate analysis, SE level < 100 µg/g and lymph node metastasis were independent poor prognostic factors for OS and DFS. (4) Discussion: PEI measured using SE levels is an independent prognostic factor in patients with pancreatic head cancer undergoing pancreaticoduodenectomy. Since poor nutritional status may be related to prognosis in patients with low levels of stool elastase preoperatively, aggressive treatment may be required.
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Liang H, Wu JG, Wang F, Chen BX, Zou ST, Wang C, Luo SW. Choice of operative method for pancreaticojejunostomy and a multivariable study of pancreatic leakage in pancreaticoduodenectomy. World J Gastrointest Surg 2021; 13:1405-1413. [PMID: 34950429 PMCID: PMC8649563 DOI: 10.4240/wjgs.v13.i11.1405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/03/2021] [Accepted: 07/21/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND As one of the major abdominal operations, pancreaticoduodenectomy (PD) involves many organs. The operation is complex, and the scope of the operation is large, which can cause significant trauma in patients. The operation has a high rate of complications. Pancreatic leakage is the main complication after PD. When pancreatic leakage occurs after PD, it can often lead to abdominal bleeding and infection, threatening the lives of patients. One study found that pancreatic leakage was affected by many factors including the choice of pancreaticojejunostomy method which can be well controlled.
AIM To investigate the choice of operative methods for pancreaticojejunostomy and to conduct a multivariate study of pancreatic leakage in PD.
METHODS A total of 420 patients undergoing PD in our hospital from January 2014 to March 2019 were enrolled and divided into group A (n = 198) and group B (n = 222) according to the pancreatointestinal anastomosis method adopted during the operation. Duct-to-mucosa pancreatojejunostomy was performed in group A and bundled pancreaticojejunostomy was performed in group B. The operation time, intraoperative blood loss, and pancreatic leakage of the two groups were assessed. The occurrence of pancreatic leakage after the operation in different patients was analyzed.
RESULTS The differences in operative time and intraoperative bleeding between groups A and B were not significant (P > 0.05). In group A, the time of pancreatojejunostomy was 26.03 ± 4.40 min and pancreatic duct diameter was 3.90 ± 1.10 mm. These measurements were significantly higher than those in group B (P < 0.05). The differences in the occurrence of pancreatic leakage, abdominal infection, abdominal hemorrhage and gastric retention between group A and group B were not significant (P > 0.05). The rates of pancreatic leakage in patients with preoperative albumin < 30 g/L, preoperative jaundice time ≥ 8 wk, and pancreatic duct diameter < 3 mm, were 23.33%, 33.96%, and 19.01%, respectively. These were significantly higher than those in patients with preoperative albumin ≥ 30 g/L, preoperative jaundice time < 8 wk, and pancreatic duct diameter ≥ 3 cm (P < 0.05). Logistic regression analysis showed that preoperative albumin < 30 g/L, preoperative jaundice time ≥ 8 wk, and pancreatic duct diameter < 3 mm were risk factors for pancreatic leakage after PD (odds ratio = 2.038, 2.416 and 2.670, P < 0.05).
CONCLUSION The pancreatointestinal anastomosis method during PD has no significant effect on the occurrence of pancreatic leakage. The main risk factors for pancreatic leakage include preoperative albumin, preoperative jaundice time, and pancreatic duct diameter.
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Affiliation(s)
- Hui Liang
- Department of Hepatobiliary and Pancreas, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Jian-Guo Wu
- Department of Nuclear Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Fei Wang
- Department of Hepatobiliary and Pancreas, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Bo-Xuan Chen
- Department of Hepatobiliary and Pancreas, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Shi-Tian Zou
- Department of Hepatobiliary and Pancreas, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Cong Wang
- Department of Hepatobiliary and Pancreas, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Shuai-Wu Luo
- Department of Hepatobiliary and Pancreas, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
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Jiménez Romero C, Alonso Murillo L, Rioja Conde P, Marcacuzco Quinto A, Caso Maestro Ó, Nutu A, Pérez Moreiras I, Justo Alonso I. Pancreaticoduodenectomy and external Wirsung stenting: Our outcomes in 80 cases. Cir Esp 2021; 99:440-449. [PMID: 34103272 DOI: 10.1016/j.cireng.2021.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 07/12/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION There is controversy regarding the ideal pancreaticojejunostomy technique after pancreaticoduodenectomy. Many authors consider the external Wirsung stenting technique to be associated with a low incidence of fistula, morbidity and mortality. We analyse our experience with this technique. PATIENTS AND METHODS A retrospective analysis of the morbidity and mortality of a series of 80 consecutive patients who had been treated surgically over a 6.5-year period for pancreatic head or periampullary tumors, performing pancreaticoduodenectomy and pancreaticojejunostomy with external Wirsung duct stenting. RESULTS Mean patient age was 68.3 ± 9 years, and the resectability rate was 78%. The texture of the pancreas was soft in 51.2% of patients and hard in 48.8%. Pylorus-preserving resection was performed in 43.8%. Adenocarcinoma was the most frequent tumor (68.8%), and R0 was confirmed in 70% of patients. Biochemical fistula was observed in 11.2%, pancreatic fistula grade B in 12.5% and C in 2.5%, whereas the abdominal reoperation rate was 10%. Median postoperative hospital stay was 16 days, and postoperative and 90-day mortality was 2.5%. Delayed gastric emptying was observed in 36.3% of patients, de novo diabetes in 12.5%, and exocrine insufficiency in 3. Patient survival rates after 1, 3 and 5 years were 80.2%, 53.6% and 19.2%, respectively. CONCLUSIONS Although our low rates of postoperative complications and mortality using external Wirsung duct stenting coincides with other more numerous recent series, it is necessary to perform a comparative analysis with other techniques, including more cases, to choose the best reconstruction technique after pancreaticoduodenectomy.
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Affiliation(s)
- Carlos Jiménez Romero
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | - Laura Alonso Murillo
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Paula Rioja Conde
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Alberto Marcacuzco Quinto
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Óscar Caso Maestro
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Anisa Nutu
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Iago Justo Alonso
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Madrid, Spain
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5
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Kamarajah SK, Bundred JR, Lin A, Halle-Smith J, Pande R, Sutcliffe R, Harrison EM, Roberts KJ. Systematic review and meta-analysis of factors associated with post-operative pancreatic fistula following pancreatoduodenectomy. ANZ J Surg 2020; 91:810-821. [PMID: 33135873 DOI: 10.1111/ans.16408] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/05/2020] [Accepted: 10/11/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Many studies have explored factors relating to post-operative pancreatic fistula (POPF); however, the original definition (All-POPF) was revised to include only 'clinically relevant' (CR) POPF. This study identified variables associated with the two International Study Group on Pancreatic Surgery definitions to identify which variables are more strongly associated with CR-POPF. METHODS A systematic review identified all studies reporting risk factors for POPF (using both International Study Group on Pancreatic Fistula definitions) following pancreatoduodenectomy. The primary outcome was factors associated with CR-POPF. Meta-analyses (random effects models) of pre-, intra- and post-operative factors associated with POPF in more than two studies were included. RESULTS Among 52 774 patients All-POPF (n = 69 studies) and CR-POPF (n = 53 studies) affected 27% (95% confidence interval (CI95% ) 23-30) and 19% (CI95% 17-22), respectively. Of the 176 factors, 24 and 17 were associated with All- and CR-POPF, respectively. Absence of pre-operative pancreatitis, presence of renal disease, no pre-operative neoadjuvant therapy, use of post-operative somatostatin analogues, absence of associated venous or arterial resection were associated with CR-POPF but not All-POPF. CONCLUSION In conclusion this study demonstrates wide variation in reported rates of POPF and that several risk factors associated with CR-POPF are not used within risk prediction models. Data from this study can be used to shape future studies, research and audit across ethnic and geographic boundaries in POPF following pancreatoduodenectomy.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle University NHS Trust Hospitals, Newcastle-Upon-Tyne, UK.,Institute of Cellular Medicine, University of Newcastle, Newcastle-Upon-Tyne, UK
| | - James R Bundred
- Department of Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Aaron Lin
- Department of Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - James Halle-Smith
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Rupaly Pande
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Robert Sutcliffe
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | - Keith J Roberts
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,Clinical Surgery, Edinburgh Royal Infirmary, Edinburgh, UK
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Abstract
INTRODUCTION There is controversy regarding the ideal pancreaticojejunostomy technique after pancreaticoduodenectomy. Many authors consider the external Wirsung stenting technique to be associated with a low incidence of fistula, morbidity and mortality. We analyse our experience with this technique. PATIENTS AND METHODS A retrospective analysis of the morbidity and mortality of a series of 80 consecutive patients who had been treated surgically over a 6.5-year period for pancreatic head or periampullary tumors, performing pancreaticoduodenectomy and pancreaticojejunostomy with external Wirsung duct stenting. RESULTS Mean patient age was 68.3 ± 9 years, and the resectability rate was 78%. The texture of the pancreas was soft in 51.2% of patients and hard in 48.8%. Pylorus-preserving resection was performed in 43.8%. Adenocarcinoma was the most frequent tumor (68.8%), and R0 was confirmed in 70% of patients. Biochemical fistula was observed in 11.2%, pancreatic fistula grade B in 12.5% and C in 2.5%, whereas the abdominal reoperation rate was 10%. Median postoperative hospital stay was 16 days, and postoperative and 90-day mortality was 2.5%. Delayed gastric emptying was observed in 36.3% of patients, de novo diabetes in 12.5%, and exocrine insufficiency in 3. Patient survival rates after 1, 3 and 5 years were 80.2, 53.6 and 19.2%, respectively. CONCLUSIONS Although our low rates of postoperative complications and mortality using external Wirsung duct stenting coincides with other more numerous recent series, it is necessary to perform a comparative analysis with other techniques, including more cases, to choose the best reconstruction technique after pancreaticoduodenectomy.
