Postoperative pancreatic fistula: an international study group (ISGPF) definition

Transverse Incision for Pancreatoduodenectomy Reduces Wound Complications: A Single-Center Analysis of 399 Patients

BACKGROUND

Even if the minimally invasive approach is advancing in pancreatic surgery, the open approach is still the standard for a pancreatoduodenectomy. There are two types of incisions used: the midline incision (MI) and transverse incision (TI). The aim of this study was to compare these two incision types, especially regarding wound complications.

METHODS

A retrospective review of 399 patients who underwent a pancreatoduodenectomy at the University Hospital Erlangen between 2012 and 2021 was performed. A total of 169 patients with MIs were compared with 230 patients with TIs, with a focus on postoperative fascial dehiscence, postoperative superficial surgical site infection (SSSI) and the occurrence of incisional hernias during follow-up.

RESULTS

Postoperative fascial dehiscence, postoperative SSSI and incisional hernias occurred in 3%, 8% and 5% of patients, respectively. Postoperative SSSI and incisional hernias were significantly less frequent in the TI group (SSI: 5% vs. 12%, p = 0.024; incisional hernia: 2% vs. 8%, p = 0.041). A multivariate analysis confirmed the TI type as an independent protective factor for the occurrence of SSSI and incisional hernias (HR 0.45 (95% CI = 0.20-0.99), p = 0.046 and HR 0.18 (95% CI = 0.04-0.92), p = 0.039, respectively).

CONCLUSION

Our data suggest that the transverse incision for pancreatoduodenectomy is associated with reduced wound complications. This finding should be confirmed by a randomized controlled trial.

Pretreatment Health-Related Quality-of-Life Status and Survival in Pancreatobiliary Surgical Patients

BACKGROUND

Pancreatobiliary (PB) disorders, especially cancer, negatively affect patients' health-related quality of life (HRQoL). However, the influence of baseline, preintervention HRQoL on perioperative and oncologic outcomes has not been well defined. We hypothesized that low baseline HRQoL is associated with worse perioperative and long-term survival outcomes for PB surgical patients.

STUDY DESIGN

Pretreatment Functional Assessment of Cancer Therapy - Hepatobiliary Survey results and clinical data from PB patients (2008 to 2016) from a single center's prospective database were analyzed. Survey responses were aggregated into composite scores and divided into quintiles. Patients in the highest quintile of HRQoL were compared to patients in the bottom four quintiles combined. Overall survival (OS) and disease-free survival (DFS) were analyzed using the Kaplan-Meier method. Logistic and Cox regressions were used to determine associations between quintiles of HRQoL scores and 30-day complications and long-term survival, respectively.

RESULTS

Of 162 patients evaluated, 99 had malignancy, and 63 had benign disease. Median follow-up was 31 months. Baseline HRQoL scores were similar for benign and malignant disease (p = 0.42) and were not associated with the development of any (p = 0.08) or major complications (p = 0.64). Patients with highest quintile HRQoL scores had improved 3-year OS (84.6 vs 61.7%, p = 0.03) compared to patients in the lowest four quintiles of HRQoL. Among cancer patients only, those with the highest quintile scores had improved 3-year OS (81.6 vs 47.4%, p = 0.02). On multivariable analysis, highest quintile HRQoL scores were associated with longer OS and DFS for patients with malignancy.

CONCLUSIONS

Pretreatment HRQoL was associated with both OS and DFS among PB patients and might have prognostic utility. Future studies are necessary to determine whether patients with poorer HRQoL may benefit from targeted psychosocial interventions.

Adjusting Drain Fluid Amylase for Drain Volume Does Not Improve Pancreatic Fistula Prediction

INTRODUCTION

Drain fluid amylase (DFA) levels have been used to predict clinically relevant postoperative pancreatic fistula (CR-POPF) and guide postoperative drain management. Optimal DFA cutoff thresholds vary between studies, thereby prompting investigation of an alternative assessment technique. As DFA measurements could, in theory, be distorted by variations in ascites fluid production, we hypothesized that adjusting DFA for volume corrected drain fluid amylase (vDFA) would improve CR-POPF predictive models.

METHODS

A single-institution retrospective cohort study of patients, who underwent pancreatoduodenectomies (PD) and distal pancreatectomies (DP) between 2013 and 2019, was performed. DFAs and vDFAs were measured on postoperative day (POD) 3. Clinicopathologic variables were compared between cohorts by univariable and multivariable analyses and Receiver operating characteristic (ROC) curves.

RESULTS

Patients developing a CR-POPF were more likely to be male and have elevated DFA, vDFA, and body mass index (BMI). vDFA use did not contribute to a superior CR-POPF predictive model compared to DFA-a finding consistent on subanalysis of surgery type PD versus DP. In CR-POPF predictive models, DFA, vDFA, and male sex significantly improved CR-POPF predictive models when considering both surgery subtypes, while only DFA and vDFA significantly improved models when cohorts were segregated by surgery type.

CONCLUSIONS

Postoperative DFA remains a preferred method of predicting CR-POPF as the proposed vDFA assessment technique only adds complexity without increased discriminability.

Intraoperative Blood Loss Estimation in Hepato-pancreato-biliary Surgery- Relevant, Not Reported, Not Standardized: Results From a Systematic Review and a Worldwide Snapshot Survey

OBJECTIVE

To provide an overview of the current practice of intraoperative blood loss (BL) estimation in hepato-pancreato-biliary (HPB) surgery.

BACKGROUND

Intraoperative BL is a major quality marker in HPB surgery and a predictor of perioperative outcomes. However, the method for BL estimation is not standardized.

METHODS

A systematic review was performed of original studies published between 2006 and 2021 reporting the intraoperative BL of patients undergoing pancreatic or hepatic resections. A web-based snapshot survey was distributed globally to all members of the International Hepato-Pancreato-Biliary Association (IHPBA).

RESULTS

A total of 806 studies were included; 480 (60%) had BL as their primary outcome, and 105 (13%) had BL as their secondary outcome. However, 669 (83%) did not specify how BL estimation was performed, and 9 different methods were found among the remaining 136 (17%) studies.The survey was completed by 252 surgeons. Most of the responders (94%) declared that they systematically performed BL estimation and considered BL predictive of postoperative complications after pancreatic (73%) and liver (74%) resection. All methods previously identified in the literature were used by responders with different frequencies. A calculation based on suction fluid amounts, operative gauze weight, and irrigation was the most used method in the literature (7%) and among responders (51%). Most responders (83%) felt that BL estimation in HPB surgery needs improved standardization.

CONCLUSIONS

Standardization of intraoperative BL estimation is urgently needed in HPB surgery to ensure the consistency of reporting and reproducibility.

Does minimally invasive surgery have a different impact on recurrence and overall survival in patients with pancreatic head versus body/tail cancer?

OBJECTIVE

This study sought to investigate the impact of minimally invasive surgery (MIS) on recurrence and overall survival between patients with pancreatic head versus body/tail cancers.

METHODS

The risk factors associated with recurrence and long-term outcomes were analyzed according to tumor location and operative modality.

RESULTS

A total of 288 and 87 patients underwent surgical resection for pancreatic head cancer and body/tail cancer, respectively. The perioperative outcomes and histopathologic results were comparable in open and MIS approach in both head and body/tail groups. There was no difference in local or systemic recurrence patterns and disease-free and overall survival rates according to primary tumor location and surgical modality. During subgroup analysis by stage; however, patients with stage III pancreatic head cancer in the MIS group had a decreased disease-free survival compared with those in the open surgery group (p = 0.020). On multivariate analysis, MIS was not a risk factor of total or local recurrences.

CONCLUSIONS

Recurrence patterns and overall survival rates of patients did not differ according to tumor location and surgical approach. However, patients with stage III pancreatic head cancer in the MIS group showed inferior disease-free survival relative to patients who underwent open surgery.

Application of Clavien-Dindo classfication-grade in evaluating overall efficacy of laparoscopic pancreaticoduodenectomy

BACKGROUND

The Clavien-Dindo classification (CDC) has been widely accepted and applied in clinical practice. We investigated its effectiveness in prediction of major complications (LPPC) after laparoscopic pancreaticoduodenectomy (LPD) and associated risk factors.

METHODS

A retrospective analysis was conducted covering clinical data of 793 patients undergoing LPD from April 2015 to November 2021. CDC was utilized to grade postoperative complications and analyze the differences. Risk factors of LPPC were identified according to univariate and multivariate analyses.

RESLUTS

For the 793 patients undergoing laparoscopic pancreaticoduodenectomy in the northeast of China, LPPC was reported in 260 (32.8%) patients, pancreatic fistula in 169 (21.3%), biliary fistula in 44 (5.5%), delayed gastric emptying in 17(2.1%), post pancreatectomy hemorrhage in 55 (6.9%), intestinal fistula in 7 (0.8%), abdominal infections in 59 (7.4%) and pulmonary complication in 28 (3.5%). All complications were classified into five levels with the C-D classification (Grade I-V), with 83 (31.9%) patients as grade I, 91 (35.0%) as grade II, 38 (14.6%) as grade IIIa, 24 (9.2%) as grade IIIb, 9 (3.5%) as grade IV and 15 (5.8%) as grade V. 86 (10.8%) patients experienced major complications (grade III-V).The results of univariate and multivariate analysis revealed the independent risk factors for laparoscopic pancreaticoduodenectomy complications to be preoperative total bilirubin (P = 0.029, OR = 1.523), soft pancreas texture (P < 0.001, OR = 1.399), male (P = 0.038, OR = 1.396) and intraoperative transfusion (P = 0.033, OR = 1.517). Preoperative total bilirubin (P = 0.036, OR = 1.906) and intraoperative transfusions (P = 0.004, OR = 2.123) were independently associated with major postoperative complications. The influence of different bilirubin levels on C-D grade of complications was statistically significant (P = 0.036, OR = 1.906).

CONCLUSIONS

The Clavien-Dindo classification (CDC) may serve as a valid tool to predict major postoperative complications and contribute to perioperative management and comparison of surgical techniques in different medical centers.

A Simple Classification of Pancreatic Duct Size and Texture Predicts Postoperative Pancreatic Fistula: A classification of the International Study Group of Pancreatic Surgery

OBJECTIVE

The aim of this study was to develop a classification system for pancreas-associated risk factors in pancreatoduodenectomy (PD).

