Management of Severe Pancreatic Fistula After Pancreatoduodenectomy

Importance

Postoperative pancreatic fistula is a potentially life-threatening complication after pancreatoduodenectomy. Evidence for best management is lacking.

Objective

To evaluate the clinical outcome of patients undergoing catheter drainage compared with relaparotomy as primary treatment for pancreatic fistula after pancreatoduodenectomy.

Design, Setting, and Participants

A multicenter, retrospective, propensity-matched cohort study was conducted in 9 centers of the Dutch Pancreatic Cancer Group from January 1, 2005, to September 30, 2013. From a cohort of 2196 consecutive patients who underwent pancreatoduodenectomy, 309 patients with severe pancreatic fistula were included. Propensity score matching (based on sex, age, comorbidity, disease severity, and previous reinterventions) was used to minimize selection bias. Data analysis was performed from January to July 2016.

Exposures

First intervention for pancreatic fistula: catheter drainage or relaparotomy.

Main Outcomes and Measures

Primary end point was in-hospital mortality; secondary end points included new-onset organ failure.

Results

Of the 309 patients included in the analysis, 209 (67.6%) were men, and mean (SD) age was 64.6 (10.1) years. Overall in-hospital mortality was 17.8% (55 patients): 227 patients (73.5%) underwent primary catheter drainage and 82 patients (26.5%) underwent primary relaparotomy. Primary catheter drainage was successful (ie, survival without relaparotomy) in 175 patients (77.1%). With propensity score matching, 64 patients undergoing primary relaparotomy were matched to 64 patients undergoing primary catheter drainage. Mortality was lower after catheter drainage (14.1% vs 35.9%; P = .007; risk ratio, 0.39; 95% CI, 0.20-0.76). The rate of new-onset single-organ failure (4.7% vs 20.3%; P = .007; risk ratio, 0.15; 95% CI, 0.03-0.60) and new-onset multiple-organ failure (15.6% vs 39.1%; P = .008; risk ratio, 0.40; 95% CI, 0.20-0.77) were also lower after primary catheter drainage.

Conclusions and Relevance

In this propensity-matched cohort, catheter drainage as first intervention for severe pancreatic fistula after pancreatoduodenectomy was associated with a better clinical outcome, including lower mortality, compared with primary relaparotomy.

Predictive factors for recurrence of cryptoglandular fistulae characterized by preoperative three-dimensional endoanal ultrasound

AIM

Precise information regarding the location of an anal fistula and its relationship to adjacent structures is necessary for selecting the best surgical strategy. Retrospective and cross-sectional studies were performed to determine predictive factors for recurrence of anal fistula from preoperative examination by three-dimensional endoanal ultrasound (3D-EAUS).

METHOD

Patients in our tertiary centre and in a private centre specialized in proctology undergoing preoperative 3D-EAUS for cryptoglandular anal fistulae between 2002 and 2012 were included. A questionnaire was sent in September 2013 to assess the patient's condition with regard to recurrence. Variables checked for association with recurrence were gender, type of centre, previous fistula surgery, secondary track formation and classification of the fistula.

RESULTS

There were 143 patients of whom 96 had a low fistula treated by fistulotomy, 28 a high fistula treated by fistulectomy and 19 a high fistula treated by fistulectomy combined with a mucosal advancement flap. The median duration of follow-up was 26 (2-118) months. The fistula recurred in 40 (27%) patients. Independent risk factors included the presence of secondary track formation [hazard ratio 2.4 (95% CI 1.2-51), P = 0.016] and previous fistula surgery [hazard ratio 1.2 (95% CI 1.0-4.6), P = 0.041]. Agreement between the 3D-EAUS examination and the evaluation under anaesthesia regarding the site of the internal opening, classification of the fistula and the presence of secondary tracks was 97%, 98% and 78%.

CONCLUSION

The identification of secondary tracks by preoperative 3D-EAUS examination was the strongest independent risk factor for recurrence. This stresses the importance of preoperative 3D-EAUS in mapping the pathological anatomy of the fistula and a thorough search for secondary track formation during surgery.

Impact of classical and basal-like molecular subtypes on overall survival in resected pancreatic cancer in the SPACIOUS-2 multicentre study

BACKGROUND

The recently identified classical and basal-like molecular subtypes of pancreatic cancer impact on overall survival (OS). However, the added value of routine subtyping in both clinical practice and randomized trials is still unclear, as most studies do not consider clinicopathological parameters. This study examined the clinical prognostic value of molecular subtyping in patients with resected pancreatic cancer.

METHODS

Subtypes were determined on fresh-frozen resected pancreatic cancer samples from three Dutch centres using the Purity Independent Subtyping of Tumours classification. Patient, treatment, and histopathological variables were compared between subtypes. The prognostic value of subtyping in (simulated) pre- and postoperative settings was assessed using Kaplan-Meier and Cox regression analyses.

RESULTS

Of 199 patients with resected pancreatic cancer, 164 (82.4 per cent) were classified as the classical and 35 (17.6 per cent) as the basal-like subtype. Patients with a basal-like subtype had worse OS (11 versus 16 months (HR 1.49, 95 per cent c.i. 1.03 to 2.15; P = 0.035)) than patients with a classical subtype. In multivariable Cox regression analysis, including only clinical variables, the basal-like subtype was a statistically significant predictor for poor OS (HR 1.61, 95 per cent c.i. 1.11 to 2.34; P = 0.013). When histopathological variables were added to this model, the prognostic value of subtyping decreased (HR 1.49, 95 per cent c.i. 1.01 to 2.19; P = 0.045).

