Pancreatoduodenectomy (PD) and postoperative pancreatic fistula (POPF): A systematic review and analysis of the POPF-related mortality rate in 60,739 patients retrieved from the English literature published between 1990 and 2015

BACKGROUND

Pancreatoduodenectomy (PD) is one of the most technically demanding operations challenging surgeons, and a postoperative pancreatic fistula (POPF) can complicate an otherwise uneventful postoperative (PO) course. This review examined the methods and procedures used to prevent postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD).

METHODS

A comprehensive systematic search of the literature was performed using PubMed (Medline), Embase, Web of science, and the Cochrane databases for studies published between January 1, 1990 and December 31, 2015. English language articles involving at least 100 patients undergoing PDs carried out in centers performing at least 10 PDs/y were screened for data regarding the Grade of any POPFs according to the definition of the International Study Group on Pancreatic Fistula (ISGPF) and the overall rate of PO mortality related to POPF.

RESULTS

We reviewed 7119 references through the major databases, and an additional 841 studies were identified by cross-checking the bibliographies of the full-text articles retrieved. After excluding 7379 out of 7960 studies, because they did not meet the eligibility criteria, the full texts of 581 articles were examined; 96 studies were excluded at this point, because they concerned partially or totally duplicate data that had already been reported. The remaining 485 articles were screened carefully for POPF-related mortality and POPF Grades as defined by the ISGPF. Of the 485 articles, 208 reported the POPF-related PO mortality rate and 162 the Grades (A, B, and C) of POPFs in 60,739 and 54,232 patients, respectively. The POPF-related mortality rates after pancreatojejunostomy and pancreatogastrostomy were similar but were less (0.5% vs. 1%; P = .014) when an externally draining, trans-anastomotic stent was placed intraoperatively. The incidence of the different Grades of POPF Grade was quite variable, but Grade C POPFs were associated with a PO mortality rate of 25.7% (range 0-100%).

CONCLUSIONS

The POPF-related mortality rate has remained at approximately 1% over the past 25 years. Only externally draining, trans-anastomotic stents decreased the POPF-related mortality rate. However, adequately designed venting drains were never tested in randomized controlled trials (RCTs).

Nationwide Outcome after Pancreatoduodenectomy in Patients at very High Risk (ISGPS-D) for Postoperative Pancreatic Fistula

OBJECTIVE

To assess nationwide surgical outcome after pancreatoduodenectomy (PD) in patients at very high risk for postoperative pancreatic fistula (POPF), categorized as ISGPS-D.

SUMMARY BACKGROUND DATA

Morbidity and mortality after ISGPS-D PD is perceived so high that a recent randomized trial advocated prophylactic total pancreatectomy (TP) as alternative aiming to lower this risk. However, current outcomes of ISGPS-D PD remain unknown as large nationwide series are lacking.

METHODS

Nationwide retrospective analysis including consecutive patients undergoing ISGPS-D PD (i.e., soft texture and pancreatic duct ≤3 mm), using the mandatory Dutch Pancreatic Cancer Audit (2014-2021). Primary outcome was in-hospital mortality and secondary outcomes included major morbidity (i.e., Clavien-Dindo grade ≥IIIa) and POPF (ISGPS grade B/C). The use of prophylactic TP to avoid POPF during the study period was assessed.

RESULTS

Overall, 1402 patients were included. In-hospital mortality was 4.1% (n=57), which decreased to 3.7% (n=20/536) in the last 2 years. Major morbidity occurred in 642 patients (45.9%) and POPF in 410 (30.0%), which corresponded with failure to rescue in 8.9% (n=57/642). Patients with POPF had increased rates of major morbidity (88.0% vs. 28.3%; P<0.001) and mortality (6.3% vs. 3.5%; P=0.016), compared to patients without POPF. Among 190 patients undergoing TP, prophylactic TP to prevent POPF was performed in 4 (2.1%).

CONCLUSION

This nationwide series found a 4.1% in-hospital mortality after ISGPS-D PD with 45.9% major morbidity, leaving little room for improvement through prophylactic TP. Nevertheless, given the outcomes in 30% of patients who develop POPF, future randomized trials should aim to prevent and mitigate POPF in this high-risk category.