SUMMARY BACKGROUND DATA

Postoperative pancreatic fistula (POPF) is the most relevant PD-associated complication. A simple standardized surgical reporting system based on pancreas-associated risk factors is lacking.

METHODS

A systematic literature search was conducted to identify studies investigating clinically relevant (CR) POPF (CR-POPF) and pancreas-associated risk factors after PD. A meta-analysis of CR-POPF rate for texture of the pancreas (soft vs not-soft) and main pancreatic duct (MPD) diameter was performed using the Mantel-Haenszel method. Based on the results, the International Study Group of Pancreatic Surgery (ISGPS) proposes the following classification: A, not-soft (hard) texture and MPD >3 mm; B, not-soft (hard) texture and MPD ≤3 mm; C, soft texture and MPD >3 mm; D, soft texture and MPD ≤3 mm. The classification was evaluated in a multi-institutional, international cohort.

RESULTS

Of the 2917 articles identified, 108 studies were included in the analyses. Soft pancreatic texture was significantly associated with the development of CR-POPF [odds ratio (OR) 4.24, 95% confidence interval (CI) 3.67-4.89, P < 0.01) following PD. Similarly, MPD diameter ≤3 mm significantly increased CR-POPF risk compared with >3 mm diameter MPDs (OR 3.66, 95% CI 2.62-5.12, P < 0.01). The proposed 4-stage system was confirmed in an independent cohort of 5533 patients with CR-POPF rates of 3.5%, 6.2%, 16.6%, and 23.2% for type A-D, respectively ( P < 0.001).

CONCLUSION

For future pancreatic surgical outcomes studies, the ISGPS recommends reporting these risk factors according to the proposed classification system for better comparability of results.

Minimally-invasive versus open pancreatic enucleation: systematic review and metanalysis of short-term outcomes

BACKGROUND

Minimally Invasive Pancreatic Enucleation, either laparoscopic or robot-assisted, is rarely performed. The aim of this study was to offer the current available evidence about the outcomes of minimally invasive pancreatic enucleations and explore the possible advantage of this approach over traditional surgery.

METHODS

PubMed (MEDLINE), Cochrane Library and Embase (ELSEVIER) medical databases were searched for articles published from January 1990 to March 2022. Studies which included more than 10 cases of minimally-invasive pancreatic enucleation were included. Data on the outcomes were synthetized and meta-analyzed when appropriate.

RESULTS

Twenty studies published between 2009 and 2022 with a total of 552 patients were included in the systematic review: three hundred fifty-one patients (63.5%) had a laparoscopic intervention, two hundred and one (36.5%) robot-assisted with a cumulative incidence of conversion rate of 5%. Minimally-invasive surgery was performed in 63% of cases on the body/tail of the Pancreas and in 37% of the cases on the head/uncinate process of the Pancreas. The cumulative post-operative 30 days - mortality rate was 0.2% and the major postoperative morbidity (Clavien-Dindo III-IV-V) 35%. Clinically relevant pancreatic fistula was observed in 17% of the patients. Compared with the standardized open approach (n: 366 patients), mean length of hospital stay was significantly reduced in patients undergoing minimally invasive pancreatic enucleation (2.45 days, p = 0.003) with a favorable trend for post-operative major morbidity (Clavien-Dindo III-IV) (- 24% RR, p: 0.13). Operative time, blood loss and clinically relevant pancreatic fistula rate were comparable between the two groups. One hundred and fourteen robot-assisted enucleations entered in a subgroup analysis with comparable results to open surgery.

CONCLUSION

Minimally-Invasive approach for pancreatic enucleation is safe, feasible and offers short-term clinical outcomes comparable with open surgery. The potential benefit of robotic surgery will need to be verified in further studies.

Outcome of combined pancreatic and biliary fistulas after pancreatoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) as well as postoperative biliary fistula (POBF) are considered the main source of postoperative morbidity and mortality after pancreatoduodenectomy (PD). However, little is known about the incidence and complications of combined POPF/POBF compared to isolated POPF or POBF.

METHODS

This single-center study investigated retrospectively the incidence and postoperative outcome of combined POPF/POBF compared to isolated fistulas following PD in a tertiary German pancreatic center between 2009 and 2018.

RESULTS

A total of 678 patients underwent PD for benign and malignant periampullary lesions. Combined fistulas occurred in 6%, isolated POPF in 16%, and isolated POBF in 2%. Pancreatic ductal adenocarcinoma and chronic pancreatitis had a protective effect on the occurrence of combined fistulas, whereas serous cystadenoma and pancreatic metastasis were risk factors. Morbidity (Grade C fistula, post-pancreatectomy hemorrhage, revisional surgery) and mortality was significantly higher in patients with combined fistulas than in those with isolated fistula. Moreover, the duration of ICU stay was longer.

CONCLUSIONS

A combined POPF/POBF is associated with a significant increase of morbidity and mortality compared to isolated fistulas after PD. Early surgical revision in these patients may improve the postoperative survival rate.

Impact of Drain Position on Drain Fluid Amylase, Fluid Collection and Postoperative Pancreatic Fistula after Distal Pancreatectomy

BACKGROUND

The current definition for postoperative pancreatic fistula (POPF) is based on the drain fluid amylase (DFA), and drains must be positioned adequately. We investigated the impact of DFA level, drain position and fluid collection after distal pancreatectomy (DP).

METHODS

We performed a retrospective study of 516 patients who underwent DP between June 2004 and December 2018. Patients were excluded if DP was not main procedure, DFA was not measured, postoperative computed tomography (CT) was not performed, or drains were removed before CT. Demographic and perioperative data were analyzed in 422 eligible patients.

RESULTS

Of 422 patients, 49(11.6%) had clinically relevant (CR)-POPF and 102(24.2%) had a malpositioned drain. There was no difference in CR-POPF rate between the high and low DFA groups (12.6% vs 10.7%, P = 0.649). Drain malposition was more frequently associated with symptomatic fluid collection and CR-POPF than well-positioned drains. Male sex, high body mass index, transfusion, and drain malposition were CR-POPF risk factors. In subgroup analysis, drain malposition was also an independent risk factor for CR-POPF in the low DFA group.

CONCLUSIONS

After DP, the incidence of CR-POPF in the high and low DFA groups was similar and drain malposition increased the risk of CR-POPF. Thus, the ISGPS definition of POPF based on DFA levels is limited in DP, and DFA levels should be interpreted together with the drain position.

Analysis of predictors for postoperative complications after pancreatectomy--what is new after establishing the definition of postpancreatectomy acute pancreatitis (PPAP)?

PURPOSE

We aimed to analyze the predictive value of hyperamylasemia after pancreatectomy for morbidity and for the decision to perform rescue completion pancreatectomy (CP) in a retrospective cohort study.

METHODS

Data were extracted from a retrospective clinical database. Postoperative hyperamylasemia (POH) and postoperative hyperlipasemia (POHL) were defined by values greater than those accepted as the upper limit at our institution on postoperative day 1 (POD1). The endpoints of the study were the association of POH with postoperative morbidity and the possible predictors for postpancreatectomy acute pancreatitis (PPAP) and severe complications such as the necessity for rescue CP.

RESULTS

We analyzed 437 patients who underwent pancreaticoduodenectomy over a period of 7 years. Among them, 219 (52.3%) patients had POH and 200 (47.7%) had normal postoperative amylase (non-POH) levels. A soft pancreatic texture (odds ratio [OR] 3.86) and POH on POD1 (OR 8.2) were independent predictors of postoperative pancreatic fistula (POPF), and POH on POD1 (OR 6.38) was an independent predictor of rescue CP. The clinically relevant POPF (49.5% vs. 11.4%, p < 0.001), intraabdominal abscess (38.3% vs. 15.3%, p < 0.001), postoperative hemorrhage (22.8% vs. 5.1%, p < 0.001), major complications (Clavien-Dindo classification > 2) (52.5% vs. 25.6%, p < 0.001), and CP (13% vs. 1.8%, p < 0.001) occurred significantly more often in the POH group than in the non-POH group.

CONCLUSION

Although POH on POD1 occurs frequently, in addition to other risk factors, it has a predictive value for the development of postoperative morbidity associated with PPAP and CP.

Comparison of perioperative outcomes between bipolar sealing, ultrasonic shears and a hybrid device during laparoscopic gastrectomy for early gastric cancer: a prospective, multicenter, randomized study

BACKGROUND

Although EBDs are essential for minimally invasive surgery, well-established prospective randomized studies comparing EBDs are scarce. This study aimed to compare the intraoperative inflammatory response and short-term surgical outcomes among different energy-based devices (EBDs) in laparoscopic distal gastrectomy (LDG).

METHODS

Patients with clinical stage I gastric cancer scheduled for LDG at two different medical centers were prospectively randomized into three groups: ultrasonic shears (US), advanced bipolar (BP) and ultrasonic-bipolar hybrid (HB). The C-reactive protein (CRP) level, operation time, intraoperative blood loss (IBL), laboratory tests, cytokines (interleukin (IL)-6 and IL-10), hospital stay, and complication rate were analyzed. A novel semiquantitative measurement method using indocyanine green (ICG) and a near-infrared camera measured the amount of lymphatic leakage.

RESULTS

The primary endpoint, the CRP level, was significantly lower in the BP (n = 60) group than in the US (n = 57) or HB (n = 57) group [9.03 ± 5.55 vs. 11.12 ± 5.02 vs. 12.67 ± 6.14, p = 0.001, on postoperative day (POD) 2 and 7.48 vs. 9.62 vs. 9.48, p = 0.026, on POD 4]. IBL was significantly lower in BP than in US or HB (26.3 ± 25.3 vs. 43.7 ± 42.0 vs. 34.9 ± 37.0, p = 0.032). Jackson-Pratt drainage triglycerides were significantly lower in BP than in US (53.6 ± 33.7 vs. 84.2 ± 59.0, p = 0.11; HB: 71.3 ± 51.4). ICG fluorescence intensity, operation time, laboratory results, cytokines, hospital stay, and complication rate were not significantly different among the 3 groups.

CONCLUSION

BP showed a lower postoperative CRP level and less IBL than US and HB, suggesting less collateral thermal damage and better sealing function. Surgeons may consider this when selecting EBDs for laparoscopic surgery.

Early postoperative risk stratification in patients with pancreatic fistula after pancreaticoduodenectomy

BACKGROUND

Early stratification of postoperative pancreatic fistula according to severity and/or need for invasive intervention may improve outcomes after pancreaticoduodenectomy. This study aimed to identify the early postoperative variables that may predict postoperative pancreatic fistula severity.

