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

Drain fluid biomarkers for prediction and diagnosis of clinically relevant postoperative pancreatic fistula: A narrative review

Clinically relevant postoperative pancreatic fistula (CR-POPF) has continued to compromise patient recovery post-pancreatectomy despite decades of research seeking to improve risk prediction and diagnosis. The current diagnostic criteria for CR-POPF requires elevated drain fluid amylase to present alongside POPF-related complications including infection, haemorrhage and organ failure. These worrying sequelae necessitate earlier and easily obtainable biomarkers capable of reflecting evolving CR-POPF. Drain fluid has recently emerged as a promising source of biomarkers as it is derived from the pancreas and hence, capable of reflecting its postoperative condition. The present review aims to summarise the current knowledge of CR-POPF drain fluid biomarkers and identify gaps in the field to invigorate future research in this critical area of clinical need. These findings may provide robust diagnostic alternatives for CR-POPF and hence, to clarify their clinical utility require further reports detailing their diagnostic and/or predictive accuracy.

Interventional Radiological Management and Prevention of Complications after Pancreatic Surgery: Drainage, Embolization and Islet Auto-Transplantation

Pancreatic surgery still remains burdened by high levels of morbidity and mortality with a relevant incidence of complications, even in high volume centers. This review highlights the interventional radiological management of complications after pancreatic surgery. The current literature regarding the percutaneous drainage of fluid collections due to pancreatic fistulas, percutaneous transhepatic biliary drainage due to biliary leaks and transcatheter embolization (or stent–graft) due to arterial bleeding is analyzed. Moreover, also, percutaneous intra-portal islet auto-transplantation for the prevention of pancreatogenic diabetes in case of extended pancreatic resection is also examined. Moreover, a topic not usually treated in other similar reviewsas percutaneous intra-portal islet auto-transplantation for the prevention of pancreatogenic diabetes in case of extended pancreatic resection is also one of our areas of focus. In islet auto-transplantation, the patient is simultaneously donor and recipient. Differently from islet allo-transplantation, it does not require immunosuppression, has no risk of rejection and is usually efficient with a small number of transplanted islets.

Endoscopic treatment of pancreaticopleural fistulas

INTRODUCTION

Pancreaticopleural fistula (PPF) is a serious complication of acute and chronic pancreatitis.

OBJECTIVE

To evaluate the effectiveness of various endoscopic techniques for the treatment of patients with PPFs.

METHODOLOGY

Prospective analysis of the results of endoscopic treatment of 22 patients with PPF due to pancreatitis was conducted at the Department of General, Gastroenterological, and Oncological Surgery, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, between 2018 and 2021.

RESULTS

PPF was diagnosed in 22 patients (21 men and 1 woman; mean age 49.52 [30-67] years) with pancreatitis. In 19/22 (86.36%) patients, PPF communicated with the left pleural cavity and in 3/22 (13.64%) patients with the right pleural cavity. Chronic pancreatitis was diagnosed in 14/22 (63.64%) patients. Symptomatic pancreatic fluid collections were found in 15/22 (68.18%) patients with PPF (pancreatic pseudocyst in 11 and walled-off pancreatic necrosis in four patients). Endoscopic retrograde cholangiopancreatography was performed in 21/22 (95.45%) patients, confirming the diagnosis of PPF. All 21 patients underwent endoscopic sphincterotomy with prosthesis implantation in the main pancreatic duct (passive transpapillary drainage). In 1/22 (4.55%) patients, active transmural/transgastric drainage of the PPF was necessary due to inflammatory infiltration of the peripapillary region, precluding endoscopic pancreatography. Endoscopic transmural drainage was performed in all the 15 patients with pancreatic fluid collection. Clinical success was achieved in 21/22 (95.45%) patients. The mean total time of endotherapy was 191 (range 88-712) days. Long-term success of endoscopic treatment of PPFs during one year follow-up period was achieved in 19/22 (86.36%) patients.

CONCLUSIONS

Endoscopic treatment is effective for managing post-inflammatory PPFs. The preferred treatment method is passive transpapillary drainage (prosthesis of the main pancreatic duct). If transpapillary drainage is not feasible, transmural drainage of the PPF remains the preferred method. Endoscopic transmural drainage leads to closure of the fistula canal in patients with pancreatic fluid collection complicated by PPF.

Pancreatic resections for benign intraductal papillary mucinous neoplasms: Collateral damages from friendly fire

BACKGROUND

Surgical resection of intraductal papillary mucinous neoplasms is based on preoperative high-risk stigmata/worrisome features, but the risk of overtreatment remains high. The aim of this study was to evaluate surgical indications and perioperative and long-term complications in patients with low-grade intraductal papillary mucinous neoplasms.