Management of Postoperative Pancreatic Fistulas After Pancreaticoduodenectomy Using Open Drainage and Negative Pressure Wound Therapy With Instillation and Dwell Times

Introduction Postoperative pancreatic fistula (POPF) is a common complication of pancreatoduodenectomy (PD) that may cause lethal complications. Therefore, it is important to properly treat POPF and prevent its aggravation during the postoperative management of PD. We have used a combination of open drainage, in which the wound above the fluid collection is opened, and negative pressure wound therapy with instillation and dwell time (NPWTi-d) to manage POPF after PD. To evaluate the feasibility and efficacy of this combination treatment, we analyzed the outcomes of patients with POPF after PD. Methods Patients who underwent PD were reviewed and those who developed POPF were extracted and divided into three groups according to the management of POPF: N group (patients treated with open drainage and NPWTi-d), O group (patients treated with open drainage without NPWTi-d), and C group (patients treated with catheter drainage). The perioperative outcomes were compared among the three groups. Results During the study period, 133 patients underwent PD, out of which 39 (29%) developed POPF (≥grade B). Among the 39 patients with POPF, eight, four, and 27 were classified into the N, O, and C group, respectively. No mortality was observed in the patients with POPF. No severe complications were observed in the patients who underwent open drainage (N and O groups), while two patients in the C group developed severe complications. Among the patients who underwent open drainage, the N group tended to have a shorter postoperative hospital stay than the O group. Conclusions The current study suggests that open drainage safely and effectively healed POPF and NPWTi-d promoted wound closure. The combination of open drainage and NPWTi-d may prevent the aggravation of POPF, reduce failure to rescue, and shorten hospital stay after PD.

Evaluation of the Value of Intraoperative Peri-Pancreatic Fluid Amylase Concentration in Predicting a Postoperative Pancreatic Fistula After Pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is a common complication after pancreaticoduodenectomy (PD) and is a cause of significant morbidity and mortality. This study aimed to assess the predictive value of the amylase concentration of fluid accumulating in the peri-pancreatic region intraoperatively or intraoperative amylase concentration (IOAC) for the development of a clinically relevant POPF after PD.

METHODS

All consecutive patients who underwent PD between April 2018 and May 2021 were prospectively included in the study. IOAC and postoperative day-three drain fluid amylase values were measured, and the incidence of clinically relevant POPF (CR-POPF) was noted. Receiver operating characteristic analysis was used to evaluate the predictive capacity of the IOAC for a CR-POPF.

RESULTS

The study included 64 patients. A clinically relevant POPF was seen in 12 (18.8%) patients. On ROC analysis, the area under the curve (AUC) was 0.912 (with 95% CI of 0.822-1.001, p<0.001), which is highly significant. A cut-off IOAC value of 236 IU/L was derived, and an IOAC above this value was shown to predict the development of a CR-POPF in the postoperative period with a sensitivity of 91.7%. The highest positive predictive value (87.5%) was obtained with a cut-off of 772 IU/L.

CONCLUSION

An IOAC is an early, simple, and sensitive predictor for the development of a clinically relevant POPF after PD and can potentially aid in managing the resulting morbidity with intraoperative and postoperative measures.

Mind the tributary of the canal: Are stents necessary for insulinoma enucleation in proximity to a prominent Duct of Santorini: A case report and literature review

RATIONALE

We describe a case of insulinoma located extremely close to the accessory pancreatic duct (APD), but away from the main pancreatic duct (MPD). Previous studies showed insulinoma enucleation is a safe procedure for small benign tumors >3 mm distant from the MPD. However, in this case enucleation of the tumor led to unanticipated APD injury and grade B post-operative pancreatic fistula (POPF). We provide detailed records of clinical management and argue that enucleation of tumors near APD needs to be carefully weighed.

PATIENT CONCERNS

The patient experienced a sudden increase of abdominal drain fluid and prolonged drainage time after a regular insulinoma enucleation surgery.

DIAGNOSIS

APD damage during the enucleation.

INTERVENTIONS

Drain fluid amylase concentration were regularly recorded and prolonged somatostatin analogs were administered.

OUTCOMES

Amount of abdominal drain gradually decreased and the drain tube was removed on postoperative 37.

LESSONS

Benign pancreatic tumor close to the APD need to be evaluated carefully and clinical evidence is warranted to affirm the necessity of placing a pancreatic duct stent before the surgery.

Vascular supply of postresection pancreatic remnant after pancreaticoduodenectomy: A cadaveric study

OBJECTIVES

The vascular supply to the neck and body of the pancreas is highly variable. The dorsal pancreatic artery is the dominant artery feeding this area. The aim of this study was to describe the vascular supply of postresection pancreatic remnants after pancreaticoduodenectomy. Patients with hazardous anatomical arrangement may be at a higher risk of postresection remnant ischemia and postoperative pancreatic fistula development.

METHODS

The modified Whipple procedure was performed on 20 cadaveric donors. The macroscopic anatomical supply of the postresection pancreatic remnant of each donor was evaluated.

RESULTS

The arterial supply of the postresection remnant was highly variable. In 30% of cases (6/20), the dorsal pancreatic artery was cut during the pancreatoduodenectomy or it was missing. In these cases, the area of the pancreaticojejunostomy construction was fed only through anastomoses between the transverse pancreatic artery and the pancreatic branches of the splenic artery.

CONCLUSIONS

In 30% of cases, the arterial supply of the postresection pancreatic remnant was dependent on inconstant intraparenchymal arterial anastomoses. These patients may be at a higher risk of postoperative pancreatic fistula development.