METHODS

All patients diagnosed with biochemical leak and clinically relevant-postoperative pancreatic fistula based on drain fluid amylase >300 U/L on the fifth postoperative day after pancreaticoduodenectomy were identified from a consecutive cohort from Birmingham, UK. Demographics, intraoperative parameters, and postoperative laboratory results on postoperative days 1 through 7 were retrospectively extracted. Independent predictors of clinically relevant-postoperative pancreatic fistula were identified using multivariable binary logistic regression and converted into a risk score, which was applied to an external cohort from Verona, Italy.

RESULTS

The Birmingham cohort had 187 patients diagnosed with postoperative pancreatic fistula (biochemical leak: 99, clinically relevant: 88). In clinically relevant-postoperative pancreatic fistula patients, the leak became clinically relevant at a median of 9 days (interquartile range: 6-13) after pancreaticoduodenectomy. Male sex (P = .002), drain fluid amylase-postoperative day 3 (P < .001), c-reactive protein postoperative day 3 (P < .001), and albumin-postoperative day 3 (P = .028) were found to be significant predictors of clinically relevant-postoperative pancreatic fistula on multivariable analysis. The multivariable model was converted into a risk score with an area under the receiver operating characteristic curve of 0.78 (standard error: 0.038). This score significantly predicted the need for invasive intervention (postoperative pancreatic fistula grades B3 and C) in the Verona cohort (n = 121; area under the receiver operating characteristic curve: 0.68; standard error = 0.06; P = .006) but did not predict clinically relevant-postoperative pancreatic fistula when grades B1 and B2 were included (area under the receiver operating characteristic curve 0.52; standard error = 0.07; P = .802).

CONCLUSION

We developed a novel risk score based on early postoperative laboratory values that can accurately predict higher grades of clinically relevant-postoperative pancreatic fistula requiring invasive intervention. Early identification of severe postoperative pancreatic fistula may allow earlier intervention.

The TPA score (total psoas muscle area) is the best marker for preoperative measurement of pre-sarcopenia in pancreatic surgery

INTRODUCTION

Pre-sarcopenia, defined by the loss of muscle mass, is significantly associated with an increased risk of postoperative complications in digestive surgery, particularly pancreatic resection. The five predominant markers of sarcopenia are: psoas muscle area (TPA), intramuscular adipose tissue content (IMAC), Average Hounsfield Unit Calculation (HUAC), Skeletal Muscle Mass Index (MMI), and the ratio between visceral adipose tissue area and muscle surface area (VFA/TAMA). No standard reference marker has been determined.

MATERIAL AND METHODS

This retrospective cohort included patients who underwent pancreatic resection at the University Hospital of Angers between January 2008 and June 2017. The goal was to determine the marker that was most significantly associated with morbidity and mortality in pancreatic surgery. The secondary objective was to determine the characteristics of pre-sarcopenic patients.

RESULTS

The TPA score is the most sensitive marker for identifying patients at highest risk for immediate complications (P=0.008), proving far more sensitive than MMI (P=0.02), HUAC (P=0.34), IMAC (P=1), or VFA/TAMA (P=0.42). Postoperative mortality was 3.3% (n=5), morbidity was 63.8% (n=97). Pre-sarcopenic patients, as identified by the TPA index had significantly more immediate complications (71.2% versus 49.5%, P=0.008), in particular, more gastroparesis (P=0.02) and pancreatic fistula (P=0.03).

CONCLUSION

In patients requiring pancreatic surgery, the prevalence of pre-sarcopenia is high and seems to be associated with a greater risk of immediate postoperative complications. The TPA score seems to be the most sensitive marker for detecting pre-sarcopenia. Evaluation of TPA preoperatively would make it possible to identify priority patients a priori who might benefit from pre-habilitation programs.

Risk of Lymph Node Metastasis in T1b Gastric Cancer: An International Comprehensive Analysis from the Global Gastric Group (G3) Alliance

OBJECTIVE

We sought to define criteria associated with low lymph node metastasis risk in patients with submucosal (pT1b) gastric cancer from 3 Western and 3 Eastern countries.

SUMMARY BACKGROUND DATA

Accurate prediction of lymph node metastasis risk is essential when determining the need for gastrectomy with lymph node dissection following endoscopic resection. Under present guidelines, endoscopic resection is considered definitive treatment if submucosal invasion is only superficial, but this is not routinely assessed.

METHODS

Lymph node metastasis rates were determined for patient groups defined according to tumor pathological characteristics. Clinicopathological predictors of lymph node metastasis were determined by multivariable logistic regression and used to develop a nomogram in a randomly selected subset that was validated in the remainder. Overall survival was compared between Eastern and Western countries.

RESULTS

Lymph node metastasis was found in 701 of 3166 (22.1%) Eastern and 153 of 560 (27.3%) Western patients. Independent predictors of lymph node metastasis were female sex, tumor size, distal stomach location, lymphovascular invasion, and moderate or poor differentiation. Patients fulfilling the National Comprehensive Cancer Network guideline criteria, excluding the requirement that invasion not extend beyond the superficial submucosa, had a lymph node metastasis rate of 8.9% (53/594). Excluding moderately differentiated tumors lowered the rate to 3.4% (10/296). The nomogram's area under the curve was 0.690. Regardless of lymph node status, overall survival was better in Eastern patients.

CONCLUSIONS

The lymph node metastasis rate was lowest in patients with well differentiated tumors that were ≤3 cm and lacked lymphovascular invasion. These criteria may be useful in decisions regarding endoscopic resection as definitive treatment for pT1b gastric cancer.

Comparison of different pancreatic stump management strategies during robot-assisted distal pancreatectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) represents the most feared complication after distal pancreatectomy, and the possible role of robotic assistance in this setting is poorly investigated so far.

METHODS

We analysed short-term outcomes of 88 patients who had undergone robot-assisted distal pancreatectomy (RDP), dividing them according to pancreatic stump management: selective Wirsung duct ligation/hand sewn suture (WirsLIG group), use of robotic EndoWrist staplers (RobSTAP group), and use of laparoscopic staplers (LapSTAP group).

RESULTS

Mean operative time resulted significantly longer in WirsLIG group (291.1 ± 77.21 min vs. 245 ± 56.22 min in RobSTAP group vs. 221.77 ± 64.64 min in LapSTAP group). No significant differences were found in median hospital stay and in POPF occurrence.

CONCLUSIONS

No strategy for pancreatic stump management during RDP has proven superior to the others in reducing POPF rates. The hand-sewn technique resulted more time consuming, nevertheless it remains essential where there is not enough space to insert the stapler.

Pancreaticoduodenectomy for benign and premalignant pancreatic and ampullary disease: is robotic surgery the better approach?

BACKGROUND

The robotic platform is increasingly being utilized in pancreatic surgery, yet its overall merits and putative advantages remain to be adjudicated. We hypothesize that the benefits of minimally invasive pancreatic surgery are maximized in pancreatic benign and premalignant disease, in the setting of friable pancreatic tissue and small pancreatic duct.

METHODS

Retrospective analysis of our prospectively maintained pancreatic database of all consecutive patients who underwent pancreaticoduodenectomy (PD) for benign or premalignant conditions between 2010 and 2020. Peri-operative outcomes and long-term complications were compared between robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD).

RESULTS

One hundred and eighty eight (n = 188) patients met our inclusion criteria, of which 68 were OPD and 120 RPD. Malignant histologies were excluded. There were only minor differences in baseline characteristics between the two groups. Post-operative merits of the RPD included lower clinically relevant post-operative pancreatic fistula 10 (8.3%) vs 24 (35.3%), p < 0.001, fewer surgical site infections; 9 (7.5%) vs 11 (16.2%), p = 0.024, shorter operative time, greater lymph node yield; 29 (IQR 21, 38) vs 21 (IQR 13, 34), p = 0.001, and lower 90 days mortality; 1 (0.8%) vs 4 (5.9%), p = 0.039. Rates of long-term complications were similar, exception made for a higher occurrence of small bowel obstruction (SBO) 2 (1.7%) vs 4 (5.9%), p = 0.031 and need for surgical intervention for SBO 0 (0.0%) vs 2 (2.9%), p = 0.019 in the OPD group.

CONCLUSION

Our study suggests that RPD benefits include lower 90-day mortality, shorter LOS, and lower rates of selected complications compared to open pancreaticoduodenectomy.

Incidence of Postoperative Complications Following Pancreatectomy for Pancreatic Cystic Lesions or Pancreatic Cancer

BACKGROUND

In contrast to pancreatic ductal adenocarcinoma (PDAC), the risks of pancreatectomy for mucinous pancreatic cysts (MCs) are balanced against the putative goal of removing potentially malignant tumors. Despite undergoing similar operations, different rates of perioperative complications and morbidity between MC and PDAC patient populations may affect recommendations for resection. We therefore sought to compare the rates of postoperative complications between patients undergoing pancreatectomies for MCs or PDAC.

METHODS

A prospectively maintained institutional database was used to identify patients who underwent surgical resection for MCs or PDAC from July 2011 to August 2019. Patient demographics, complications, and perioperative data were compared between groups.

RESULTS

A total of 103 patients underwent surgical resection for MCs and 428 patients underwent resection for PDAC. Combined major 90-day postoperative complications were similar between MC and PDAC patients undergoing pancreaticoduodenectomy (PD, 32.5% vs. 20.0%, p = 0.068) or distal pancreatectomy (DP, 30.2% vs. 20.5%, p = 0.172). The most frequent complications were postoperative pancreatic fistula (POPF), abscess, and postoperative bleeding. The incidence of 90-day ISGPS Grade B/C POPF was higher in cyst patients undergoing PD (17.5% vs. 4.1%, p = 0.003) but not DP (25.4% vs. 20.5%, p = 0.473). No significant differences in operative time or length of stay between MCs and PDAC cohorts were observed.

CONCLUSIONS

POPFs occur more frequently and at higher grades in patients undergoing PD for MCs than for PDAC and should inform patient selection. Accordingly, the perioperative management of MC patients undergoing PD should emphasize POPF risk mitigation.

