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Hartman V, Roeyen E, Bracke B, Huysentruyt F, De Gendt S, Chapelle T, Ysebaert D, Hendrikx B, Roeyen G. Prevalence of pancreatic exocrine insufficiency after pancreatic surgery measured by 13C mixed triglyceride breath test: A prospective cohort study. Pancreatology 2023; 23:563-568. [PMID: 37301695 DOI: 10.1016/j.pan.2023.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 05/04/2023] [Accepted: 05/28/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Patients undergoing pancreatic surgery are at risk of pancreatic exocrine insufficiency (PEI) and needing pancreatic enzyme replacement therapy (PERT). METHODS This study included 254 patients undergoing pancreatic surgery for oncologic indications. A13C mixed triglyceride breath test was performed immediately preoperative and postoperative. This test analyzes the pancreatic remnant lipase activity measuring 13CO2 in breath samples after a test meal with 1.3-distearyl-(13C-Carboxyl)octanol-glycerol. Cumulative percent dose recovery after 6 h of less than 23% confirms PEI. In addition, PEI was compared between pathology subgroups. RESULTS In 197 patients undergoing pancreaticoduodenectomy, cPDR-6h decreased significantly from a median of 32.84% before to 15.80% after surgery (p < 0.0001). This decrease in exocrine function was significant in all pathology subgroups except in pancreatic neuroendocrine tumors. Exocrine function decreased most in pancreatic ductal adenocarcinoma (PDAC). In addition, the percentage of patients needing PERT because of PEI increased from 25.9% to 68.0% postoperative (p < 0.001). Overall, patients with an MPD diameter of more than 3 mm had a higher risk of developing postoperative PEI: 62.7% compared to 37.3% (p = 0.009), OR = 3.11. In contrast, the majority of the 57 patients undergoing a distal pancreatectomy did not experience any significant change in exocrine function. CONCLUSIONS The vast majority of patients undergoing pancreaticoduodenectomy for oncologic indications experience a significant drop in exocrine function, are at high risk of developing pancreatic exocrine insufficiency and consequently need to be treated with pancreatic enzyme replacement therapy. Therefore, systematic screening for pancreatic exocrine insufficiency is needed after pancreaticoduodenectomy.
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Affiliation(s)
- V Hartman
- Antwerp University Hospital, Department of HPB, Endocrine and Transplantation Surgery, Drie Eikenstraat 655, 2650, Edegem, Belgium; University of Antwerp, Belgium.
| | - E Roeyen
- Antwerp University Hospital, Department of HPB, Endocrine and Transplantation Surgery, Drie Eikenstraat 655, 2650, Edegem, Belgium
| | - B Bracke
- Antwerp University Hospital, Department of HPB, Endocrine and Transplantation Surgery, Drie Eikenstraat 655, 2650, Edegem, Belgium
| | - F Huysentruyt
- Antwerp University Hospital, Department of HPB, Endocrine and Transplantation Surgery, Drie Eikenstraat 655, 2650, Edegem, Belgium
| | - S De Gendt
- Antwerp University Hospital, Department of HPB, Endocrine and Transplantation Surgery, Drie Eikenstraat 655, 2650, Edegem, Belgium
| | - T Chapelle
- Antwerp University Hospital, Department of HPB, Endocrine and Transplantation Surgery, Drie Eikenstraat 655, 2650, Edegem, Belgium; University of Antwerp, Belgium
| | - D Ysebaert
- Antwerp University Hospital, Department of HPB, Endocrine and Transplantation Surgery, Drie Eikenstraat 655, 2650, Edegem, Belgium; University of Antwerp, Belgium
| | - B Hendrikx
- Antwerp University Hospital, Department of HPB, Endocrine and Transplantation Surgery, Drie Eikenstraat 655, 2650, Edegem, Belgium
| | - G Roeyen
- Antwerp University Hospital, Department of HPB, Endocrine and Transplantation Surgery, Drie Eikenstraat 655, 2650, Edegem, Belgium; University of Antwerp, Belgium
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Manuel-Vázquez A, Balakrishnan A, Agami P, Andersson B, Berrevoet F, Besselink MG, Boggi U, Caputo D, Carabias A, Carrion-Alvarez L, Franco CC, Coppola A, Dasari BVM, Diaz-Mercedes S, Feretis M, Fondevila C, Fusai GK, Garcea G, Gonzabay V, Bravo MÁG, Gorris M, Hendrikx B, Hidalgo-Salinas C, Kadam P, Karavias D, Kauffmann E, Kourdouli A, La Vaccara V, van Laarhoven S, Leighton J, Liem MSL, Machairas N, Magouliotis D, Mahmoud A, Marino MV, Massani M, Requena PM, Mentor K, Napoli N, Nijhuis JHT, Nikov A, Nistri C, Nunes V, Ruiz EO, Pandanaboyana S, Saborido BP, Pohnán R, Popa M, Pérez BS, Bueno FS, Serrablo A, Serradilla-Martín M, Skipworth JRA, Soreide K, Symeonidis D, Zacharoulis D, Zelga P, Aliseda D, Santiago MJC, Mancilla CF, Fragua RL, Hughes DL, Llorente CP, Lesurtel M, Gallagher