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Hayashi H, Amaya K, Fujiwara Y, Tokai R, Sugimoto Y, Hashimoto Y, Nakura M, Kawai S, Yamaguchi T, Hirose A, Watanabe T, Tsukada T, Kaji M, Maeda K, Shimizu K. Comparison of three fistula risk scores after pancreatoduodenectomy: A single-institution retrospective study. Asian J Surg 2020; 44:143-146. [PMID: 32409242 DOI: 10.1016/j.asjsur.2020.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 04/04/2020] [Accepted: 04/13/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) after pancreatoduodenectomy greatly influences patients' postoperative course. Several evaluation methods have been used to assess the risk of clinically relevant POPF (CR-POPF) after pancreatoduodenectomy namely, the original, alternative, and updated alternative fistula risk scores (o-FRS, a-FRS, and ua-FRS, respectively). METHODS We enrolled 106/179 patients who underwent pancreatoduodenectomy in our institution between April 2013 and Mar 2018. CR-POPF was defined as grade B and C POPF according to the 2016 definitions of the International Study Group on Pancreatic Surgery. RESULTS Pancreatic gland texture was the only significant risk factor for CR-POPF (p = 0.007). The CR-POPF incidence increased significantly according to the risk groups defined by both o-FRS (p = 0.004) and a-FRS (p = 0.004). The area under the curve for o-FRS, a-FRS, and ua-FRS was 0.693, 0.693, and 0.671, respectively. CONCLUSION o-FRS, a-FRS, and ua-FRS were almost equally useful for risk evaluation for CR-POPF after pancreatoduodenectomy. Further studies, especially for preoperative objective evaluation of pancreatic gland texture, are needed for more useful and accurate risk evaluation.
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Affiliation(s)
- Hironori Hayashi
- Department of Surgery, Toyama Prefectural Central Hospital, 2-2-78 Nishi-nagae, Toyama, 930-8550, Japan.
| | - Koji Amaya
- Department of Surgery, Toyama Prefectural Central Hospital, 2-2-78 Nishi-nagae, Toyama, 930-8550, Japan
| | - Yuta Fujiwara
- Department of Surgery, Toyama Prefectural Central Hospital, 2-2-78 Nishi-nagae, Toyama, 930-8550, Japan
| | - Ryutaro Tokai
- Department of Surgery, Toyama Prefectural Central Hospital, 2-2-78 Nishi-nagae, Toyama, 930-8550, Japan
| | - Yuya Sugimoto
- Department of Surgery, Toyama Prefectural Central Hospital, 2-2-78 Nishi-nagae, Toyama, 930-8550, Japan
| | - Yu Hashimoto
- Department of Surgery, Toyama Prefectural Central Hospital, 2-2-78 Nishi-nagae, Toyama, 930-8550, Japan
| | - Makoto Nakura
- Department of Surgery, Toyama Prefectural Central Hospital, 2-2-78 Nishi-nagae, Toyama, 930-8550, Japan
| | - Shunsuke Kawai
- Department of Surgery, Toyama Prefectural Central Hospital, 2-2-78 Nishi-nagae, Toyama, 930-8550, Japan
| | - Takahisa Yamaguchi
- Department of Surgery, Toyama Prefectural Central Hospital, 2-2-78 Nishi-nagae, Toyama, 930-8550, Japan
| | - Atsushi Hirose
- Department of Surgery, Toyama Prefectural Central Hospital, 2-2-78 Nishi-nagae, Toyama, 930-8550, Japan
| | - Toshifumi Watanabe
- Department of Surgery, Toyama Prefectural Central Hospital, 2-2-78 Nishi-nagae, Toyama, 930-8550, Japan
| | - Tomoya Tsukada
- Department of Surgery, Toyama Prefectural Central Hospital, 2-2-78 Nishi-nagae, Toyama, 930-8550, Japan
| | - Masahide Kaji
- Department of Surgery, Toyama Prefectural Central Hospital, 2-2-78 Nishi-nagae, Toyama, 930-8550, Japan
| | - Kiichi Maeda
- Department of Surgery, Toyama Prefectural Central Hospital, 2-2-78 Nishi-nagae, Toyama, 930-8550, Japan
| | - Koichi Shimizu
- Department of Surgery, Toyama Prefectural Central Hospital, 2-2-78 Nishi-nagae, Toyama, 930-8550, Japan
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Kang I, Hwang HK, Lee WJ, Kang CM. First experience of pancreaticoduodenectomy using Revo-i in a patient with insulinoma. Ann Hepatobiliary Pancreat Surg 2020; 24:104-108. [PMID: 32181438 PMCID: PMC7061047 DOI: 10.14701/ahbps.2020.24.1.104] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 07/13/2019] [Accepted: 07/15/2019] [Indexed: 12/12/2022] Open
Abstract
Robotic surgery systems have been developed to overcome the limitations of laparoscopic surgery. Recently, Meerecompany Inc. in Korea successfully manufactured a robotic surgical system called Revo-i. A 65-year old woman was referred for a pancreatic head tumor, detected as an incidental finding during a routine check-up. Contrast abdominopelvic CT revealed a pancreatic uncinate tumor measuring around 13 mm in diameter, with no other focal lesions. The patient underwent a robot-assisted pancreaticoduodenectomy (laparoscopic resection and robotic reconstruction) using Revo-i. The patient's recovery was uneventful and discharged on postoperative day 7. Our case showed the technical feasibility of the Korean robotic surgical system Revo-i. Further experiences are mandatory to validate this finding.
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Affiliation(s)
- Incheon Kang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.,Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Ho Kyoung Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.,Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Woo Jung Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.,Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Chang Moo Kang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.,Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
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9
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Influence of margin histology on development of pancreatic fistula following pancreatoduodenectomy. J Surg Res 2020; 246:315-324. [DOI: 10.1016/j.jss.2018.02.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 12/18/2017] [Accepted: 02/27/2018] [Indexed: 12/25/2022]
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10
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Du F, Wang X, Lin H, Zhao X. Pancreaticoduodenectomy With Arterial Approach of Total Mesenteric Resection of the Pancreas for Pancreatic Head Cancer. Gastroenterology Res 2019; 12:256-262. [PMID: 31636776 PMCID: PMC6785284 DOI: 10.14740/gr1225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 09/28/2019] [Indexed: 01/08/2023] Open
Abstract
Background This study aims to observe and analyze the clinical efficacy of the pancreaticoduodenectomy (PD) with total mesopancreas excision (TMpE) via the artery approach for carcinoma of head of the pancreas. Methods From October 2015 to October 2016, 60 patients with pancreatic head cancer were enrolled in this study. Twenty-eight patients were treated with PD with TMpE via the artery approach (group A), while 32 patients were treated with PD alone (group B) in our hospital. The clinical data of the patients were retrospectively collected, including intra-operative evaluation index, R0 resection rate of postoperative pathological specimens, postoperative complications, and the tumor recurrence time was observed after operation (at third, sixth, and 12th months). Clinical efficacy of PD with TMpE via the artery approach was evaluated between the two groups. Results There was no significant difference in the operation time or perioperative death between the two groups (P > 0.05). Postoperative specimen pathology showed that there was a statistically significant difference in the R0 resection rate between the two groups (P < 0.05). There was no significant difference in the incidence of postoperative complications between the two groups (P > 0.05). Tumor recurrence rate at month 3 post operation was 0 (0/28) in group A and 3.13% (1/32) in group B. There was no significant difference in the 6-month recurrence rate (P > 0.05). Postoperative recurrence rate in group A was significantly lower than that in group B at month 12 (P < 0.05). Conclusions The PD with TMpE via the artery approach treatment of pancreatic head cancer can reduce the amount of intra-operative bleeding and save the operation time without increasing postoperative complications. It provides effective technical support for combined vascular anastomosis in the treatment of pancreatic head cancer with venous system invasion, and ensures the safety of operation. Moreover, this procedure can improve the R0 resection rate and reduce the recurrence rate in the near future. As a safe, effective and feasible surgical method for the treatment of pancreatic head cancer, it can be widely used in clinical practice.