Postoperative Hypophosphatemia as a Prognostic Factor for Postoperative Pancreatic Fistula: A Systematic Review

Background and Objectives: Postoperative pancreatic fistula (POPF) is one of the most challenging complications after pancreatic resections, associated with prolonged hospital stay and high mortality. Early identification of pancreatic fistula is necessary for the treatment to be effective. Several prognostic factors have been identified, although it is unclear which one is the most crucial. Some studies show that post-pancreatectomy hypophosphatemia may be associated with the development of POPF. The aim of this systematic review was to determine whether postoperative hypophosphatemia can be used as a prognostic factor for postoperative pancreatic fistula. Materials and Methods: The systematic literature review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations (PRISMA) and was registered in the International Prospective Register of Systematic Reviews (PROSPERO). The PubMed, ScienceDirect, and Web of Science databases were systematically searched up to the 31st of January 2022 for studies analyzing postoperative hypophosphatemia as a prognostic factor for POPF. Data including study characteristics, patient characteristics, operation type, definitions of postoperative hypophosphatemia and postoperative pancreatic fistula were extracted. Results: Initially, 149 articles were retrieved. After screening and final assessment, 3 retrospective studies with 2893 patients were included in this review. An association between postoperative hypophosphatemia and POPF was found in all included studies. Patients undergoing distal pancreatectomy were more likely to develop severe hypophosphatemia compared to patients undergoing proximal pancreatectomy. Serum phosphate levels on postoperative day 4 (POD 4) and postoperative day 5 (POD 5) remained significantly lower in patients who developed leak-related complications showing a slower recovery of hypophosphatemia from postoperative day 3 (POD 3) through postoperative day 7 (POD 7). Moreover, body mass index (BMI) higher than 30 kg/m², soft pancreatic tissue, abnormal white blood cell count on postoperative day 3 (POD 3), and shorter surgery time were associated with leak-related complications (LRC) and lower phosphate levels. Conclusions: Early postoperative hypophosphatemia might be used as a prognostic biomarker for early identification of postoperative pancreatic fistula. However, more studies are needed to better identify significant cut-off levels of postoperative hypophosphatemia and development of hypophosphatemia in the postoperative period.

Assessment of the Predictive Value of Preoperative Serum Albumin and Postoperative Albumin Drop (ΔAlb) for Complications after Pancreas Surgery: A Single-Center Cross-Sectional Study

BACKGROUND

Serum albumin has been shown to be predictive of complications after various gastrointestinal operations. The present study aimed to assess whether preoperative serum albumin and serum albumin drop on postoperative day 1 are associated with postoperative complications after pancreatic surgery.

METHODS

A single-center cross-sectional study was performed. All patients who underwent pancreatectomy between January 2010 and June 2019 and had preoperative serum albumin value and serum albumin value on postoperative day 1 were included. ΔAlb was defined as the difference between preoperative serum albumin and serum albumin on postoperative day 1. Binary logistic regressions were performed to determine independent predictors of postoperative complications.

RESULTS

A total of 185 patients were included. Pancreatoduodenectomies were performed in 133 cases, left pancreatectomies in 36, and other pancreas operations in 16. The preoperative serum albumin value was found to be an independent predictor of complications (OR 0.9, 95%CI 0.9-1.0, p = 0.041), whereas ΔAlb was not significantly associated with postoperative complications (OR 1.0, 95%CI 0.9-1.1, p = 0.787). The threshold of 44.5 g/L for preoperative albumin level was found to have the highest combined sensitivity and specificity based on the maximum Youden index. Patients with preoperative albumin < 44.5 g/L had a higher incidence of postoperative complications and higher median comprehensive complication index than patients with preoperative albumin ≥ 44.5 g/L.

CONCLUSIONS

This study highlighted that preoperative serum albumin is an independent predictor of postoperative complications after pancreas surgery.

Laparoscopic versus open pancreaticoduodenectomy for pancreatic and periampullary tumor: A meta-analysis of randomized controlled trials and non-randomized comparative studies

Objective

This meta-analysis compares the perioperative outcomes of laparoscopic pancreaticoduodenectomy (LPD) to those of open pancreaticoduodenectomy (OPD) for pancreatic and periampullary tumors.

Background

LPD has been increasingly applied in the treatment of pancreatic and periampullary tumors. However, the perioperative outcomes of LPD versus OPD are still controversial.

Methods

PubMed, Web of Science, EMBASE, and the Cochrane Library were searched to identify randomized controlled trials (RCTs) and non-randomized comparative trials (NRCTs) comparing LPD versus OPD for pancreatic and periampullary tumors. The main outcomes were mortality, morbidity, serious complications, and hospital stay. The secondary outcomes were operative time, blood loss, transfusion, postoperative pancreatic fistula (POPF), postpancreatectomy hemorrhage (PPH), bile leak (BL), delayed gastric emptying (DGE), lymph nodes harvested, R0 resection, reoperation, and readmission. RCTs were evaluated by the Cochrane risk-of-bias tool. NRCTs were assessed using a modified tool from the Methodological Index for Non-randomized Studies. Data were pooled as odds ratio (OR) or mean difference (MD). This study was registered at PROSPERO (CRD42022338832).

Results

Four RCTs and 35 NRCTs concerning a total of 40,230 patients (4,262 LPD and 35,968 OPD) were included. Meta-analyses showed no significant differences in mortality (OR 0.91, p = 0.35), serious complications (OR 0.97, p = 0.74), POPF (OR 0.93, p = 0.29), PPH (OR 1.10, p = 0.42), BL (OR 1.28, p = 0.22), harvested lymph nodes (MD 0.66, p = 0.09), reoperation (OR 1.10, p = 0.41), and readmission (OR 0.95, p = 0.46) between LPD and OPD. Operative time was significantly longer for LPD (MD 85.59 min, p < 0.00001), whereas overall morbidity (OR 0.80, p < 0.00001), hospital stay (MD -2.32 days, p < 0.00001), blood loss (MD -173.84 ml, p < 0.00001), transfusion (OR 0.62, p = 0.0002), and DGE (OR 0.78, p = 0.002) were reduced for LPD. The R0 rate was higher for LPD (OR 1.25, p = 0.001).

Conclusions

LPD is associated with non-inferior short-term surgical outcomes and oncologic adequacy compared to OPD when performed by experienced surgeons at large centers. LPD may result in reduced overall morbidity, blood loss, transfusion, and DGE, but longer operative time. Further RCTs should address the potential advantages of LPD over OPD.

Systematic review registration

PROSPERO, identifier CRD42022338832.

Clinically Relevant Pancreatic Fistula after Pancreaticoduodenectomy: How We Do It

(1) Background: This study's goals were to investigate possible risk factors for clinically relevant postoperative pancreatic fistula (POPF) grade B/C according to the updated definitions of the International Study Group of Pancreatic Surgery and to analyze possible treatment strategies; (2) Methods: Between 2017 and 2021, 200 patients were analyzed regarding the development of POPF grade B/C with an emphasis on postoperative outcome and treatment strategies; (3) Results: POPF grade B/C was observed in 39 patients (19.5%). These patients were younger, mainly male, had fewer comorbidities and showed a higher body mass index. Also, they had lower CA-19 levels, a smaller tumor size and softer pancreatic parenchyma. They experienced a worse outcome without affecting the overall mortality rate (10% vs. 6%, p = 0.481), however, this lead to a prolonged postoperative stay (28 (32-36) d vs. 20 (15-28) d, p ≤ 0.001). The majority of patients with POPF grade B/C were able to receive conservative treatment, followed by drainage placement, endoscopic vacuum-assisted therapy (EVT) and surgery. Conservative treatment resulted in a shorter length of the postoperative stay (24 (22-28) d vs. 34 (26-43) d, p = 0.012); (4) Conclusions: Patients developing POPF grade B/C had a worse outcome; however, this did not affect the overall mortality rate. The majority of the patients were able to receive conservative treatment, resulting in a shorter length of their hospital stay.

Selective use of pancreatic duct occlusion during pancreaticoduodenectomy in patients with a small-size duct and atrophic parenchyma in the distal pancreas: A retrospective study

BACKGROUND

Despite the advancements in surgical techniques, postoperative pancreatic fistula (POPF) remains a potentially life-threatening complication of pancreaticoduodenectomy (PD). Pancreatic duct occlusion (PDO) without anastomosis has also been proposed to alleviate the clinical consequences of POPF in selected patients after PD.

OBJECTIVES

To assess the safety and effectiveness of PDO with mechanical closure after PD in patients with an atrophic pancreatic body-tail and a small pancreatic duct.

METHODS

We retrospectively identified two female and two male patients from April 2019 to October 2020 through preoperative computed tomography of the abdomen. Among them, three patients underwent PDO with mechanical closure after PD, and one underwent PDO after pylorus-preserving PD. In addition, patients' medical records and medium-and long-term follow-up data were analyzed.

RESULTS

Postoperative histological examination revealed a solid pseudopapillary tumor in two patients, pancreatic ductal adenocarcinoma in one patient, and chronic pancreatitis with pancreatic duct stones in one patient. However, none of the patients developed biochemical or clinically relevant POPF, with no postpancreatectomy hemorrhage, biliary leakage, delayed gastric emptying, intra-abdominal abscess, or chyle leakage. Among the four patients, three developed new-onset diabetes mellitus, and one had impaired glucose tolerance. Furthermore, three patients received pancreatic enzyme supplementation at a dose of 90,000 Ph. Eur. units/d, and one was prescribed a higher dose of 120,000 Ph. Eur. units/d.

CONCLUSIONS

PDO with mechanical closure is an alternative approach for patients with an atrophic pancreatic body-tail and a small pancreatic duct after PD. Therefore, further evidence should evaluate the potential benefits of selective PDO in these patients.

Novel end-to-side one-layer continuous pancreaticojejunostomy vs. end-to-end invaginated pancreaticojejunostomy in pancreatoduodenectomy: A single-center retrospective study

Background and Objective

Postoperative pancreatic fistula (POPF) is the most common critical complication after pancreatoduodenectomy (PD) and is the primary reason for increased mortality and morbidity after PD. We aim to investigate the clinical significance of a novel approach, i.e., end-to-side one-layer continuous pancreaticojejunostomy, for patients with PD.

Methods

The clinical data of 65 patients who underwent pancreatoduodenectomy at the Xiangya Hospital, Central South University, from September 2020 to December 2021 were retrospectively analyzed.