T, Ramia JM. A scoring system for predicting malignancy in intraductal papillary mucinous neoplasms of the pancreas: a multicenter EUROPEAN validation. Langenbecks Arch Surg 2022; 407:3447-3455. [PMID: 36198881 DOI: 10.1007/s00423-022-02687-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 09/14/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE A preoperative estimate of the risk of malignancy for intraductal papillary mucinous neoplasms (IPMN) is important. The present study carries out an external validation of the Shin score in a European multicenter cohort. METHODS An observational multicenter European study from 2010 to 2015. All consecutive patients undergoing surgery for IPMN at 35 hospitals with histological-confirmed IPMN were included. RESULTS A total of 567 patients were included. The score was significantly associated with the presence of malignancy (p < 0.001). In all, 64% of the patients with benign IPMN had a Shin score < 3 and 57% of those with a diagnosis of malignancy had a score ≥ 3. The relative risk (RR) with a Shin score of 3 was 1.37 (95% CI: 1.07-1.77), with a sensitivity of 57.1% and specificity of 64.4%. CONCLUSION Patients with a Shin score ≤ 1 should undergo surveillance, while patients with a score ≥ 4 should undergo surgery. Treatment of patients with Shin scores of 2 or 3 should be individualized because these scores cannot accurately predict malignancy of IPMNs. This score should not be the only criterion and should be applied in accordance with agreed clinical guidelines.
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Affiliation(s)
- Alba Manuel-Vázquez
- Department of General and Digestive Surgery, Hospital Universitario de Getafe, Carretera de Toledo, Km 12, 500, 28905, Madrid, Spain.
| | - Anita Balakrishnan
- Department of Hepatopancreatobiliary Surgery, Addenbrooke's Hospital, and Department of Surgery, University of Cambridge, Cambridge, UK
| | - Paul Agami
- Moscow Clinical Scientific Center, Moscow, Russia
| | - Bodil Andersson
- Department of Clinical Sciences Lund, Surgery, Lund University and Skåne University Hospital, Lund, Sweden
| | - Frederik Berrevoet
- Department of General and HPB Surgery and Liver Transplantation, University Hospital Ghent, Ghent, Belgium
| | | | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Damiano Caputo
- General Surgery Department, Medico University of Rome, Campus Bio, Rome, Italy
| | - Alberto Carabias
- Department of General and Digestive Surgery, Hospital Universitario de Getafe, Carretera de Toledo, Km 12, 500, 28905, Madrid, Spain
| | | | - Carmen Cepeda Franco
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Team, Virgen del Rocio University Hospital, Seville, Spain
| | - Alessandro Coppola
- General Surgery Department, Medico University of Rome, Campus Bio, Rome, Italy
| | | | - Sherley Diaz-Mercedes
- Department of Pathology, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Michail Feretis
- Department of Hepatopancreatobiliary Surgery, Addenbrooke's Hospital, Cambridge, UK
| | - Constantino Fondevila
- Department of General and Digestive Surgery, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, CIBERehd, Spain
| | - Giuseppe Kito Fusai
- Department of HPB Surgery and Liver Transplant, Royal Free Hospital NHS Foundation Trust, London, UK
| | - Giuseppe Garcea
- Leicester General Hospital, University Hospitals of Leicester, Leicester, UK
| | - Victor Gonzabay
- Department of General and Digestive Surgery, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, CIBERehd, Spain
| | - Miguel Ángel Gómez Bravo
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Team, Virgen del Rocio University Hospital, Seville, Spain
| | - Myrte Gorris
- Academic Medical Center, Amsterdam, The Netherlands
| | - Bart Hendrikx
- Department of General and HPB Surgery and Liver Transplantation, University Hospital Ghent, Ghent, Belgium
| | - Camila Hidalgo-Salinas
- Department of HPB Surgery and Liver Transplant, Royal Free Hospital NHS Foundation Trust, London, UK
| | | | - Dimitrios Karavias
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Emanuele Kauffmann
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Amar Kourdouli
- Leicester General Hospital, University Hospitals of Leicester, Leicester, UK
| | - Vincenzo La Vaccara
- General Surgery Department, Medico University of Rome, Campus Bio, Rome, Italy
| | - Stijn van Laarhoven
- Department of HPB Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | | | - Mike S L Liem
- Division of HPB Surgery, Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Nikolaos Machairas
- Department of HPB Surgery and Liver Transplant, Royal Free Hospital NHS Foundation Trust, London, UK
| | | | - Adel Mahmoud