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Affiliation(s)
- Futian Du
- Department of Hepatobiliary Surgery, Weifang People's Hospital, Weifang, Shandong 261000, China
| | - Xin Wang
- Department of Hepatobiliary Surgery, Weifang People's Hospital, Weifang, Shandong 261000, China
| | - Hongfeng Lin
- Department of Hepatobiliary Surgery, Weifang People's Hospital, Weifang, Shandong 261000, China
| | - Xuelin Zhao
- Department of Hepatobiliary Surgery, Weifang People's Hospital, Weifang, Shandong 261000, China
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Xiang Y, Wu J, Lin C, Yang Y, Zhang D, Xie Y, Yao X, Zhang X. Pancreatic reconstruction techniques after pancreaticoduodenectomy: a review of the literature. Expert Rev Gastroenterol Hepatol 2019; 13:797-806. [PMID: 31282769 DOI: 10.1080/17474124.2019.1640601] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Postoperative pancreatic fistula is the most troublesome complication after pancreaticoduodenectomy, and is an on-going area of concern for pancreatic surgeons. The specific pancreatic reconstruction technique is an important factor influencing the development of postoperative pancreatic fistula after pancreaticoduodenectomy. Areas covered: In this paper, we briefly introduced the definition and relevant influencing factors of postoperative pancreatic fistula. We performed a search of all meta-analyses published in the last 5 years and all published randomized controlled trials comparing different pancreatic anastomotic techniques, and we evaluated the advantages and disadvantages of different techniques. Expert opinion: No individual anastomotic method can completely avoid postoperative pancreatic fistula. Selecting specific techniques tailored to the patient's situation intraoperatively may be key to reducing the incidence of postoperative pancreatic fistula.
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Affiliation(s)
- Yien Xiang
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Jiacheng Wu
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Chao Lin
- b Department of Hepatobiliary and Pancreatic Surgery, Jilin University Third Affiliated Hospital , Changchun , Jilin , CN
| | - Yongsheng Yang
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Dan Zhang
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Yingjun Xie
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Xiaoxiao Yao
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Xuewen Zhang
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
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12
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Wiltberger G, Krenzien F, Atanasov G, Hau HM, Schmelzle M, Bartels M, Benzing C. Pancreaticoduodenectomy for periampullary cancer: does the tumour entity influence perioperative morbidity and long-term outcome? Acta Chir Belg 2018; 118:341-347. [PMID: 30203717 DOI: 10.1080/00015458.2017.1385894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Malignant tumours of the periampullary region include ductal adenocarcinoma of the pancreas (Pan-Ca), distal bile duct cancer (DBDC) and adenocarcinoma of the ampulla (Amp-Ca). The present retrospective clinical study was designed to evaluate the influence of tumour entity on postoperative complications and identify risk factors predicting survival and morbidity. METHODS We retrospectively analysed data from all patients who underwent pancreatic resection for periampullary cancer with curative intent (R0 or R1). Demographic data, risk factors, perioperative complications and survival rates for the different subtypes were assessed. RESULTS A total of 225 patients with periampullary cancer were identified: 124 (55.1%) had Pan-Ca, 55 (24.4%) had DBDC and 46 had (20.4%) Amp-Ca. Sixty-nine patients (30.7%) had major complications (grade IIIb-V). Patients with DBDC had significantly more grade C pancreatic fistulas. Univariate analysis revealed male gender, BMI >30, R1-status, and low-grade tumour differentiation as risk factors for major complications. Overall in-hospital-mortality was 6.7%. CONCLUSIONS Further research will be needed to implement more individualized therapy.
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Affiliation(s)
- Georg Wiltberger
- Department of Visceral, Transplantation, Thoracic, and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Felix Krenzien
- Department of Surgery, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Georgi Atanasov
- Department of Surgery, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Hans-Michael Hau
- Department of Visceral, Transplantation, Thoracic, and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Moritz Schmelzle
- Department of Surgery, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Bartels
- Department of Visceral, Transplantation, Thoracic, and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Christian Benzing
- Department of Surgery, Charité – Universitätsmedizin Berlin, Berlin, Germany
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13
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Cuellar E, Muscari F, Tuyeras G, Maulat C, Charrière B, Duffas JP, Otal P, Bournet B, Suc B. Use of routine CT-SCANS to detect severe postoperative complications after pancreato-duodenectomy. J Visc Surg 2018; 155:375-382. [DOI: 10.1016/j.jviscsurg.2017.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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14
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Fang CH, Chen QS, Yang J, Xiang F, Fang ZS, Zhu W. Body Mass Index and Stump Morphology Predict an Increased Incidence of Pancreatic Fistula After Pancreaticoduodenectomy. World J Surg 2017; 40:1467-76. [PMID: 26796886 DOI: 10.1007/s00268-016-3413-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND A majority of factors associated with the occurrence of clinical relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD) can only be identified intra- or postoperatively. There are no reports for assessing the morphological features of pancreatic stump and analyzing its influence on CR-POPF risk after PD preoperatively. METHOD A total of 90 patients underwent PD between April 2012 and May 2014 in our hospital were included. Preoperative computed tomographic (CT) images were imported into the Medical Image Three-Dimensional Visualization System (MI-3DVS) for acquiring the morphological features of pancreatic stump. The demographics, laboratory test and morphological features of pancreatic stump were recorded prospectively. The clinical course was evaluated focusing on the occurrence of pancreatic fistula as defined by the International Study Group on Pancreatic Fistula (ISGPF). Logistic regression analysis was used to identify independent predictors of CR-POPF. RESULTS CR-POPF occurred in 18 patients (14 grade B, 4 grade C). In univariate analysis, male gender (P = 0.026), body mass index (BMI) ≥ 25.3 kg/m(2) (P = 0.002), main pancreas duct diameter (MPDD) < 3.1 mm (P = 0.005), remnant pancreatic parenchymal volume (RPPV) > 27.8 mL (P < 0.001), and area of cut surface (AOCS) > 222.3 mm(2) (P < 0.001) were associated with an increased risk of CR-POPF. In multivariate analysis, BMI ≥ 25.3 kg/m(2) (OR 12.238, 95 % CI 1.822-82.215, P = 0.010) and RPPV > 27.8 mL (OR 12.907, 95 % CI 1.602-104.004, P = 0.016) were the only independent risk factors associated with CR-POPF. A cut-off value of 27.8 mL for RPPV established based on the receiver operating characteristic (ROC) curve, which was the strongest single predictive factor for CR-POPF, with a sensitivity and specificity of 77.8 and 86.1 %, respectively. The area under the ROC curve of RPPV was 0.770 (95 % CI 0.629-0.911, P < 0.001). CONCLUSIONS Our study demonstrated that CR-POPF is correlated with BMI and RRPV. MI-3DVS provides us a novel and convenient method for measuring the RPPV. Preoperative acquisition of RPPV and BMI may help the surgeons in fitting postoperative management to patient's individual risk after PD.
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Affiliation(s)
- Chi-Hua Fang
- Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, Guangdong, China.
| | - Qing-Shan Chen
- Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, Guangdong, China
| | - Jian Yang
- Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, Guangdong, China
| | - Fei Xiang
- Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, Guangdong, China
| | - Zhao-Shan Fang
- Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, Guangdong, China
| | - Wen Zhu
- Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University, Guangzhou, 510282, Guangdong, China
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15
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Lee CHA, Shingler G, Mowbray NG, Al-Sarireh B, Evans P, Smith M, Usatoff V, Pilgrim C. Surgical outcomes for duodenal adenoma and adenocarcinoma: a multicentre study in Australia and the United Kingdom. ANZ J Surg 2017; 88:E157-E161. [PMID: 28122405 DOI: 10.1111/ans.13873] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 11/03/2016] [Accepted: 11/05/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy is often required in patients with duodenal adenoma and adenocarcinoma and these patients generally have soft pancreatic texture and small pancreatic ducts, the two most significant factors associated with post-operative pancreatic fistula (POPF). The aims of the study were to evaluate the rate of POPF and long-term outcomes for patients with duodenal adenoma and adenocarcinoma who underwent curative resection. METHODS This retrospective study (2004-2014) examined patients treated surgically with non-ampullary duodenal tumours (NADTs) in two hepatopancreaticobiliary units in Victoria, Australia, and Swansea, UK. RESULTS There were 49 resections performed including 33 pancreaticoduodenectomies, five pancreas-preserving total duodenectomies and 11 segmental duodenal resections. Median length of follow-up was 23.5 months. Final histopathology revealed 18 duodenal adenomas and 31 adenocarcinomas. POPF rate for NADTs was 28.9% (of which 54.5% were grade C) compared to 14.5% for all other pathologies. Grade C POPF was associated with poorer survival outcomes (hazard ratio = 6.73; P = 0.005). The 5-year overall survival for patients with duodenal adenocarcinoma was 66.5%. CONCLUSION Due to the soft pancreatic texture and small pancreatic duct, pancreatic resection for NADTs is associated with a high rate of POPF which contributes to reduced survival. Nevertheless, surgery is associated with favourable 5-year survival compared to pancreatic resection for pancreatic adenocarcinoma.