Results

Forty patients underwent end-to-end invaginated pancreaticojejunostomy, and 25 underwent the novel end-to-side one-layer continuous pancreaticojejunostomy. No significant differences were observed in pancreatic fistula, intraperitoneal infection, intraperitoneal bleeding, reoperation, postoperative hospital stay, or perioperative death between the two groups. However, the novel end-to-side one-layer continuous pancreaticojejunostomy group had significantly shorter operation duration (32.6 ± 5.1 min vs. 8.3 ± 2.2 min, p < 0.001). The incidence of pancreatic fistula in the novel pancreaticojejunostomy group was 12%, including two cases of grade A POPF and only one case of grade B POPF. No cases of grade C POPF occurred. No deaths were observed during the perioperative period.

Conclusions

The novel anastomosis method leads to a shorter operation duration than the traditional anastomosis method and does not increase postoperative complications. In conclusion, it is a simplified and feasible method for pancreatic anastomosis.

Short-term Outcomes After Spleen-preserving Minimally Invasive Distal Pancreatectomy With or Without Preservation of Splenic Vessels: A Pan-European Retrospective Study in High-volume Centers

OBJECTIVE

To compare short-term clinical outcomes after Kimura and Warshaw MIDP.

BACKGROUND

Spleen preservation during distal pancreatectomy can be achieved by either preservation (Kimura) or resection (Warshaw) of the splenic vessels. Multicenter studies reporting outcomes of Kimura and Warshaw spleen-preserving MIDP are scarce.

METHODS

Multicenter retrospective study including consecutive MIDP procedures intended to be spleen-preserving from 29 high-volume centers (≥15 distal pancreatectomies annually) in 8 European countries. Primary outcomes were secondary splenectomy for ischemia and major (Clavien-Dindo grade ≥III) complications. Sensitivity analysis assessed the impact of excluding ("rescue") Warshaw procedures which were performed in centers that typically (>75%) performed Kimura MIDP.

RESULTS

Overall, 1095 patients after MIDP were included with successful splenic preservation in 878 patients (80%), including 634 Kimura and 244 Warshaw procedures. Rates of clinically relevant splenic ischemia (0.6% vs 1.6%, P = 0.127) and major complications (11.5% vs 14.4%, P = 0.308) did not differ significantly between Kimura and Warshaw MIDP, respectively. Mortality rates were higher after Warshaw MIDP (0.0% vs 1.2%, P = 0.023), and decreased in the sensitivity analysis (0.0% vs 0.6%, P = 0.052). Kimura MIDP was associated with longer operative time (202 vs 184 minutes, P = 0.033) and less blood loss (100 vs 150 mL, P < 0.001) as compared to Warshaw MIDP. Unplanned splenectomy was associated with a higher conversion rate (20.7% vs 5.0%, P < 0.001).

CONCLUSIONS

Kimura and Warshaw spleen-preserving MIDP provide equivalent short-term outcomes with low rates of secondary splenectomy and postoperative morbidity. Further analyses of long-term outcomes are needed.

Comparing the Warshaw technique with vessel-preservation in laparoscopic spleen preserving distal pancreatectomy: is there a better approach?

BACKGROUND

Laparoscopic spleen-preserving distal pancreatectomy (LSPDP) can be accomplished with either resection of the splenic vessels via the Warshaw Technique (WT) or via preservation of the splenic vessels (SVP). Our study aims to compare outcomes for the two methods of LSPDP.

METHODS

We performed a retrospective chart review with intent-to-treat analysis of adults undergoing LSPDP at a single institution from 2009 to 2021. We compared demographic characteristics, operative parameters, oncologic pathology review, and postoperative outcomes.

RESULTS

There were 102 consecutive cases of LSPDP (59 WT, 43 SVP) over 12 years. The rate of successful spleen preservation was not significantly different between the two groups (76.3%WT, 65.1%VSP,p = 0.27). Rates of conversion to laparotomy, postoperative complications including pancreatic fistulas and splenic infarcts and amount of intraoperative blood loss were similar between the groups. Median operative time was significantly shorter with the WT (141 vs. 177 min, p < 0.05). The median length of stay in hospital was not significantly different among the groups.

CONCLUSION

Both techniques are safe and effective in preserving the spleen in laparoscopic distal pancreatectomy. Our experience suggests that the Warshaw Technique may be more efficient with respect to the use of limited operative resources.

Metal vs plastic stents for preoperative biliary drainage in patients with periampullary cancer: An updated systematic review and meta-analysis

BACKGROUND/PURPOSE

Metal stents (MS) are recommended for preoperative biliary drainage (PBD) in patients with periampullary cancer, but whether MS are superior in terms of re-intervention and direct cost is debatable. This study aimed to compare the effects of MS and PS on the outcomes of patients with periampullary cancer.

METHODS

For this random-effects meta-analysis, electronic databases were screened for randomized controlled trials (RCTs) published until January 2022. Subgroup analyses were performed basis on the center type and presence of NAC.

RESULTS

In this meta-analysis, seven RCTs (440 participants) were included. MS reduced re-interventions (risk ratio [RR] = 0.42, 95% confidence interval [CI] = 0.25-0.72) and direct costs (mean difference = -474 USD, 95% CI = -656 to -292). PBD-related complications (RR = 0.74, 95% CI = 0.32-1.71) and postoperative complications (RR = 0.73, 95% CI = 0.45-1.17) did not differ between MS and PS. Compared PS, MS reduced postoperative complications in high-volume centers (RR = 0.64, 95% CI = 0.49-0.84) and PBD-related complications in patients receiving NAC (RR = 0.29, 95% CI = 0.08-1.08).

CONCLUSIONS

Metal stents likely reduces re-interventions and direct costs. Further studies are needed to confirm the effects of MS on the outcomes.

Pancreaticogastrostomy as a fistula mitigating strategy for a high-risk pancreatic anastomosis following pancreaticoduodenectomy

BACKGROUND

Clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD) has been associated with soft gland texture and/or small pancreatic duct. We hypothesized that selective use of pancreaticogastrostomy (PG) over pancreaticojejunostomy (PJ) in those scenarios would decrease the rate of CR-POPF.

METHODS

Review of prospective database of all PD's performed at a single institution between 2009 and 2019 was performed. The pancreatic remnant was deemed "high risk" if soft gland and/or small duct were present.

RESULTS

PJ was performed in 199 (147 "low-risk" and 52 "high-risk") cases, and 110 patients (all "high-risk") had a PG. Overall CR-POPF rate was 11.9% with no difference between the groups. Risk-stratified analysis within PJ group showed CR-POPF rate of 5.4% versus 36% in "low-risk" versus "high risk" scenarios, respectively; the use of PG significantly decreased CR-POPF rate (9.1%, p < 0.0001). Gastrointestinal bleeding was more likely to occur following PG than PJ. Soft gland texture and gastrointestinal bleeding were the strongest predictors of CR-POPF in PJ and PG groups, respectively.

CONCLUSION

Selective use of PG after PD in "high-risk" scenarios mitigates the risk of CR-POPF. Increased rate of gastrointestinal bleeding calls for further refinement of the technique and heightened postoperative vigilance.

Prevention and Treatment of Grade C Postoperative Pancreatic Fistula

Postoperative pancreatic fistula (POPF) is a troublesome complication after pancreatic surgeries, and grade C POPF is the most serious situation among pancreatic fistulas. At present, the incidence of grade C POPF varies from less than 1% to greater than 9%, with an extremely high postoperative mortality rate of 25.7%. The patients with grade C POPF finally undergo surgery with a poor prognosis after various failed conservative treatments. Although various surgical and perioperative attempts have been made to reduce the incidence of grade C POPF, the rates of this costly complication have not been significantly diminished. Hearteningly, several related studies have found that intra-abdominal infection from intestinal flora could promote the development of grade C POPF, which would help physicians to better prevent this complication. In this review, we briefly introduced the definition and relevant risk factors for grade C POPF. Moreover, this review discusses the two main pathways, direct intestinal juice spillover and bacterial translocation, by which intestinal microbes enter the abdominal cavity. Based on the abovementioned theory, we summarize the operation techniques and perioperative management of grade C POPF and discuss novel methods and surgical treatments to reverse this dilemma.

The consistencies and inconsistencies between distal cholangiocarcinoma and pancreatic ductal adenocarcinoma: A systematic review and meta-analysis

Objective

To evaluate the consistencies and inconsistencies between distal cholangiocarcinoma (DCCA) and pancreatic ductal adenocarcinoma (PDCA) regarding their biological features and long-term prognosis.

Methods

PubMed, the Cochrane Library, and EMBASE were searched to find comparative studies between DCCA and PDCA. RevMan5.3 and Stata 13.0 software were used for the statistical analyses.

Results

Eleven studies with 4,698 patients with DCCA and 100,629 patients with PDCA were identified. Pooled results indicated that patients with DCCA had a significantly higher rate of preoperative jaundice (p = 0.0003). Lymphatic metastasis (p < 0.00001), vascular invasion (p < 0.0001), and peri-neural invasion (p = 0.005) were more frequently detected in patients with PDCA. After curative pancreaticoduodenectomy (PD), a significantly higher R0 rate (p < 0.0001) and significantly smaller tumor size (p < 0.00001) were detected in patients with DCCA. Patients with DCCA had a more favorable overall survival (OS) (p < 0.00001) and disease-free survival (DFS) (p = 0.005) than patients with PDCA. However, postoperative morbidities (p = 0.02), especially postoperative pancreatic fistula (POPF) (p < 0.00001), more frequently occurred in DCCA.

Conclusion

Patients with DCCA had more favorable tumor pathological features and long-term prognosis than patients with PDCA. An early diagnosis more frequently occurred in patients with DCCA. However, postoperative complications, especially POPF, were more frequently observed in patients with DCCA.

Association between the Preoperative C-Reactive Protein-to-Albumin Ratio and the Risk for Postoperative Pancreatic Fistula following Distal Pancreatectomy for Pancreatic Cancer

Postoperative pancreatic fistula (POPF) are major postoperative complications (POCs) following distal pancreatectomy (DP). Notably, POPF may worsen the prognosis of patients with pancreatic cancer. Previously reported risks for POCs include body mass index, pancreatic texture, and albumin levels. Moreover, the C-reactive protein-to-albumin ratio (CAR) is a valuable parameter for prognostication. On the other hand, POCs sometimes lead to a worse prognosis in several cancer types. Thus, we assumed that CAR could be a risk factor for POPFs. This study investigated whether CAR can predict POPF risk in patients with pancreatic cancer following DP. This retrospective study included 72 patients who underwent DP for pancreatic cancer at Ehime University between January 2009 and August 2022. All patients underwent preoperative CAR screening. Risk factors for POPF were analyzed. POPF were observed in 17 of 72 (23.6%) patients. POPF were significantly associated with a higher CAR (p = 0.001). The receiver operating characteristic curve analysis determined the cutoff value for CAR to be 0.05 (sensitivity: 76.5%, specificity: 88.9%, likelihood ratio: 6.88), indicating an increased POPF risk. Univariate and multivariate analysis revealed that CAR ≥ 0.05 was a statistically independent factor for POPF (p < 0.001, p = 0.013). Therefore, CAR has the potential to predict POPF following DP.