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Marco V Marino
- Azienda Ospedaliera, Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Marco Massani
- Department of Surgery, Regional Hospital "Ca Foncello"Azienda ULSS2 Marca Trevigiana, Treviso, Italy
| | | | | | - Niccolò Napoli
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Jorieke H T Nijhuis
- Division of HPB Surgery, Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Andrej Nikov
- Department of Surgery, Military University Hospital Prague, Prague, Czech Republic
| | - Cristina Nistri
- Department of Surgery, Regional Hospital "Ca Foncello"Azienda ULSS2 Marca Trevigiana, Treviso, Italy
| | - Victor Nunes
- HPB Surgery, Hospital Prof Dr Fernando Fonseca, Amadora, Portugal
| | - Eduardo Ortiz Ruiz
- Department of Pathology, Hospital Clínico Universitario Virgen de La Arrixaca, Murcia, Spain
| | | | - Baltasar Pérez Saborido
- Department of General and Digestive Surgery, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Radek Pohnán
- Department of Surgery, Military University Hospital Prague, Prague, Czech Republic
| | - Mariuca Popa
- Leicester General Hospital, University Hospitals of Leicester, Leicester, UK
| | | | | | - Alejandro Serrablo
- Department of Surgery, Miguel Servet University Hospital, Saragossa, Spain
| | | | - James R A Skipworth
- Department of HPB Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Kjetil Soreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | | | | | - Piotr Zelga
- Department of Hepatopancreatobiliary Surgery, Addenbrooke's Hospital, Cambridge, UK
| | | | | | | | | | - Daniel Llwyd Hughes
- Department of HPB Surgery, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | | | - Mickaël Lesurtel
- Department of Digestive Surgery and Liver Transplantation, Croix Rousse University Hospital, University of Lyon I, Hospices Civils de Lyon, Lyon, France
| | - Tom Gallagher
- Department of Surgery, St. Vincent's University Hospital, Dublin, Ireland
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Apers T, Hendrikx B, Bracke B, Hartman V, Roeyen G, Ysebaert D, Op de Beeck B, Chapelle T. Parenchymal-sparing hepatectomy with hepatic vein resection and reconstruction. Acta Chir Belg 2021; 122:334-340. [PMID: 33860723 DOI: 10.1080/00015458.2021.1915021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Hepatectomy remains the most important treatment modality for most malignant liver tumors. Vascular involvement stays a reason for unresectability or major parenchymal resection. A possible way to avoid this is parenchymal-sparing hepatectomy (PSHX) with vascular resection and reconstruction (HVRR). In this article, we aim to demonstrate the specific role of this technique in avoiding post-hepatectomy liver failure (PHLF). METHODS A retrospective analysis of 10 patients who underwent HVRR was conducted. 99mTechnetium-mebrofenin hepatobiliary scintigraphy (HBS) was used to predict the future liver remnant function (FLRF). Calculations were made for each patient to compare HVRR and major hepatectomy (with or without portal vein embolization). RESULTS In our cohort, there was no perioperative mortality. Two patients suffered a Clavien-Dindo grade 3a complication and none had clinically significant PHLF. Estimated FLRF was significantly higher in HVRR compared to major hepatectomy after portal vein embolization (p < .005). CONCLUSIONS Instead of focusing on inducing liver remnant hypertrophy, preserving parenchyma through HVRR can be an interesting treatment strategy. It can be performed with an acceptable operative risk. Calculations of FLRF (using HBS) suggest that this approach is able to reduce the risk for PHLF and related morbidity or mortality.
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Affiliation(s)
- Thomas Apers
- Department of Hepatobiliary and Transplantation Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Bart Hendrikx
- Department of Hepatobiliary and Transplantation Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Bart Bracke
- Department of Hepatobiliary and Transplantation Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Vera Hartman
- Department of Hepatobiliary and Transplantation Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Geert Roeyen
- Department of Hepatobiliary and Transplantation Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Dirk Ysebaert
- Department of Hepatobiliary and Transplantation Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Bart Op de Beeck
- Department of Radiology, Antwerp University Hospital, Edegem, Belgium
| | - Thiery Chapelle
- Department of Hepatobiliary and Transplantation Surgery, Antwerp University Hospital, Edegem, Belgium
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