METHODS

Patients who underwent surgical resection between 2009 and 2018 with a final histology of low-grade intraductal papillary mucinous neoplasms were included. Surgical indications, type of surgery, and short- and long-term outcomes were evaluated.

RESULTS

A significant decrease in the rate of patients resected for low-grade intraductal papillary mucinous neoplasms was observed (43.6% in 2009-2012 vs 27.8% in 2013-2018; P = .003), and 133 patients were finally included (62 women, median age: 68 years). Of these, 24.1% had 1 worrisome feature, 39.8% had ≥2 worrisome features, 18.8% had ≥1 high-risk stigmata, and 15.8% had ≥1 worrisome features + 1 high-risk stigmata. Overall surgical morbidity was 55.6%, 15.8% had Clavien-Dindo ≥3 complications, reoperation rate was 3.8%, and 90-day postoperative mortality was 1.5%. After a median follow-up of 60 months, 13 patients (11.5%) had a recurrence of benign intraductal papillary mucinous neoplasm in the pancreatic remnant, and 2 patients (1.8%) developed pancreatic ductal adenocarcinoma. After partial pancreatectomy, 51.3% of patients were taking pancreatic enzyme replacement therapy. Among nondiabetics, 26% developed diabetes after partial pancreatectomy, of which 38% were insulin-dependent. Eighteen patients (13.7%) developed incisional hernia.

CONCLUSION

Given the rates of morbidity and long-term complications after pancreatic resections, surgeons should attentively balance the true risks of intraductal papillary mucinous neoplasm degeneration with the risks of surgical resection in each patient.

Laparoscopic versus open pancreatoduodenectomy: an individual participant data meta-analysis of randomized controlled trials

BACKGROUND

Randomized trials have compared laparoscopic pancreatoduodenectomy (LPD) to open pancreatoduodenectomy (OPD) with conflicting results. An IPDMA may give more insight into the differences between LPD and OPD, and could identify high-risk subgroups.

METHODS

A systematic literature search was performed in the Pubmed, Embase, and the Cochrane library databases (October 2019). Out of 1410 studies, three randomized trials were identified. Primary outcome was major complications (Clavien-Dindo grade ≥ III). Subgroup analyses were performed for high-risk subgroups including patients with BMI of ≥25 kg/m2, pancreatic duct <3 mm, age ≥70 years, and malignancy.

RESULTS

Data from 224 patients were collected. After LPD, major complications occurred in 33/114 (29%) patients compared to 34/110 (31%) patients after OPD (adjusted odds ratio (OR) 0.62; 95% confidence interval (CI) 0.3-1.4, P = 0.257). No differences were seen for major complications and 90-day mortality LPD 8 (7%) vs OPD 4 (4%) (adjusted OR 0.2; 95% CI 0.02-1.3, P = 0.080). With LPD, operative time was longer (420 vs 318 min, p < 0.001) and hospital stay was shorter (mean difference -6.97 days). Outcomes remained stable in the high-risk subgroups.

CONCLUSION

LPD did not reduce the rate of major postoperative complications as compared to OPD. LPD increased operative time and shortened hospital stay with 7 days.

A clinical observational study on the application of enhanced recovery after laparoscopic pancreaticoduodenectomy

PURPOSE

The safety and feasibility of enhanced recovery after surgery (ERAS) for laparoscopic pancreaticoduodenectomy (LPD) are unclear. The aim of this retrospective clinical study was to evaluate the impact of ERAS protocols for LPD.

PATIENTS AND METHODS

Between March 2016 and December 2018, a total of 34 consecutive patients with ERAS for LPD were prospectively enrolled and compared with 68 consecutive patients previously treated for non-ERAS after LPD during an equal time frame. The intraoperative and postoperative data were collected and comparatively analyzed.

RESULTS

The mean length of postoperative hospital stay (15.8 ± 3.4 and 23.1 ± 5.1 days, P < 0.001) was reduced significantly in ER group than those in non-ER group. The operation time (462.7 ± 117.0 vs. 450.9 ± 109.8 min, P = 0.627) and intraoperative blood loss (523.5 ± 270.0 vs. 537.5 ± 241.8 ml, P = 0.800) were similar in the two groups. The complications (ER: 32.4% vs. non-ER: 35.3%, P > 0.05) and their severities (Clavien-Dindo grade ≥3 complications, 2 vs. 5 patients; P = 0.783) of patients with ERAS protocols were not increased. No difference in mortality and readmission rates was found. Finally, the total medical costs ($2.1 ± 0.7 × 104 and $2.3 ± 0.7 × 104, P = 0.017) in ER group were lower than those in non-ER group.

CONCLUSION

the ERAS is safe and effective in the perioperative period of LPD. It could effectively reduce the length of postoperative stay and medical costs, and does not increase the incidence of postoperative complications.