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Affiliation(s)
- Chun Hin Angus Lee
- Department of Surgery (Upper Gastrointestinal - Hepatopancreaticobiliary Service), Alfred Hospital, Melbourne, Victoria, Australia
| | - Guy Shingler
- Department of Surgery (Upper Gastrointestinal - Hepatopancreaticobiliary Service), Alfred Hospital, Melbourne, Victoria, Australia.,Department of Pancreaticobiliary Surgery, Morriston Hospital, Swansea, UK
| | - Nicholas G Mowbray
- Department of Pancreaticobiliary Surgery, Morriston Hospital, Swansea, UK
| | - Bilal Al-Sarireh
- Department of Pancreaticobiliary Surgery, Morriston Hospital, Swansea, UK
| | - Peter Evans
- Department of Surgery (Upper Gastrointestinal - Hepatopancreaticobiliary Service), Alfred Hospital, Melbourne, Victoria, Australia.,Victorian HepatoPancreatoBiliary Surgery Group, Cabrini Hospital, Melbourne, Victoria, Australia
| | - Marty Smith
- Department of Surgery (Upper Gastrointestinal - Hepatopancreaticobiliary Service), Alfred Hospital, Melbourne, Victoria, Australia.,Victorian HepatoPancreatoBiliary Surgery Group, Cabrini Hospital, Melbourne, Victoria, Australia.,Department of Upper GI/HPB Surgery, Western Hospital, Melbourne, Victoria, Australia
| | - Val Usatoff
- Department of Surgery (Upper Gastrointestinal - Hepatopancreaticobiliary Service), Alfred Hospital, Melbourne, Victoria, Australia.,Victorian HepatoPancreatoBiliary Surgery Group, Cabrini Hospital, Melbourne, Victoria, Australia.,Department of Upper GI/HPB Surgery, Western Hospital, Melbourne, Victoria, Australia
| | - Charles Pilgrim
- Department of Surgery (Upper Gastrointestinal - Hepatopancreaticobiliary Service), Alfred Hospital, Melbourne, Victoria, Australia.,Victorian HepatoPancreatoBiliary Surgery Group, Cabrini Hospital, Melbourne, Victoria, Australia
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Risk by indication for pancreaticoduodenectomy in patients 80 years and older: a study from the American College of Surgeons National Surgical Quality Improvement Program. HPB (Oxford) 2016; 18:900-907. [PMID: 27594118 PMCID: PMC5094480 DOI: 10.1016/j.hpb.2016.07.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 06/17/2016] [Accepted: 07/23/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Expected mortality after elective pancreaticoduodenectomy (PD) in contemporary series is less than 5% in elderly patients; however, to our knowledge, mortality rate has not been correlated with indication for PD. We hypothesized that perioperative risk following PD would correlate with diagnostic indication in older patients. METHODS The American College of Surgeons NSQIP database was reviewed to identify patients (<80 and ≥80 years) who underwent PD from January 1, 2005, through December 31, 2012. High- and low-risk diagnoses were determined by using 30-day, major-morbidity data. Univariate and multivariable analyses were used to compare outcomes. RESULTS Pancreatic cancer and chronic pancreatitis were found to be low-risk diagnoses in elderly patients, whereas bile duct and ampullary neoplasm, duodenal neoplasm, and neuroendocrine tumors were high-risk diagnoses. The risk of 30-day mortality for older patients (≥80 y) undergoing PD was 6.1% for those with high-risk diagnoses vs 4.5% for those with low-risk diagnoses (P = .27). On multivariable analysis (controlling for confounders), a high-risk diagnosis was shown to be an independent predictor of prolonged length of stay, superficial surgical-site infection (SSI), and organ-space SSI. There was no increased risk of complications in patients ≥80 years with low-risk diagnoses. CONCLUSION In patients 80 or older undergoing PD, perioperative risk varies by diagnostic indication. Patients should receive preoperative counseling about their risk.
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Wang G, Li L, Ma Y, Qu FZ, Zhu H, Lv JC, Jia YH, Wu LF, Sun B. External Versus Internal Pancreatic Duct Drainage for the Early Efficacy After Pancreaticoduodenectomy: A Retrospectively Comparative Study. J INVEST SURG 2016; 29:226-33. [DOI: 10.3109/08941939.2015.1105327] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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18
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Assessing surgical quality: comparison of general and procedure-specific morbidity estimation models for the risk adjustment of pancreaticoduodenectomy outcomes. World J Surg 2015; 38:2412-21. [PMID: 24705780 DOI: 10.1007/s00268-014-2554-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The use of outcomes to evaluate surgical quality implies the need for detailed risk adjustment. The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) is a generally applicable risk adjustment model suitable for pancreatic surgery. A pancreaticoduodenectomy (PD)-specific intraoperative pancreatic risk assessment (IPRA) estimates the risk of postoperative pancreatic fistula (POPF) and associated morbidity based on factors that are not incorporated into POSSUM. OBJECTIVE The aim of the study was to compare the risk estimations of POSSUM and IPRA in patients undergoing PD. METHODS An observational single-center cohort study was conducted including 195 patients undergoing PD in 2008-2010. POSSUM and IPRA data were recorded prospectively. Incidence and severity of postoperative morbidity was recorded according to established definitions. The cohort was grouped by POSSUM and IPRA risk groups. The estimated and observed outcomes and morbidity profiles of POSSUM and IPRA were scrutinized. RESULTS POSSUM-estimated risk (62 %) corresponded with observed total morbidity (65 %). Severe morbidity was 17 % and in-hospital-mortality 3.1 %. Individual and grouped POSSUM risk estimates did not reveal associations with incidence (p = 0.637) or severity (p = 0.321) of total morbidity or POPF. The IPRA model identified patients with high POPF risk (p < 0.001), but was even associated with incidence (p < 0.001) and severity (p < 0.001) of total morbidity. CONCLUSION The risk factors defined by a PD-specific model were significantly stronger predictive indicators for the incidence and severity of postoperative morbidity than the factors incorporated in POSSUM. If available, reliable procedure-specific risk factors should be utilized in the risk adjustment of surgical outcomes. For pancreatic surgery, generally applicable tools such as POSSUM still have to prove their relevance.
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An analysis of risk factors for pancreatic fistula after robotic pancreaticoduodenectomy: outcomes from a consecutive series of standardized pancreatic reconstructions. Surg Endosc 2015; 30:1523-9. [DOI: 10.1007/s00464-015-4366-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 06/15/2015] [Indexed: 12/18/2022]
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20
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Shubert CR, Wagie AE, Farnell MB, Nagorney DM, Que FG, Reid Lombardo KM, Truty MJ, Smoot RL, Kendrick ML. Clinical Risk Score to Predict Pancreatic Fistula after Pancreatoduodenectomy: Independent External Validation for Open and Laparoscopic Approaches. J Am Coll Surg 2015; 221:689-98. [PMID: 26296680 DOI: 10.1016/j.jamcollsurg.2015.05.011] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 04/27/2015] [Accepted: 05/11/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND A clinical risk score for pancreatic fistula (CRS-PF) was recently reported to predict postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD). An independent external validation has not been performed. Our hypothesis was that CRS-PF predicts POPF after both laparoscopic and open PD. STUDY DESIGN The CRS-PF was calculated from a retrospective review of patients undergoing PD from January 2007 to February 2014. Postoperative pancreatic fistula was graded using International Study Group of Pancreatic Fistula criteria. Grade B and C leaks were defined as clinically significant. Performance was measured based on sensitivity, specificity, positive and negative predictive value, accuracy, and R(2). RESULTS There were 808 patients who met inclusion criteria; 539 (66.7%) had open and 269 (33.3%) had laparoscopic PD. The CRS-PF was high risk in 134 patients, intermediate in 492, low in 135, and negligible in 47. Postoperative pancreatic fistula occurred in 191 (23.6%) patients (grade A, 3.8%; B, 14.2%; and C, 5.6%), and it increased with risk category (R(2) = 0.935 all, 0.898 open, and 0.968 laparoscopic). High and intermediate risk categories were combined and classified as "test positive," and negligible and low risk categories were combined and classified "test negative," resulting in a CRS-PF with a sensitivity of 95% and a negative predictive value of 96% for predicting POPF. Contrary to previous studies, grade A POPF increased with increasing CRS-PF and POPF did not correlate with estimated blood loss (R(2) = 0.04). CONCLUSIONS The CRS-PF was validated independently by predicting POPF for both laparoscopic and open PD. Predictive performance was at least as good for laparoscopic PD as for open PD. Lack of correlation with estimated blood loss suggests CRS-PF might be tailored for improved performance. The CRS-PF is a clinically useful tool for POPF risk stratification after PD and allows for targeted intra- and postoperative measures to address patients at increased risk.