CONCLUSION

The basal-like subtype was associated with worse OS in patients with resected pancreatic cancer. Adding molecular classification to inform on tumor biology may be used in patient stratification.

Medical aspects of lay resuscitations in Rotterdam

In the Rotterdam system of prehospital care for patients with circulatory failure, the cardiopulmonary resuscitation (CPR) training programme for lay persons contributes to the first link in the chain of care, i.e. the period of time spent awaiting the arrival of professional staff. In this paper we describe some of the medical aspects of this programme. The material used was obtained in a study of 5312 trainees who had followed a CPR course. Case histories were reconstructed of 91 victims who had been resuscitated by 109 respondents. At least 20% of resuscitated persons had collapsed as a result of non-cardiac causes. In this category the longer term survival rates were relatively the most favourable. In several instances the indication for resuscitation had been incorrect, while the technical proficiency in the delivery of CPR was often inadequate. We conclude that one course is insufficient for the development of the required 'skill'. We also conclude that the courses should dwell more elaborately on the non-cardiac causes of collapse, particularly in training programmes addressing the public at large. Attention is drawn to the need of designing and implementing special courses for family members and relatives of persons known to be cardiac patients. The need for continuing evaluation, involving active contributions from lay resuscitators, is underlined.

Machakos project studies. Agents affecting health of mother and child in a rural area of Kenya. XXII. Schistosomiasis transmission in relation to some socio-economic and other environmental factors

A schistosomiasis research project, carried out in part of the Machakos area, yielded data by which it was possible to relate household egg outputs to some socioeconomic and other environmental variables. A significant negative correlation with schistosome scores was found for most variables when tested individually. Multiple regression analysis revealed a relatively strong relation with altitude and a much weaker association with some other variables. It is discussed whether the influence of altitude may be explained by differences in temperature, 'distance from infected water', or both. Furthermore it is hypothesized whether relations with social and economical variables are due to the fact that members of wealthier families stay away from contaminated water more often, have more knowledge of schistosomiasis and differ in hygienic behaviour.

Machakos Project Studies. Agents affecting health of mother and child in a rural area of Kenya. VI. The social and hygienic environment

As part of an investigation into determinants of health and disease in children below five years old, a household survey on social and hygienic conditions was carried out in the Machakos Project area. This paper deals with the field methodology of the survey, the selection of variables from the material collected and the differences between the eastern and western parts of the area in respect of the variables selected. In later issues of the Machakos Project Studies, the data obtained will be related to those from other cross-sectional surveys as well as to findings on morbidity and mortality in the child population.

Climate change, human health, and sustainable development

Human-induced climate change threatens ecosystems and human health on a global scale. In order to withstand the worldwide threats to ecosystems, the concept of sustainable development was introduced during the 1980s. Since then, this concept has been widely applied to guide and focus policy-making. The present article reviews the health consequences of human-induced climate change on sustainable development, particularly the potential impact of such change of food supply, natural disasters, infectious diseases, ecosystems, and sea level rise. Discussed is an integrated model containing the key indicators of sustainable development. The relevance of climate change, human health, and sustainable development for international climate change policy is also examined.

Ovarian development and biting frequency in Anopheles culicifacies Giles in Sri Lanka

In order to determine the duration of the gonotrophic cycle in Anopheles culicifacies Giles in Sri Lanka, ovarian development in freshly blood-fed wild-caught females was studied in the laboratory and the findings were compared with mark-and-release recoveries in the field. In specimens of unknown parity at first capture probable feeding intervals of 1, 2 and 3 days (mean: 1.7 - 2.1 days) were found. The release of freshly blood-fed nullipars bred from larvae produced two recaptures from which it could be concluded that the time required to become parous need not be more than three days. These results are of consequence in the assessment of the efficacy of insecticide spraying as an anti-malarial measure in Sri Lanka and possibly in other countries in South Asia where A. culicifacies is the vector. An equation is proposed for deriving the mosquito's daily survival rate (p) from the proportion of parous females in biting samples.

Vector-borne disease problems in rapid urbanization: new approaches to vector control

Owing to population growth, poor levels of hygiene, and increasing urban poverty, the urban environment in many developing countries is rapidly deteriorating. Densely packed housing in shanty towns or slums and inadequate drinking-water supplies, garbage collection services, and surface-water drainage systems combine to create favourable habitats for the proliferation of vectors and reservoirs of communicable diseases. As a consequence, vector-borne diseases such as malaria, lymphatic filariasis and dengue are becoming major public health problems associated with rapid urbanization in many tropical countries. The problems in controlling these diseases and eliminating vectors and pests can be resolved by decision-makers and urban planners by moving away from the concept of "blanket" applications of pesticides towards integrated approaches. Sound environmental management practices and community education and participation form the mainstay of some of the most outstanding successes in this area. On the basis of these examples, it is argued that the municipal authorities need to apply a flexible methodology, which must be based on the possibilities of mobilizing community resources, with minimal reliance on routine pesticidal spraying. In this way, vector control becomes a by-product of human development in the city environment. This is now a true challenge.

Machakos Project Studies: Agents affecting health of mother and child in a rural area of Kenya. XV. The economic setting at the household level

In 1974 a household survey on economic conditions was carried out in about 80% of all households in the Machakos Project study area. This survey formed a part of an investigation into determinants of health and disease in children below five years of age. This paper deals with some background information, the field methodology employed, the construction of variables and the differences found between the eastern and western parts of the area in respect of some of these variables. The results are compared with those from in-depth sample studies carried out earlier.