Personal predictive model based on systemic inflammation markers for estimation of postoperative pancreatic fistula following pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (PF) is a serious life-threatening complication after pancreaticoduodenectomy (PD). Our research aimed to develop a machine learning (ML)-aided model for PF risk stratification.

AIM

To develop an ML-aided model for PF risk stratification.

METHODS

We retrospectively collected 618 patients who underwent PD from two tertiary medical centers between January 2012 and August 2021. We used an ML algorithm to build predictive models, and subject prediction index, that is, decision curve analysis, area under operating characteristic curve (AUC) and clinical impact curve to assess the predictive efficiency of each model.

RESULTS

A total of 29 variables were used to build the ML predictive model. Among them, the best predictive model was random forest classifier (RFC), the AUC was [0.897, 95% confidence interval (CI): 0.370–1.424], while the AUC of the artificial neural network, eXtreme gradient boosting, support vector machine, and decision tree were between 0.726 (95%CI: 0.191–1.261) and 0.882 (95%CI: 0.321–1.443).

CONCLUSION

Fluctuating serological inflammatory markers and prognostic nutritional index can be used to predict postoperative PF.

The effect of duct width and pancreatic gland structure on pancreatic fistula rates in patients who underwent pancreaticoduodenectomy for pancreatic cancer

Introduction: One of the most important causes of morbidity in pancreaticoduodenectomy (PD) surgery is pancreatic anastomosis leakage. There is a possibility of pancreatic fistula even in the most experienced hands. After PD, pancreatic fistula occurs between 10% and 20% in various series. This study aims to evaluate the effects of pancreatic duct size and pancreatic tissue on the development of pancreatic fistula after PD is performed in our center. Material and Method: Pancreatic duct size was categorized as small &lt;3 mm and large &gt;3 mm. Pancreatic gland tissue was categorized as a soft, medium, and hard. These variables were calculated preoperatively with the help of computed tomography (CT), ultrasonography(USG), and Endoscopic ultrasound (EUS), and postoperative pathology results. It was accepted that the 24-hour flow rate of the drain behind the pancreatic anastomosis was more than 50 ml during 3 days after PD and/or the amylase concentration of the drain content measured at 3 different times was 3 times higher than the serum amylase concentration. Results: A total of 90 patients were included in the study, anastomotic leakage was not observed in 63 (70%) of 90 patients, and leakage was observed in 27 (30%) patients. The mean age was 71.22±10.78 years (p=0.615). There was no statistically significant difference between the ductus diameters between the two groups (p=0.240). There was no statistical difference between the groups formed according to pancreatic duct width. (p=0.059). It was observed that 60.3% of the patients in the non-leakage group had a hard appearance, and this rate was statistically significantly reduced to 29.6% in the patients with leakage (p=0.008). Conclusion: In summary, our study showed that pancreatic fistula after PD is associated with soft pancreatic parenchyma. The surgeon should consider this risk factor when performing a PD and be more careful to reduce the rate of pancreatic fistula.

Prophylactic abdominal drainage or no drainage after distal pancreatectomy (PANDORINA): a binational multicenter randomized controlled trial

BACKGROUND

Prophylactic abdominal drainage is current standard practice after distal pancreatectomy (DP), with the aim to divert pancreatic fluid in case of a postoperative pancreatic fistula (POPF) aimed to prevent further complications as bleeding. Whereas POPF after pancreatoduodenectomy, by definition, involves infection due to anastomotic dehiscence, a POPF after DP is essentially sterile since the bowel is not opened and no anastomoses are created. Routine drainage after DP could potentially be omitted and this could even be beneficial because of the hypothetical prevention of drain-induced infections (Fisher, Surgery 52:205-22, 2018). Abdominal drainage, moreover, should only be performed if it provides additional safety or comfort to the patient. In clinical practice, drains cause clear discomfort. One multicenter randomized controlled trial confirmed the safety of omitting abdominal drainage but did not stratify patients according to their risk of POPF and did not describe a standardized strategy for pancreatic transection. Therefore, a large pragmatic multicenter randomized controlled trial is required, with prespecified POPF risk groups and a homogeneous method of stump closure. The objective of the PANDORINA trial is to evaluate the non-inferiority of omitting routine intra-abdominal drainage after DP on postoperative morbidity (Clavien-Dindo score ≥ 3), and, secondarily, POPF grade B/C.

METHODS/DESIGN

Binational multicenter randomized controlled non-inferiority trial, stratifying patients to high and low risk for POPF grade B/C and incorporating a standardized strategy for pancreatic transection. Two groups of 141 patients (282 in total) undergoing elective DP (either open or minimally invasive, with or without splenectomy). Primary outcome is postoperative rate of morbidity (Clavien-Dindo score ≥ 3), and the most relevant secondary outcome is grade B/C POPF. Other secondary outcomes include surgical reintervention, percutaneous catheter drainage, endoscopic catheter drainage, abdominal collections (not requiring drainage), wound infection, delayed gastric emptying, postpancreatectomy hemorrhage as defined by the international study group for pancreatic surgery (ISGPS) (Wente et al., Surgery 142:20-5, 2007), length of stay (LOS), readmission within 90 days, in-hospital mortality, and 90-day mortality.