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Affiliation(s)
- Christopher R Shubert
- Division of Subspecialty General Surgery, Department of Surgery, Section of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN; Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program, Mayo Clinic, Rochester, MN
| | - Amy E Wagie
- Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program, Mayo Clinic, Rochester, MN
| | - Michael B Farnell
- Division of Subspecialty General Surgery, Department of Surgery, Section of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN
| | - David M Nagorney
- Division of Subspecialty General Surgery, Department of Surgery, Section of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN
| | - Florencia G Que
- Division of Subspecialty General Surgery, Department of Surgery, Section of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN
| | - K Marie Reid Lombardo
- Division of Subspecialty General Surgery, Department of Surgery, Section of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN
| | - Mark J Truty
- Division of Subspecialty General Surgery, Department of Surgery, Section of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN
| | - Rory L Smoot
- Division of Subspecialty General Surgery, Department of Surgery, Section of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN
| | - Michael L Kendrick
- Division of Subspecialty General Surgery, Department of Surgery, Section of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN.
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21
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Shubert CR, Kendrick ML, Thomsen KM, Farnell MB, Habermann EB. Identification of risk categories for in pancreaticoduodenectomy based on diagnosis. HPB (Oxford) 2015; 17:428-37. [PMID: 25516234 PMCID: PMC4402054 DOI: 10.1111/hpb.12369] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 11/02/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Studies of pancreaticoduodenectomy (PD) frequently overlook diagnosis as a variable when evaluating postoperative outcomes or generically group patients according to whether they have 'benign' or 'malignant' disease. Large multicentre studies comparing postoperative outcomes in PD stratified by diagnosis are lacking. The present study was conducted to verify the hypothesis that postoperative morbidity and length of stay (LoS) following PD vary by diagnosis and that patients may be grouped into low- and high-risk categories. METHODS The database of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was reviewed for all PDs performed during 2005-2011. Diagnoses were identified using ICD-9 codes and grouped based on the incidence of major morbidity. Univariate and multivariate analyses were utilized to assess the impact of diagnosis on PD outcomes. RESULTS Of 5537 patients, those with pancreas cancer (n = 3173) and chronic pancreatitis (n = 485) experienced similar incidences of major morbidity (P = 0.95) and were grouped as having low-risk diagnoses. Patients with bile duct and ampullary (n = 1181), duodenal (n = 558) and neuroendocrine (n = 140) disease experienced similar levels of major morbidity (P = 0.78) and were grouped as having high-risk diagnoses. A high-risk diagnosis was identified as an independent risk factor for a prolonged LoS [odds ratio (OR) 1.67], organ space infection (OR 2.57), sepsis or septic shock (OR 1.83), and major morbidity (OR 1.70). Diagnosis did not predict readmission. CONCLUSIONS The high-risk diagnosis is independently associated with postoperative morbidity and prolonged LoS. Patients with PD should be stratified by diagnosis to more accurately reflect their risk for postoperative complications and the complexity of care they will require.
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Affiliation(s)
- Christopher R Shubert
- Department of Surgery, Division of Subspecialty General Surgery, Mayo ClinicRochester, MN, USA,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo ClinicRochester, MN, USA
| | - Michael L Kendrick
- Department of Surgery, Division of Subspecialty General Surgery, Mayo ClinicRochester, MN, USA
| | - Kristine M Thomsen
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo ClinicRochester, MN, USA
| | - Michael B Farnell
- Department of Surgery, Division of Subspecialty General Surgery, Mayo ClinicRochester, MN, USA
| | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo ClinicRochester, MN, USA,Correspondence, Elizabeth B. Habermann, Health Care Policy and Research, Mayo Clinic, 200 First Street South West, Rochester, MN 55905, USA. Tel: + 1 507 255 5123. Fax: + 1 507 284 1731. E-mail:
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Yang H, Lu XF, Xu YF, Liu HD, Guo S, Liu Y, Chen YX. Application of air insufflation to prevent clinical pancreatic fistula after pancreaticoduodenectomy. World J Gastroenterol 2015; 21:1872-1879. [PMID: 25684954 PMCID: PMC4323465 DOI: 10.3748/wjg.v21.i6.1872] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 07/28/2014] [Accepted: 09/16/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To introduce an air insufflation procedure and to investigate the effectiveness of air insufflation in preventing pancreatic fistula (PF).
METHODS: From March 2010 to August 2013, a total of 185 patients underwent pancreaticoduodenectomy (PD) at our institution, and 74 patients were not involved in this study for various reasons. The clinical outcomes of 111 patients were retrospectively analyzed. The air insufflation test was performed in 46 patients to investigate the efficacy of the pancreaticojejunal anastomosis during surgery, and 65 patients who did not receive the air insufflation test served as controls. Preoperative assessments and intraoperative outcomes were compared between the 2 groups. Univariate and multivariate analyses were performed to identify the risk factors for PF.
RESULTS: The two patient groups had similar baseline demographics, preoperative assessments, operative factors, pancreatic factors and pathological results. The overall mortality, morbidity, and PF rates were 1.8%, 48.6%, and 26.1%, respectively. No significant differences were observed in either morbidity or mortality between the two groups. The rate of clinical PF (grade B and grade C PF) was significantly lower in the air insufflation test group, compared with the non-air insufflation test group (6.5% vs 23.1%, P = 0.02). Univariate analysis identified the following parameters as risk factors related to clinical PF: estimated blood loss; pancreatic duct diameter ≤ 3 mm; invagination anastomosis technique; and not undergoing air insufflation test. By further analyzing these variables with multivariate logistic regression, estimated blood loss, pancreatic duct diameter ≤ 3 mm and not undergoing air insufflation test were demonstrated to be independent risk factors.
CONCLUSION: Performing an air insufflation test could significantly reduce the occurrence of clinical PF after PD. Not performing an air insufflation test was an independent risk factor for clinical PF.
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Yamashita K, Sasaki T, Itoh R, Kato D, Hatano N, Soejima T, Ishii K, Takenawa T, Hiromatsu K, Yamashita Y. Pancreatic fistulae secondary to trypsinogen activation by Pseudomonas aeruginosa infection after pancreatoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:454-62. [PMID: 25678202 DOI: 10.1002/jhbp.223] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 01/13/2015] [Indexed: 01/27/2023]
Abstract
BACKGROUND Pancreatic fistula after pancreatoduodenectomy (PD) is associated with high mortality and morbidity. Trypsinogen activation and bacteria, although hypothesized to be interrelated etiopathogenetically, have not had their relationship and pathogenic mechanisms elucidated. This study investigated bacterial involvement in pancreatic juice activation perioperatively after PD at sites of pancreatic fistula formation. METHODS Fifty patients underwent PD; postoperative pancreatic fistulae were graded based on the International Study Group for Pancreatic Fistula grading criteria. Bacteria were isolated from cultures of drainage fluid. Digested peptides from trypsinogen and bacterial culture supernatants underwent sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) separation and mass spectrometric analysis. Zymography was used to detect the trypsinogen activator. RESULTS Pseudomonas aeruginosa and Enterobacter cloacae isolated from drainage fluid in patients with grades B and C pancreatic fistulae could cause trypsinogen activation. Trypsinogen activation by P. aeruginosa and E. cloacae were preventable by the use of a serine protease inhibitor in vitro. A protease in the supernatant from P. aeruginosa-positive cultures acted as the trypsinogen activator. CONCLUSIONS Infection with P. aeruginosa perioperatively to PD entails secretion of a protease activator of trypsinogen to trypsin. Bacterial infection control in the perioperative PD period could be crucial to prevent development of pancreatic fistula.