The usefulness of presepsin in the diagnosis of postoperative infectious complications after gastrectomy for gastric cancer: a prospective cohort study

This prospective study aimed to evaluate presepsin use as a biomarker of on postoperative infectious complications after gastrectomy, compared to C-reactive protein (CRP), white blood cells (WBCs), and neutrophils (Neuts). Overall, 108 patients were enrolled between October 2019 and December 2020. Presepsin, CRP, WBC, and Neut levels were measured preoperatively and on postoperative days (PODs) 1, 3, 5, and 7, using a postoperative morbidity survey. Grade II or higher infectious complications occurred in 18 patients (16.6%). Presepsin levels on all evaluated PODs were significantly higher in the infectious complication group than in the non-complication group (p = 0.002, p < 0.0001, p < 0.0001, and p = 0.025, respectively). The area under the curve (AUC) values were the highest for presepsin on PODs 3 and 7 (0.89 and 0.77, respectively) and similar to that of CRP, with a high value > 0.8 (0.86) on POD 5. For presepsin, the optimal cut-off values were 298 pg/mL (sensitivity, 83.3%; specificity, 83.3%), 278 pg/mL (sensitivity, 83.3%; specificity, 82.2%), and 300 pg/mL (sensitivity, 83.3%; specificity, 82%) on PODs 3, 5, and 7, respectively. Presepsin levels on PODs 3, 5, and 7 after gastrectomy is a more useful biomarker of postoperative infectious complications compared to CRP, WBCs, and Neuts, with a high sensitivity and specificity.

Impact of biliary drainage prior to pancreatectomy

BACKGROUND

There is still a lack of clarity about the benefits of preoperative biliary drainage (PBD), which was introduced to improve the perioperative outcome in patients with obstructive jaundice caused by a periampullary tumour. The aim of this study was to determine whether operative and postoperative complications increase in patients undergoing PBD during pancreatoduodenectomy (PD).

MATERIAL AND METHODS

Retrospective examination was made of patients who underwent PBD for a periampullary tumour in our hospital between 2006 and 2014. From these, the patients were identified who had PBD with endoscopic retrograde cholangiopancreatography and these patients were further separated into two groups, as one group of patients with plastic stents and the other group of patients with metallic stents. Patients with pancreas head cancer were also separated into two groups as those who were and were not applied with PBD. The preoperative, intraoperative and postoperative characteristics of the patients were evaluated.

RESULTS

A total of 123 patients were retrospectively reviewed. Biliary stent placement with PBD was applied to 48 patients, of whom 31 had metallic stents and 17 had plastic stents. In general, there was no difference between the PBD and the non-PBD groups in respect of the preoperative, operative and postoperative results. When patients with tumour of the pancreas head only were examined, the rate of wound infection was higher in the PBD group and there was no difference in the other parameters. Moreover, there was no difference between the patients with metallic stents and those with plastic stents in respect of outcomes.

CONCLUSIONS

With the exception of wound site infection, although no difference was observed between the PBD and the non-PBD groups based on intraoperative and postoperative complications, because of the distinctive inherent complications of PBD it is essential to manage such patients properly and to carefully select the patients for the PBD procedure.

Predictive factors for early recurrence after pancreaticoduodenectomy in patients with resectable pancreatic head cancer: A multicenter retrospective study

BACKGROUND

Patients diagnosed with resectable pancreatic ductal adenocarcinoma often experience early recurrence even after upfront R0 resection. This study aimed to define early recurrence and identify preoperative risk factors for early recurrence after upfront pancreaticoduodenectomy in patients with resectable pancreatic ductal adenocarcinoma of the pancreatic head.

METHODS

This multicenter, retrospective study involved 500 patients who underwent pancreaticoduodenectomy resectable pancreatic ductal adenocarcinoma of the pancreatic head at 10 institutions between 2007 and 2016. Preoperative, intraoperative, and postoperative clinicopathological results were compared between early and non-early recurrence groups. Predictors of early recurrence were determined using statistical analyses.

RESULTS

Log-rank tests revealed a significant difference (P < .001) between recurrence within 3 to 6 months and 6 to 9 months. Early recurrence was subsequently defined as recurrence within 6 months. Patients were categorized into early recurrence (n = 104) and non-early recurrence groups (n = 389). The median overall survival of the early and non-early recurrence groups was 8.6 months and 42.6 months (P < .001), respectively. Preoperatively, high carbohydrate antigen 19-9 levels ≥120 U/mL, retroperitoneal invasion, and diabetes mellitus were identified as independent predictive risk factors for early recurrence according to multivariate analysis. Comparing survival rates among patients with 3, 2, 1, or none of these factors, the median overall survival was 17.6 (n = 90), 21.2 (n = 184), 47 (n = 141), and 61.5 (n = 73) months, respectively.

CONCLUSION

The optimal period that defines the early recurrence for resectable pancreatic ductal adenocarcinoma of the pancreatic head is 6 months. Tumor size ≥20 mm, preoperative carbohydrate antigen 19-9 levels ≥120 U/mL, retroperitoneal invasion of the tumor, and the presence of diabetes mellitus are independently associated with early recurrence.

Complications of modern pancreaticoduodenectomy: A systematic review and meta-analysis

BACKGROUND

In the past decades, the perioperative management of patients undergoing pancreaticoduodenectomy (PD) has undergone major changes worldwide. This review aimed to systematically determine the burden of complications of PD performed in the last 10 years.

DATA SOURCES

A systematic review was conducted in PubMed for randomized controlled trials and observational studies reporting postoperative complications in at least 100 PDs from January 2010 to April 2020. Risk of bias was assessed using the Cochrane RoB2 tool for randomized studies and the methodological index for non-randomized studies (MINORS). Pooled complication rates were estimated using random-effects meta-analysis. Heterogeneity was investigated by subgroup analysis and meta-regression.

RESULTS

A total of 20 randomized and 49 observational studies reporting 63 229 PDs were reviewed. Mean MINORS score showed a high risk of bias in non-randomized studies, while one quarter of the randomized studies were assessed to have high risk of bias. Pooled incidences of 30-day mortality, overall complications and serious complications were 1.7% (95% CI: 0.9%-2.9%; I2 = 95.4%), 54.7% (95% CI: 46.4%-62.8%; I2 = 99.4%) and 25.5% (95% CI: 21.8%-29.4%; I2= 92.9%), respectively. Clinically-relevant postoperative pancreatic fistula risk was 14.3% (95% CI: 12.4%-16.3%; I2 = 92.0%) and mean length of stay was 14.8 days (95% CI: 13.6-16.1; I2 = 99.3%). Meta-regression partially attributed the observed heterogeneity to the country of origin of the study, the study design and the American Society of Anesthesiologists class.

CONCLUSIONS

Pooled complication rates estimated in this study may be used to counsel patients scheduled to undergo a PD and to set benchmarks against which centers can audit their practice. However, cautious interpretation is necessary due to substantial heterogeneity.

Role of biliary drainage before pancreatoduodenectomy for pancreatic adenocarcinoma: a retrospective study

BACKGROUND

Utilization of preoperative biliary drainage prior to pancreatoduodenectomy for patients with pancreatic ductal adenocarcinoma and obstructive jaundice remains controversial.

METHODS

All patients that underwent pancreatoduodenectomy for pancreatic ductal adenocarcinoma at the authors' institution were analyzed retrospectively to evaluate the effect of endoscopic biliary drainage on postoperative outcomes and long-term survival. Age, gender, ASA-Score, operative time, blood loss, intraoperative transfusion rate, and postoperative complications, including postoperative pancreatic fistula, delayed gastric emptying, bleeding, bile fistula, wound infections, sepsis, pulmonary and cardiac complications as well as the need for relaparotomy were analyzed.

RESULTS

Two hundred eighty-five patients with similar baseline characteristics underwent pancreatoduodenectomy, 151 patients with biliary drainage (group 1) and 134 without drainage (group 2). More than 60% of patients had one or more postoperative complications, without significant difference between the two groups (P=0.140). The overall incidence of pancreatic fistula was 21.75% in both groups (group 1: 19.87% vs. group 2: 23.88%, P=0.659). Wound healing impairment was the only postoperative complication that differed significantly between the two groups (group 1: 24.50% vs. group 2: 8.96%, P<0.001). In multivariate risk analysis, biliary drainage was the only independent risk factor for wound healing impairment (OR 4.126; 95% CI: 1.295-13.143; P=0.017). The median overall survival was similar in both groups.

CONCLUSIONS

Preoperative endoscopic biliary drainage is associated with an increased risk for wound healing impairment and wound infections. Therefore, biliary drainage should not be used routinely in patients with obstructive jaundice prior to pancreatoduodenectomy.

Lymph node metastases and recurrence in pancreatic neuroendocrine neoplasms

BACKGROUND

The impact of lymph node metastasis on survival in pancreatic neuroendocrine neoplasms as well as their best surgical treatment is controversial. We aimed to determine the frequency and prognostic impact of lymph node involvement in pancreatic neuroendocrine neoplasms.

METHODS

Patients undergoing pancreatic resections for pancreatic neuroendocrine neoplasms between 2001 and 2019 were retrospectively analyzed based on a prospective database. Clinicopathological parameters and perioperative outcome were assessed. Overall and disease-free survival was analyzed. Subgroup analysis was performed for sporadic, nonfunctional pancreatic neuroendocrine neoplasms without distant metastases and ≥4 analyzed lymph nodes.