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Affiliation(s)
- Kanefumi Yamashita
- Department of Gastroenterological Surgery, Fukuoka University School of Medicine, Nanakuma 7-45-1, Jonan-ku, Fukuoka 814-0180, Japan
| | - Takamitsu Sasaki
- Department of Gastroenterological Surgery, Fukuoka University School of Medicine, Nanakuma 7-45-1, Jonan-ku, Fukuoka 814-0180, Japan.
| | - Ryota Itoh
- Department of Microbiology and Immunology, Fukuoka University School of Medicine, Jonan-ku, Fukuoka, Japan
| | - Daisuke Kato
- Department of Gastroenterological Surgery, Fukuoka University School of Medicine, Nanakuma 7-45-1, Jonan-ku, Fukuoka 814-0180, Japan
| | - Naoya Hatano
- Integrated Center for Mass Spectrometry, Kobe University, Kobe, Hyogo, Japan
| | - Toshinori Soejima
- Department of Microbiology and Immunology, Fukuoka University School of Medicine, Jonan-ku, Fukuoka, Japan
| | - Kazunari Ishii
- Department of Microbiology and Immunology, Fukuoka University School of Medicine, Jonan-ku, Fukuoka, Japan
| | - Tadaomi Takenawa
- Integrated Center for Mass Spectrometry, Kobe University, Kobe, Hyogo, Japan
| | - Kenji Hiromatsu
- Department of Microbiology and Immunology, Fukuoka University School of Medicine, Jonan-ku, Fukuoka, Japan
| | - Yuichi Yamashita
- Department of Gastroenterological Surgery, Fukuoka University School of Medicine, Nanakuma 7-45-1, Jonan-ku, Fukuoka 814-0180, Japan
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Kanda M, Fujii T, Takami H, Suenaga M, Inokawa Y, Yamada S, Kobayashi D, Tanaka C, Sugimoto H, Koike M, Nomoto S, Fujiwara M, Kodera Y. Novel diagnostics for aggravating pancreatic fistulas at the acute phase after pancreatectomy. World J Gastroenterol 2014; 20:8535-8544. [PMID: 25024608 PMCID: PMC4093703 DOI: 10.3748/wjg.v20.i26.8535] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Revised: 01/28/2014] [Accepted: 03/06/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To identify sensitive predictors of clinically relevant postoperative pancreatic fistula (POPF) at the acute phase after pancreatectomy.
METHODS: This study included 153 patients diagnosed as having POPFs at postoperative day (POD) 3 after either open pancreatoduodenectomy or distal pancreatectomy between January 2008 and March 2013. The POPFs were categorized into three grades based on the International Study Group on Pancreatic Fistula Definition, and POPFs of grades B or C were considered to be clinically relevant. The predictive performance for the clinically relevant POPF formation of values at PODs 1, 3 and 5 as well as time-dependent changes in levels of inflammatory markers, including white blood cell count, neutrophil count, total lymphocyte count, C-reactive protein (CRP), procalcitonin level, platelet-to-lymphocyte ratio and neutrophil-to-lymphocyte ratio, and amylase content in the drain fluid were compared using the receiver operating characteristic (ROC) curve and multivariable analyses. A scoring system for the prediction of clinically relevant POPFs was created using five risk factors identified in this study, and its diagnostic performance was also evaluated.
RESULTS: Over time, 77 (50%) of 153 enrolled patients followed a protracted course and were categorized as having clinically relevant POPFs. ROC curve analyses revealed that changes in CRP levels from POD 1 to POD 3 had the greatest area under the curve value (0.767) and that an elevated CRP level of 28.4 mg/L yielded the most optimal predictive value for clinically relevant POPFs. Multivariable analyses for the risk factors of clinically relevant POPFs identified invasive carcinomas of the pancreas and elevation of the CRP level (≥ 28.4 mg/L, from POD 1 to POD 3) as independent diagnostic factors for clinically relevant POPFs (OR 2.94, 95%CI: 1.08-8.55, P = 0.035 and OR 4.82, 95%CI: 1.25-20.2, P = 0.022, respectively). A gradual increase in the prevalence of clinically relevant POPFs in proportion to the risk classification score was confirmed. A highly elevated CRP level and a risk score ≥ 8 were significantly associated with a prolonged duration of drain placement and postoperative hospitalization.
CONCLUSION: A steep rise in the serum CRP level from POD 1 to POD 3 was a highly predictive factor for subsequent clinically relevant POPFs.
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Palani Velu LK, Chandrabalan VV, Jabbar S, McMillan DC, McKay CJ, Carter CR, Jamieson NB, Dickson EJ. Serum amylase on the night of surgery predicts clinically significant pancreatic fistula after pancreaticoduodenectomy. HPB (Oxford) 2014; 16:610-9. [PMID: 24246024 PMCID: PMC4105898 DOI: 10.1111/hpb.12184] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 08/31/2013] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Drainage after pancreaticoduodenectomy (PD) remains controversial because the risk for uncontrolled postoperative pancreatic fistula (POPF) must be balanced against the potential morbidity associated with prolonged and possibly unnecessary drainage. This study investigated the utility of the level of serum amylase on the night of surgery [postoperative day (PoD) 0 serum amylase] to predict POPF. METHODS A total of 185 patients who underwent PD were studied. Occurrences of POPF were graded using the International Study Group on Pancreatic Fistula (ISGPF) classification. Receiver operating characteristic (ROC) analysis identified a threshold value of PoD 0 serum amylase associated with clinically significant POPF (ISGPF Grades B and C) in a test cohort (n = 45). The accuracy of this threshold value was then tested in a validation cohort (n = 140). RESULTS Overall, 43 (23.2%) patients developed clinically significant POPF. The threshold value of PoD 0 serum amylase for the identification of clinically significant POPF was ≥ 130 IU/l (P = 0.003). Serum amylase of <130 IU/l had a negative predictive value of 88.8% for clinically significant POPF (P < 0.001). Serum amylase of ≥ 130 IU/l on PoD 0 and a soft pancreatic parenchyma were independent risk factors for clinically significant POPF. CONCLUSIONS Postoperative day 0 serum amylase of <130 IU/l allows for the early and accurate categorization of patients at least risk for clinically significant POPF and may identify patients suitable for early drain removal.
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Affiliation(s)
- Lavanniya K Palani Velu
- West of Scotland Pancreatic Unit, Glasgow Royal InfirmaryGlasgow, UK,Academic Department of Surgery, University of GlasgowGlasgow, UK
| | - Vishnu V Chandrabalan
- West of Scotland Pancreatic Unit, Glasgow Royal InfirmaryGlasgow, UK,Academic Department of Surgery, University of GlasgowGlasgow, UK
| | - Salman Jabbar
- West of Scotland Pancreatic Unit, Glasgow Royal InfirmaryGlasgow, UK
| | | | - Colin J McKay
- West of Scotland Pancreatic Unit, Glasgow Royal InfirmaryGlasgow, UK
| | - C Ross Carter
- West of Scotland Pancreatic Unit, Glasgow Royal InfirmaryGlasgow, UK
| | - Nigel B Jamieson
- West of Scotland Pancreatic Unit, Glasgow Royal InfirmaryGlasgow, UK,Academic Department of Surgery, University of GlasgowGlasgow, UK
| | - Euan J Dickson
- West of Scotland Pancreatic Unit, Glasgow Royal InfirmaryGlasgow, UK
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McMillan MT, Vollmer CM. Predictive factors for pancreatic fistula following pancreatectomy. Langenbecks Arch Surg 2014; 399:811-24. [DOI: 10.1007/s00423-014-1220-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Accepted: 06/17/2014] [Indexed: 12/15/2022]
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External stent versus no stent for pancreaticojejunostomy: a meta-analysis of randomized controlled trials. J Gastrointest Surg 2013; 17:1516-25. [PMID: 23568149 DOI: 10.1007/s11605-013-2187-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 03/18/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND The effectiveness of an external pancreatic duct stent for reduction of the pancreatic fistula after pancreaticoduodenectomy remains controversial. METHODS MEDLINE, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials were searched for eligible randomized controlled trials (RCTs). Reviews of each trial were conducted and data were extracted. The primary outcome was pancreatic fistula. Statistical pooling used the fixed or random effects model and reported as risk ratio (RR) or mean difference (MD) with the corresponding 95 % confidence intervals (CI). RESULTS Four RCTs including a total of 416 patients were detected. Methodological quality assessment revealed a better quality of all analyzed trials. Placing an external stent across pancreaticojejunal anastomosis could significantly reduce the incidence of pancreatic fistula (RR = 0.57, 95 % CI = 0.41-0.80, P = 0.001, I (2) = 0 %), overall morbidity (RR = 0.79, 95 % CI = 0.64-0.98, P = 0.03), and the length of hospital stay (MD = -3.98 days, 95 % CI = -6.42 to -1.54, P = 0.001, I (2) = 13 %). No significant difference was found in terms of hospital mortality, delayed gastric emptying, operation time, operative blood loss, blood replacement, and reoperation rate. CONCLUSIONS This meta-analysis provides compelling evidence that the application of an external pancreatic duct stent after pancreaticoduodenectomy can decrease the incidence of pancreatic leakage when compared with no stent. Moreover, the external drainage of pancreatic juice is associated with lower postoperative overall morbidity and shorter hospital stay.
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The impact of internal or external transanastomotic pancreatic duct stents following pancreaticojejunostomy. Which one is better? A meta-analysis. J Gastrointest Surg 2012; 16:2322-35. [PMID: 23011201 DOI: 10.1007/s11605-012-1987-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The use of pancreatic duct stent to improve postoperative outcomes of pancreatic anastomosis remains a matter of debate, and the value of stenting when performing anastomosis for normal pancreas (soft and duct less than 3 mm) needs further study. The aim of the present meta-analysis was to evaluate the perioperative outcomes of patients with stenting during pancreatic anastomosis and compare the effect of external stent with that of internal stent indirectly. METHODS A systematic literature search (EMBASE, MEDLINE, PubMed, The Cochrane Library, and Web of Science) was performed to identify studies evaluating external stent or internal stent. Included literature was assessed and extracted by two independent reviewers. A meta-analysis including comparative studies providing data on patients with and without external stenting or internal stenting during pancreaticojejunostomy anastomosis was performed. RESULTS Thirteen articles including 1,867 patients were identified for inclusion: five randomized controlled trials study and eight observational clinical studies. Meta-analyses revealed that use of external stent was associated with a significantly decreased risk for pancreatic fistula in total (odds ratio (OR) 0.47; 95 % confidence interval (CI) 0.31-0.71; P = 0.0004; I (2) = 3 %), pancreatic fistula in normal pancreas(OR 0.5; 95 % CI 0.30-0.82; P = 0.007; I (2) = 5 %), and overall morbidity(OR 0.64; 95 % CI 0.45-0.90; P = 0.01; I (2) = 0 %); however, the meta-analysis showed that there were no significant differences between internal stenting and non-stenting groups as regards perioperative outcomes and that in fact it may increase pancreatic fistula rate in normal pancreas(OR 1.97; 95 % CI 1.05-3.69; P = 0.03; I (2) = 0 %). CONCLUSIONS The results of this analysis demonstrate a trend toward reduced pancreatic fistula with the use of external pancreatic stents in pancreaticojejunostomy. An internal stent does not impact development of fistula and that in fact it was not useful in a soft pancreas. Our conclusion may be limited to stenting during the duct-to-mucosa pancreaticojejunostomy anastomosis, and the value of stenting during invagination anastomosis needs further study.
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Nutritional risk index as an independent predictive factor for the development of surgical site infection after pancreaticoduodenectomy. Surg Today 2012; 43:276-83. [DOI: 10.1007/s00595-012-0350-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Accepted: 01/12/2012] [Indexed: 02/06/2023]
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Ansorge C, Strömmer L, Andrén-Sandberg Å, Lundell L, Herrington MK, Segersvärd R. Structured intraoperative assessment of pancreatic gland characteristics in predicting complications after pancreaticoduodenectomy. Br J Surg 2012; 99:1076-1082. [DOI: 10.1002/bjs.8784] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Abstract
Background
The morbidity rate after pancreaticoduodenectomy remains high (20–50 per cent) and postoperative pancreatic fistula (POPF) is a major underlying factor. POPF has been reported to be associated with pancreatic consistency (PC) and pancreatic duct diameter (PDD). The aim was to quantify the risk of pancreaticojejunostomy-associated morbidity (PJAM) by means of a structured intraoperative assessment of both characteristics.
Methods
This single-centre prospective observational study included pancreaticoduodenectomies performed between 2008 and 2010 with a standardized duct-to-mucosa end-to-side pancreaticojejunostomy. PC and PDD were assessed during surgery and classified into four grades each (from very hard to very soft, and from larger than 4 mm to smaller than 2 mm, respectively). PJAM was defined as POPF (grade B or C in International Study Group on Pancreatic Fistula classification) or symptomatic peripancreatic collection of either abscess or fluid. PJAM of at least Clavien grade IIIb was considered severe.
Results
PJAM and POPF were observed in 24 (21·8 per cent) and 17 (15·5 per cent) of 110 patients respectively. Softer PC and smaller PDD were risk factors for POPF (both P < 0·001), symptomatic peripancreatic collections (P = 0·071 and P = 0·015) and PJAM (both P < 0·001). Combining consistency and duct characteristics in a composite classification the PJAM risk was stratified as ‘high’ (both risk factors, PJAM incidence 51 per cent), ‘intermediate’ (softer PC or smaller PDD, PJAM 26 per cent) or ‘low’ (no risk factors, PJAM 2 per cent). Severe PJAM was observed only in patients with smaller PDD.
Conclusion
A high-risk pancreatic gland had a 25-fold higher risk of PJAM after pancreaticoduoden- ectomy than a low-risk gland. This simple classification can contribute to more individualized patient management and allow stratification of study cohorts with homogeneous POPF risk.
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Affiliation(s)
- C Ansorge
- Division of Surgery, CLINTEC, Department of Surgical Gastroenterology, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden
| | - L Strömmer
- Division of Surgery, CLINTEC, Department of Surgical Gastroenterology, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden
| | - Å Andrén-Sandberg
- Division of Surgery, CLINTEC, Department of Surgical Gastroenterology, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden
| | - L Lundell
- Division of Surgery, CLINTEC, Department of Surgical Gastroenterology, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden
| | - M K Herrington
- Division of Surgery, CLINTEC, Department of Surgical Gastroenterology, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden
- Department of Biology, Adams State College, Alamosa, Colorado, USA
| | - R Segersvärd
- Division of Surgery, CLINTEC, Department of Surgical Gastroenterology, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden
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Xiong JJ, Altaf K, Mukherjee R, Huang W, Hu WM, Li A, Ke NW, Liu XB. Systematic review and meta-analysis of outcomes after intraoperative pancreatic duct stent placement during pancreaticoduodenectomy. Br J Surg 2012; 99:1050-61. [PMID: 22622664 DOI: 10.1002/bjs.8788] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2012] [Indexed: 02/05/2023]
Abstract
BACKGROUND Postoperative pancreatic leakage after pancreaticoduodenectomy is often serious. Although some studies have suggested that stenting the anastomosis can reduce the incidence of this complication, the value of stenting in the setting of pancreaticoduodenectomy remains unclear. METHODS Studies comparing outcomes of stent versus no stent, and internal versus external stent placement for pancreaticoduodenectomy were eligible for inclusion. Pooled odds ratios (ORs) with 95 per cent confidence intervals were calculated using fixed- or random-effects models. RESULTS From a search of the literature published between January 1973 and September 2011, five randomized clinical trials (RCTs) and 11 non-randomized observational clinical studies (OCS) involving 1726 patients were selected for inclusion in this review. Meta-analysis of RCTs revealed that placing a stent in the pancreatic duct did not reduce the incidence of postoperative pancreatic fistula. External stents had no advantage over internal stents in terms of clinical outcome. Subgroup analyses revealed that use of an external stent significantly reduced the incidence of pancreatic fistula (RCTs: OR 0·42, 0·24 to 0·76, P = 0·004; OCS: OR 0·43, 0·27 to 0·68, P < 0·001), delayed gastric emptying (RCTs: OR 0·41, 0·19 to 0·87, P = 0·02) and postoperative morbidity (RCTs: OR 0·55, 0·34 to 0·89, P = 0·02) compared with no stent. CONCLUSION Pancreatic duct stenting did not reduce the incidence of pancreatic fistula and other complications in pancreaticoduodenectomy compared with no stenting. Although no difference was found between external and internal stents in terms of efficacy, external stents seemed to reduce the incidence of pancreatic fistula compared with control.
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Affiliation(s)
- J J Xiong
- Department of Hepato-Biliary-Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
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Motoi F, Egawa S, Rikiyama T, Katayose Y, Unno M. Randomized clinical trial of external stent drainage of the pancreatic duct to reduce postoperative pancreatic fistula after pancreaticojejunostomy. Br J Surg 2012; 99:524-31. [PMID: 22497024 DOI: 10.1002/bjs.8654] [Citation(s) in RCA: 141] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) remains one of the most common causes of morbidity following pancreaticoduodenectomy (PD). This randomized trial examined whether external stent drainage of the pancreatic duct decreases the rate of POPF after PD and subsequent pancreaticojejunostomy (PJ). METHODS Consecutive patients who underwent PD with subsequent construction of a duct-to-mucosa PJ were randomized into a stented and a non-stented group. The primary outcome was the incidence of clinically relevant POPF. Secondary outcomes were morbidity and mortality rates, and hospital stay. RESULTS Of 114 PD procedures, 93 were suitable for inclusion in the study after informed consent. The rate of clinically relevant POPF was significantly lower in the stented group than in the non-stented group: three of 47 (6 per cent) versus ten of 46 (22 per cent) (P = 0·040). Among patients with a dilated duct, rates of POPF were similar in both groups. Among patients with a non-dilated duct, clinically relevant POPF was significantly less common in the stented group than in the non-stented group: two of 21 (10 per cent) versus eight of 20 (40 per cent) (P = 0·033). No significant differences in morbidity or mortality were observed. Univariable analysis identified body mass index (BMI), pancreatic cancer,pancreatic texture, pancreatic duct size and duct stenting as risk factors related to clinically relevant POPF. Multivariable analysis taking these five factors into account identified high BMI (risk ratio(RR) 11·45; P = 0·008), non-dilated duct (RR 5·33; P = 0·046) and no stent (RR 10·38; P = 0·004) as significant risk factors. CONCLUSION External duct stenting reduced the risk of clinically relevant POPF after PD and subsequent duct-to-mucosa PJ.