RESULTS

Of 605 surgically resected pancreatic neuroendocrine neoplasms, 55% were G1, 36% were G2, and 9% were G3 differentiated. At the time of resection, 34% of patients had lymph node metastasis, and 16% had distant metastases. For subgroup analysis, 314 patients were analyzed. Lymph node metastases occurred in 36% of patients and were most frequent in G3 patients (67%). An increase in tumor size and advancement was associated with higher rates of lymph node metastasis, and disease-free survival was significantly impaired. Significant differences in disease-free survival were observed between 1 and 3 (5-year disease-free survival 52%) and ≥4 positive lymph nodes (5-year disease-free survival 28%), as well as when G3 tumors were excluded. In multivariable analysis, grading, tumor stage, and especially lymph node metastases as well as the proposed pN1 and pN2 categories were confirmed as independent predictors of recurrence.

CONCLUSION

The presence and extent of lymph node involvement has considerable prognostic impact in pancreatic neuroendocrine neoplasms. This study, for the first time, validated the proposed pN2 stage for well-differentiated pancreatic neuroendocrine neoplasms.

Effect of preoperative biliary stent on postoperative complications after pancreaticoduodenectomy for cancer: Neoadjuvant versus upfront treatment

BACKGROUND

Limited data are available regarding the effect of preoperative biliary stent, during long-course neoadjuvant chemotherapy, on postoperative complications. The aim of the study is to analyze whether the association of neoadjuvant chemotherapy and biliary stent increases overall and infectious complications after pancreaticoduodenectomy.

METHODS

Data for 538 consecutive pancreatic ductal adenocarcinoma patients who underwent pancreaticoduodenectomy between 2015 and 2020 were retrospectively analyzed. Four groups of patients were identified: neoadjuvant chemotherapy + biliary stent (171 patients), neoadjuvant chemotherapy-no biliary stent (65 patients), upfront surgery + biliary stent (184 patients), and upfront surgery-no biliary stent (118 patients). Median neoadjuvant chemotherapy duration was 6 months. The main outcome of the study was the occurrence of postoperative infections.

RESULTS

No differences among the 4 groups were observed for pancreaticoduodenectomy-specific complications (ie, POPF, DGE, PPH). Infectious complications, in particular surgical site infections, were more frequent in neoadjuvant chemotherapy + biliary stent group (P = 0.001). At multivariate analysis, biliary stent was significantly associated with postoperative infectious complications in the overall cohort (odds ratio 1.996, confidence interval 95% 1.29-3.09, P = .002) and in neoadjuvant chemotherapy patients (odds ratio 5.974, 95% confidence interval 2.52-14.13, P < .001). Biliary stent significantly increased the comprehensive complication index by 9.5% (95% confidence interval 0.04-0.64, P = 0.024) in the overall cohort and 18.9% (95% confidence interval 0.22-1.23, P = .005) in the neoadjuvant chemotherapy group. The presence of multidrug-resistant microorganisms in intraoperative bile culture was not influenced by long-course neoadjuvant chemotherapy.

CONCLUSION

In neoadjuvant chemotherapy patients, biliary stent increased the occurrence of postoperative infectious complications and surgical site infections, while the incidence of multidrug-resistant bacteria in intraoperative bile culture was similar between groups.

Chronological improvement of pancreatectomy for resectable but advanced pancreatic neuroendocrine neoplasms

BACKGROUND

Progress of non-surgical treatments in the last decade has improved the prognosis of pancreatic neuroendocrine neoplasms (PanNEN). However, the improvement of surgery for advanced PanNEN remains unknown. This study aimed to investigate the chronological changes of the clinical impact of pancreatectomy for PanNEN.

METHODS

Patients undergoing curative-intent pancreatectomy for PanNEN between 1991 and 2010 were categorized into the earlier period group, and those between 2011 and 2021 were into the later period group. Advanced PanNEN was defined as showing resectable synchronous liver metastases or invasion to portal venous systems or adjacent organs. The recurrence-free survival (RFS) and overall survival (OS) were analyzed among patients with non-advanced and advanced PanNENs. The independent prognostic risk factors were identified using a Cox proportional hazard model.

RESULTS

A total of 189 patients (n = 54 in the earlier period and n = 135 in the later period) were included. The proportion of advanced PanNEN increased from 15% to 30% (P = 0.027). The RFS and OS of non-advanced PanNEN were similar between the periods. Whereas, among patients with advanced PanNEN, the later period group showed improved prognosis; The 5-year RFS of the earlier period vs. the later period was 0% vs. 27%, and the 5-year OS was 38% vs. 82% (p = 0.013).

CONCLUSIONS

A radical surgical treatment for advanced PanNEN has shown prognostic improvement in this decade. However, more careful perioperative examinations and possibly, additional treatments are required for PanNEN with portal vein invasion.

Appraising pancreatic fistula in pancreas transplantation: A comprehensive complication index based analysis of postoperative outcomes and predictors of graft survival

BACKGROUND

A definition of pancreatic fistula specifically addressing pancreas transplantation (PT) is lacking. This study sought to characterize pancreatic fistula in this setting and to define its clinical relevance on the postoperative course and long-term graft survival (GS).

METHODS

Consecutive simultaneous pancreas and kidney transplantations were analysed. The global postoperative course was assessed through the comprehensive complication index (CCI). PF was defined according to the original International Study Group for Pancreatic Surgery (ISGPS) definition. Predictors of poor postoperative course and GS were explored.

RESULTS

Seventy-eight patients were analysed. Surgical morbidity was 48.7%, with severe complications occurring in 39.7%. Ninety-day mortality was 2.6%. PF occurred in 56.6% of patients, although its average clinical burden was low and did not correlate with either early or long-term outcomes. Peri-graft fluid collections, postoperative day (POD) 1 drain fluid amylase (DFA) ≥ 2200 U/L, and POD 5 DFA/serum amylase ratio ≥7.0 independently correlated with poor postoperative course. Perigraft fluid collections were associated with reduced GS.

CONCLUSION

Conventionally defined pancreatic fistula is frequent following PT, although its clinical impact is negligible. To define clinically relevant PF, novel cut-offs for DFA might be pondered in a future series, while perigraft fluid collections should be strongly considered.

International assessment and validation of the prognostic role of lymph node ratio in patients with resected pancreatic head ductal adenocarcinoma

Background

Lymph node ratio (LNR; positive/harvested lymph nodes) was identified as overall survival predictor in several cancers, including pancreatic adenocarcinoma. It remains unclear if LNR is predictive of overall survival in pancreatic adenocarcinoma patients staged pN2. This study assessed the prognostic overall survival role of LNR in pancreatic adenocarcinoma patients in relation with lymph node involvement.

Methods

A retrospective international study in six different centers (Europe and United States) was performed. Pancreatic adenocarcinoma patients who underwent pancreatoduodenectomy from 2000 to 2017 were included. Patients with neoadjuvant treatment, metastases, R2 resections, or missing data regarding nodal status were excluded. Survival curves were calculated using Kaplan-Meier method and compared using log-rank test. Multivariable Cox regressions were performed to find independent overall survival predictors adjusted for potential confounders.

Results

A total of 1,327 patients were included. Lymph node involvement (pN+) was found in 1,026 patients (77%), 561 pN1 (55%) and 465 pN2 (45%). Median LNR in pN+ patients was 0.214 [interquartile range (IQR): 0.105-0.364]. On multivariable analysis, LNR was the strongest overall survival predictor in the entire cohort [hazard ratio (HR) =5.5; 95% confidence interval (CI): 3.1-9.9; P<0.001] and pN+ patients (HR =3.8; 95% CI: 2.2-6.6; P<0.001). Median overall survival was better in patients with LNR <0.225 compared to patients with LNR ≥0.225 in the entire cohort and pN+ patients. Similar results were found in pN2 patients (worse overall survival when LNR ≥0.225).

Conclusions

LNR appeared as an important prognostic factor in patients undergoing surgery for pancreatic adenocarcinoma and permitted to stratify overall survival in pN2 patients. LNR should be routinely used in complement to tumor-node-metastasis (TNM) stage to better predict patient prognosis.

Which style of duodenojejunostomy is better after resection of distal duodenum

BACKGROUND

Distal duodenal resections are sometimes necessary for radical surgery, but how to restore duodenal continuity is still unclear. This study aimed at determining which style of anastomosis was more suitable for the duodenojejunostomy after resection of distal duodenum.

PATIENTS AND METHODS

We retrospectively identified 34 patients who underwent distal duodenum resection at our center between January 2014 and December 2021. According to whether the end or the side of the proximal duodenum was involved in reconstruction, duodenojejunostomy were classified as End style (E-style) and Side style (S-style). Demographic data, clinicopathological details, and postoperative complications were analyzed between two groups.

RESULTS

Thirteen patients (38.2%) received E-style duodenojejunostomy, and 21 patients (62.8%) received S-style duodenojejunostomy. Comparative analysis showed that in group of E-style, patients had a lower rate of multivisceral resection(5/13 vs 18/21; P = 0.008), delayed gastric emptying (DGE) (1/13 vs 11/21; P = 0.011) and intraperitoneal infection (2/13 vs 12/21; P = 0.03). In this study, the incidence of major complications was up to 35.3% (12/34) and no patient died of complication in perioperative period. In two group, there was no difference in the incidence of major complications (E-style vs S-style: 3/13 vs 9/21; P = 0.292).

CONCLUSIONS

The E-style duodenojejunostomy for the reconstruction of distal duodenum resection is safe and feasible. The E-style anastomosis may have potential value in decreasing the occurrence of complications such as DGE and intraperitoneal infection, and the definitive advantages still need to be verified.

Comparison of laparoscopic and open pancreaticoduodenectomy for the treatment of distal cholangiocarcinoma: A propensity score matching analysis

BACKGROUND

There are few studies comparing the oncological outcomes of laparoscopic pancreaticoduodenectomy (LPD) and open pancreaticoduodenectomy (OPD) for distal cholangiocarcinoma (DCC). Our objective was to assess the short-term efficacy and long-term survival of LPD and OPD in patients with DCC.

METHODS

The data of 124 DCC patients who underwent LPD or OPD at the Third Affiliated Hospital of Soochow University from May 2010 to May 2021 were retrospectively analyzed. Propensity score matching was performed to balance the two groups of baseline characteristics. After 1:1 matching, the overall survival (OS) of the two groups was compared by the Kaplan-Meier method. Univariate and multivariate Cox regression analyses were used to identify independent predictors of OS.

RESULTS

The original cohort consisted of 124 patients. Nineteen patients were excluded because of incomplete baseline or follow-up data, and the remaining 105 patients were divided into two cohorts (45 in the LPD group and 60 in the OPD group). The LPD group showed more favorable results in OS analysis (LPD vs. OPD, 56.4 [46.2-66.5] vs. 48.9 [36.4-61.4], months, P=0. 01). PSM analysis identified 30 pairs of patients, and differences between matching groups were still significant (LPD vs. OPD, 67.9[58.2-77.6] vs. 47.4[31.4-67.5], months, P=0.002). Moreover, the LPD group experienced less intraoperative bleeding (LPD vs. OPD, 292.67 vs. 519.17 mL, P=0.002). Univariate analysis showed that surgical modality (P=0.012), carbohydrate antigen 19-9 (P=0.043), carcinoembryonic antigen (P=0.003), neutrophil-to-lymphocyte ratio (P=0.012), blood transfusion (P=0.031), clinically relevant postoperative pancreatic fistula (P<0.001) and lymphatic metastasis (P=0.004) were predictors of OS. Multivariate Cox analysis demonstrated that carbohydrate antigen 19-9 (P=0.048), carcinoembryonic antigen (P=0.031) and lymphatic metastasis (P=0.023) were independent predictive factors of OS. However, adjuvant therapy had no significant effect on the OS of DCC patients after radical pancreaticoduodenectomy (P>0.05).

CONCLUSIONS

For DCC patients, LPD may be a more recommended procedure because of its advantages over OPD in terms of intraoperative bleeding and long-term survival.

Preoperative risk assessment for postoperative pancreatic fistula (POPF): Image-based calculation of duct-to-parenchyma (D/P) ratio and an Alignment of Duct and Mucosa (ADAM) anastomosis may lead to a low POPF rate—results from 386 patients

Background

Postoperative pancreatic fistula (POPF) is the most critical complication after pancreatoduodenectomy (PD). Preoperative identification of high-risk patients and optimal pancreatic reconstruction technique can be a way to reduce postoperative complications.

Methods

A series of 386 patients underwent PD over a 10-year period (2009–2019). On routinely performed preoperative computed tomography (CT) images, the ventro-dorsal diameters of duct (D) and parenchyma (P) were measured in the cutting plane at the superior mesenteric vein. Then, the ratio of both values was calculated (D/P ratio) Double-layer pancreatojejunostomy with alignment of duct and mucosa (ADAM) by two monofilament threads (MFT) was performed in 359 patients and pancreatogastrostomy (PG) in 27 patients. The incidence of POPF was diagnosed according to the International Study Group for Pancreatic Fistula criteria.

Results

The overall rate of POPF was 21% (n = 80), and the rate of clinically relevant type B/C fistulas 6.5% (n = 25). A D/P ratio of &lt;0.2 was significantly associated with type B/C fistula (11%, p &lt; 0.01). In low-risk patients (D/P ratio &gt;0.2), type B/C fistula occurred only in 2%, and in high-risk patients (D/P ratio &lt;0.2) in 9%. ADAM anastomosis was performed safely by two different surgeons. A PG anastomosis had double-digit POPF rates in all groups.

Conclusion

Preoperative CT imaging with D/P measurement may predict the risk of POPF development. A cut off D/P ratio of &lt;0.2 was significantly associated with clinical relevant POPF. ADAM anastomosis may be an option for pancreatojejunostomy. However, preoperative knowledge of the D/P ratio could guide decision-making for primary pancreatectomy when pancreatic reconstruction is critical.

Predictors of post-operative pancreatic fistula formation in pancreatic neuroendocrine tumors: A national surgical quality improvement program analysis

BACKGROUND

Post-operative pancreatic fistula (POPF) is a serious complication following pancreas surgery. We aimed to establish factors associated with POPF specifically in patients with pancreatic neuroendocrine tumors (PNET).

METHODS

The 2014-2018 American College of Surgeons National Surgical Quality Improvement Program database was querried for patients undergoing resection for PNET. The impact of patient, tumor, and operative factors on POPF formation was evaluated.

RESULTS

3532 patient underwent resections for PNET. The POPF rate was significantly higher in patients with PNET (24.8%) versus non-PNET (16.4%) (p < 0.0001). Male sex (OR 1.45, 95% CI 1.11-1.89), enucleation (OR 3.14, 95% CI 1.10-8.98), pancreaticoduodenectomy (OR 1.51, 95% CI 1.13-2.03), small duct size <3 mm (OR 3.24, 95% CI 1.62-6.48), and soft gland texture (OR 1.81, 95% CI 1.18-2.77) were independently associated with POPF in PNET patients on multivariable analysis.

CONCLUSIONS

POPF is more common in patients undergoing resection for PNET and is dictated primarily by surgical approach and gland characteristics.

Preoperative Rapid Weight Loss as a Prognostic Predictor After Surgical Resection for Pancreatic Cancer

OBJECTIVE

The aim of the study is to evaluate the influence of cachexia at the time of diagnosis of pancreatic ductal adenocarcinoma (PDAC) on prognosis in patients undergoing surgical resection.

METHODS

Patients with data on preoperative body weight (BW) change followed by surgical resection during 2008-2017 were selected. Large BW loss was defined as weight loss >5% or >2% in individuals with body mass index less than 20 kg/m2 within 1 year preoperatively. Influence of large BW loss, ΔBW defined as preoperative BW change (%) per month, prognostic nutrition index, and indices of sarcopenia.

RESULTS

We evaluated 165 patients with PDAC. Preoperatively, 78 patients were categorized as having large BW loss. ΔBW was ≤ -1.34% per month (rapid) and > -1.34% per month (slow) in 95 and 70 patients, respectively. The median postoperative overall survival of rapid and slow ΔBW groups was 1.4 and 4.4 years, respectively (P < 0.001). In multivariate analyses rapid ΔBW (hazard ratio [HR], 3.88); intraoperative blood loss ≥430 mL (HR, 1.89); tumor size ≥2.9 cm (HR, 1.74); and R1/2 resection (HR, 1.77) were independent predictors of worse survival.

CONCLUSIONS

Preoperative rapid BW loss ≥1.34% per month was an independent predictor of worse survival of patients with PDAC.

Fully covered metal stents vs plastic stents for preoperative biliary drainage in patients with resectable pancreatic cancer without neoadjuvant chemotherapy: A multicenter, prospective, randomized controlled trial

BACKGROUND/PURPOSE

Whether a fully covered self-expanding metal stent (FCSEMS) or plastic stent (PS) is preferable for preoperative biliary drainage in patients with resectable pancreatic cancer (RPC) is controversial. This study aimed to evaluate the safety and efficacy of drainage with FCSEMS for obstructive jaundice caused by RPC without neoadjuvant chemotherapy.

METHODS

Seventy patients with RPC who required preoperative biliary drainage were randomly assigned 1:1 to the FCSEMS or PS group. The primary endpoint was endoscopic re-intervention rate during the waiting period for surgery. Secondary endpoints were drainage procedure time, drainage-related adverse events (AE), waiting period for surgery, operative time, intraoperative blood loss, surgery-related AE, and postoperative hospital stay.

RESULTS

Thirty-nine patients underwent surgery. None required re-intervention in the FCSEMS group, whereas five PS patients underwent re-intervention (P = .023). The FCSEMS group had significantly more intraoperative blood loss (P = .0068) and AE (P = .011) than the PS group. Postoperative hospital stay was significantly longer in the FCSEMS group (P = .016).

CONCLUSIONS

Fully covered self-expanding metal stent had a lower rate of endoscopic re-intervention during the waiting period for surgery than PS, but showed more intraoperative blood loss, higher incidence of surgery-related AE, and longer postoperative hospital stays.

Hepatopancreaticobiliary Surgical Outcomes at a Community Hospital

There is a national trend towards regionalizing complex hepatopancreaticobiliary (HPB) surgeries to high-volume institutions. Due to geographic and socioeconomic constraints, however, many patients in the United States continue to undergo HPB surgery at local community hospitals. This study evaluated complex HPB surgeries performed by a single surgeon at a low-volume community hospital from May 2007 to June 2021. A retrospective review of medical records (n=163) was done to collect data on patient demographics and outcomes. Surgical outcomes of HPB procedures were compared to published data from high-volume centers. Overall mortality within 30 days of the procedure was 1% (n=1). Using Clavien-Dindo classification, the major complication rate was 10%, including 8% grade III and 2% grade IV complications. Reoperation (2%) and readmission (3%) were rare in this population. Median length of stay was 7 days and median estimated blood loss was 500 milliliters. Surgical outcomes from the community hospital were comparable to high-volume centers. For pancreatic cancer patients treated at the community hospital, Kaplan-Meier curves revealed comparable 5-year survival time to national data. Complex HPB procedures can be safely performed at a low-volume hospital in Hawai'i with outcomes comparable to large tertiary centers.

Preoperative serum CA19-9 predicts postoperative pancreatic fistula in PDAC patients: retrospective analysis at a single institution

Background

Postoperative pancreatic fistula (POPF) is a critical complication of pancreatectomy in patients with pancreatic ductal adenocarcinoma (PDAC). Recent papers reported that serum carbohydrate antigen (CA)19-9 levels predicted long-term prognosis. We investigated whether preoperative serum CA19-9 levels were associated with POPF in PDAC patients.

Methods

This cohort study was conducted at a single institution retrospectively. Clinicopathologic features were determined using medical records.

Results

Among of 196 consecutive patients who underwent pancreatectomy against PDAC, 180 patients whose CA19-9 levels were above the measurement sensitivity, were registered in this study. The patients consisted of 122 patients who underwent pancreaticoduodenectomy and 58 patients who underwent distal pancreatectomy. Several clinicopathological factors, including CA 19-9 level, as well as surgical factors were determined retrospectively based on the medical records. Patients with high CA19-9 levels had a significantly higher incidence of POPF than those with low levels (43.9 vs. 13.0%, P < 0.0001). The receiver operating characteristic curves calculated that the cutoff CA19-9 value to predict POPF was 428 U/mL. CA19-9, BMI, curability, and histology were statistically significant risk factors for POPF by univariate analysis. Multivariate analysis showed that CA19-9 and BMI levels were statistically significant independent risk factors for POPF. CA19-9 levels were correlated with both histology and curability. Disease free survival and overall survival of patients with higher levels of CA19-9 were significantly shorter than that of patients with lower levels of preoperative serum CA19-9.

Conclusions

In patients undergoing pancreatectomy for PDAC, higher preoperative CA19-9 levels are a significant predictor for POPF.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01825-3.