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Affiliation(s)
- F Motoi
- Division of Gastroenterological Surgery, Department of Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryo-machi, Aoba-ku, Sendai980-8574, Japan.
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Ramacciato G, Mercantini P, Petrucciani N, Nigri GR, Kazemi A, Muroni M, Del Gaudio M, Balesh A, Cescon M, Cucchetti A, Ravaioli M. Article Commentary: Risk Factors of Pancreatic Fistula after Pancreaticoduodenectomy: A Collective Review. Am Surg 2011. [DOI: 10.1177/000313481107700310] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Postoperative pancreatic fistula (POPF) is the most frequent complication after pancreaticoduodenectomy, results in increased morbidity and mortality, and adversely affects length of stay and costs. Reported rates of postoperative pancreatic fistula vary from 0 per cent up to more than 30 per cent. Plenty of randomized trails and meta-analysis were published to analyze the ideal procedure, technique of anastomosis, and perioperative management of patients undergoing pancreaticoduodenectomy; however, results are often discordant and clear evidence on the ideal management and surgical technique to reduce POPF rate is not yet provided. This collective review examined the current evidence about risk factors contributing to postoperative pancreatic fistula and delineates methods of diagnosis and treatment of this universally dreaded complication.
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Affiliation(s)
- Giovanni Ramacciato
- University “Sapienza,” II Faculty of Medicine, Hospital “ Sant'Andrea,” Rome, Italy
| | - Paolo Mercantini
- University “Sapienza,” II Faculty of Medicine, Hospital “ Sant'Andrea,” Rome, Italy
| | - Niccolò Petrucciani
- University “Sapienza,” II Faculty of Medicine, Hospital “ Sant'Andrea,” Rome, Italy
| | - Giuseppe R. Nigri
- University “Sapienza,” II Faculty of Medicine, Hospital “ Sant'Andrea,” Rome, Italy
| | - Andrea Kazemi
- University “Sapienza,” II Faculty of Medicine, Hospital “ Sant'Andrea,” Rome, Italy
| | - Mirko Muroni
- University “Sapienza,” II Faculty of Medicine, Hospital “ Sant'Andrea,” Rome, Italy
| | - Massimo Del Gaudio
- University “Sapienza,” II Faculty of Medicine, Hospital “ Sant'Andrea,” Rome, Italy
| | - Albert Balesh
- University “Sapienza,” II Faculty of Medicine, Hospital “ Sant'Andrea,” Rome, Italy
| | - Matteo Cescon
- University “Sapienza,” II Faculty of Medicine, Hospital “ Sant'Andrea,” Rome, Italy
| | - Alessandro Cucchetti
- University “Sapienza,” II Faculty of Medicine, Hospital “ Sant'Andrea,” Rome, Italy
| | - Matteo Ravaioli
- University “Sapienza,” II Faculty of Medicine, Hospital “ Sant'Andrea,” Rome, Italy
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Kanda M, Fujii T, Kodera Y, Nagai S, Takeda S, Nakao A. Nutritional predictors of postoperative outcome in pancreatic cancer. Br J Surg 2011; 98:268-74. [PMID: 20960457 DOI: 10.1002/bjs.7305] [Citation(s) in RCA: 443] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Nutritional status plays an important role in the incidence of postoperative complications and the prognosis of various tumours. The prognostic value of preoperative nutritional factors in patients with pancreatic cancer is not known. METHODS This retrospective study included 268 patients who underwent resection for adenocarcinoma of the pancreas. The predictive value of preoperative nutritional status for postoperative outcome (survival, complications) was assessed. Nutritional factors included the three constitutional indices, serum albumin and Onodera's prognostic nutrition index (PNI), calculated as 10 × serum albumin (g/dl) + 0·005× total lymphocyte count (per mm(3)). RESULTS In multivariable analysis preoperative low PNI (but not low albumin) was an independent prognostic factor for poor survival: hazard ratio (HR) 1·73 (95 per cent confidence interval (c.i.) 1·21 to 2·47). The accuracy of a PNI value of less than 45 as cut-off for clinically significant preoperative malnutrition in predicting 1- or 2-year survival after surgery was, however, limited (66·4 and 56·3 per cent respectively). Low preoperative albumin concentration and PNI were significantly associated with postoperative complications: odds ratio 1·98 (95 per cent c.i. 1·18 to 3·32) and 2·14 (1·23 to 3·73) respectively. Low PNI and low body mass index were independently associated with pancreatic fistula: HR 2·52 (1·37 to 4·63) and 0·40 (0·17 to 0·93) respectively. CONCLUSION The PNI is associated with overall survival and postoperative complications, in particular pancreatic fistula, in patients with pancreatic cancer. The moderate accuracy of PNI as a predictor of survival limits its clinical use.
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Affiliation(s)
- M Kanda
- Department of Surgery II, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan
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Ochiai T, Sonoyama T, Soga K, Inoue K, Ikoma H, Shiozaki A, Kuriu Y, Kubota T, Nakanishi M, Kikuchi S, Ichikawa D, Fujiwara H, Sakakura C, Okamoto K, Kokuba Y, Otsuji E. Application of polyethylene glycolic acid felt with fibrin sealant to prevent postoperative pancreatic fistula in pancreatic surgery. J Gastrointest Surg 2010; 14:884-90. [PMID: 20177808 DOI: 10.1007/s11605-009-1149-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2009] [Accepted: 12/16/2009] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The purpose of this nonrandomized retrospective study was to report our new procedures using polyethylene glycolic acid (PGA) felt with fibrin sealant to prevent severe pancreatic fistula in patients undergoing pancreatic surgery. METHODS From 2000 to 2008, 54 and 63 patients underwent pancreaticoduodenectomy (PD) and distal pancreatectomy (DP), respectively. Of those patients, we applied PGA felt with fibrin sealant to 18 PD patients and 26 DP patients. In PD patients, the PGA felt was wrapped around the pancreatic suture site, while in DP patients, the PGA felt was wrapped around the predictive division site. The pancreaticojejunostomy site in PD patients and the cut stump in DP patients were coated with fibrin sealant. We compared the occurrence rates for severe postoperative pancreatic fistula (POPF) that occurred after PD or DP both with and without our new procedures. RESULTS Before introduction of our procedures, severe POPF developed in 14 of 36 PD patients (39%) and 10 of 37 DP patients (27%). In contrast, after introduction of our procedures, the incidence of POPF was only one in both of 18 PD (6%; P = 0.016) and 26 DP (4%; P = 0.017) patients. CONCLUSION In summary, our procedure using PGA felt with fibrin sealant may reduce the risk of severe POPF.
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Affiliation(s)
- Toshiya Ochiai
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto 6028566, Japan.
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Risk factors for postoperative pancreatic fistula after pancreaticoduodenectomy: the significance of the ratio of the main pancreatic duct to the pancreas body as a predictor of leakage. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2010; 17:322-8. [PMID: 20464562 DOI: 10.1007/s00534-009-0248-6] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Accepted: 10/16/2009] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Postoperative pancreatic fistula (POPF) is a severe and frequent complication after pancreaticoduodenectomy (PD). The aim of this study was to identify an independent predictor of POPF and to assess the efficacy of preoperative multidetector row computed tomography (MDCT) images as an indicator for POPF. METHODS A total of 122 patients who underwent PD with an end-to-side, duct-to-mucosa pancreaticojejunostomy between January 2005 and May 2009 were retrospectively reviewed. The diameter of the main pancreatic duct (MPD), the diameter of the short axis of the pancreas body, and the ratio of the MPD to the pancreas body (MPD index) were digitally measured based on the curved reformatted images of preoperative MDCT. RESULTS Postoperative pancreatic fistula occurred in 33 patients (27%). The operative mortality rate was 3.3% (4 patients). All four patients had grade C POPF. Three died because of hemorrhage from a pseudoaneurysm of the gastroduodenal artery stump, and one died because of sepsis due to major leakage from the pancreaticojejunostomy. In a multivariate analysis, the intraoperative blood loss (/100 ml) [odds ratio (OR), 1.1; 95% confidence interval (CI), 1.05-1.17] and MPD index (<0.2) (OR 50; 95% CI 6-41) proved to be independent predictors of POPF. In patients with an MPD index of <0.2, the incidence of POPF was 45%, and the mortality rate was 7.5%. CONCLUSION The MPD index obtained from preoperative MDCT can be a reliable predictor of POPF after PD.
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