DISCUSSION

PANDORINA is the first binational, multicenter, randomized controlled non-inferiority trial with the primary objective to evaluate the hypothesis that omitting prophylactic abdominal drainage after DP does not worsen the risk of postoperative severe complications (Wente etal., Surgery 142:20-5, 2007; Bassi et al., Surgery 161:584-91, 2017). Most of the published studies on drain placement after pancreatectomy focus on both pancreatoduodenectomy and DP, but these two entities present are associated with different complications and therefore deserve separate evaluation (McMillan et al., Surgery 159:1013-22, 2016; Pratt et al., J Gastrointest Surg 10:1264-78, 2006). The PANDORINA trial is innovative since it takes the preoperative risk on POPF into account based on the D-FRS and it warrants homogenous stump closing by using the same graded compression technique and same stapling device (de Pastena et al., Ann Surg 2022; Asbun and Stauffer, Surg Endosc 25:2643-9, 2011).

USE of Biodegradable STENTS in Pancreaticoduodenectomy: Initial Experience

Background. Plastic stents have been used to avoid postoperative pancreatic fistula (POPF) following Whipple's Pancreaticoduodenectomy (WPD), but they may cause some stent-related complications. Biodegradable stents have been recently introduced and might be a safe alternative. Here we present our initial experience with their use. Methods. Between March 1, 2020, and September 30, 2020, ten (10) consecutive patients underwent WPD. They all had conventional two-layer pancreaticojejunostomy with the placement of an internal biodegradable stent. They were assessed for technical feasibility, pancreatic leak, and stent-related complications. Results. The use of biodegradable stents was technically feasible in all patients, despite some difficulties in insertion due to stent stiffness and design. After a median follow-up period of 124 days, none of the patients suffered POPF. One patient had a biochemical pancreatic leak with no clinical significance. The median hospital stay was 7 days, and there were no stent-related complications. Conclusion. Biodegradable stents are technically feasible and safe in WPD with good short-term outcomes. They might provide a better alternative to plastic stents and their potential complications. Larger long-term studies are needed to validate efficacy and safety. Few modifications of the stent's design might be needed to facilitate use in open surgery.

Advantage of endoscopic papillectomy for ampullary tumors as an alternative treatment for pancreatoduodenectomy

Endoscopic papillectomy for early ampullary tumors is considered a minimally invasive and useful alternative to pancreatoduodenectomy; however, its indications remain unclear. This study aimed to clarify the advantages of endoscopic papillectomy by investigating the clinical outcomes of patients who underwent endoscopic papillectomy or pancreatoduodenectomy for early ampullary tumors. Patients diagnosed with early ampullary tumors (adenoma, Tis, T1a) who underwent endoscopic papillectomy or pancreatoduodenectomy between June 2008 and October 2019 were included, and their clinical outcomes were analyzed. Seventy-four patients (34 patients with adenomas and 40 patients with adenocarcinomas) were divided into two groups, namely endoscopic papillectomy (n = 43) and pancreatoduodenectomy (n = 31). The estimated 5-year overall survival rate of all early ampullary tumors was 92%. Complete resection rate was significantly lower for endoscopic papillectomy patients versus pancreatoduodenectomy patients (48.8% vs. 100%; p < 0.001). Recurrence was more common in the endoscopic papillectomy group compared to the pancreatoduodenectomy group (16.3% vs. 3.2%; p = 0.128), but all recurrences were controllable by endoscopic treatment. The median length of hospital stay for the endoscopic papillectomy group was significantly shorter compared to the endoscopic papillectomy group (11 days vs. 42 days; p < 0.001). The Comprehensive Complication Index was significantly lower in the endoscopic papillectomy group compared to the pancreatoduodenectomy group (14.8 vs 22.6%; p = 0.002). Endoscopic papillectomy for early ampullary tumors is useful and may be an alternative treatment for pancreatoduodenectomy in selected cases.

A Multicenter, Randomized, Double-Blinded, Clinical Trial Comparing Cattell-Warren and Blumgart Anastomoses Following Partial Pancreatoduodenectomy: PANasta Trial

Whether a Blumgart anastomosis (BA) is superior to Cattell-Warren anastomosis (CWA) in terms of postoperative pancreatic fistula (POPF) following pancreatoduodenectomy.

Importance

Complications driven by POPF following pancreatic cancer resection may hinder adjuvant therapy, shortening survival. BA may reduce complications compared to CWA, improving the use of adjuvant therapy and prolonging survival.

Methods

A multicenter double-blind, controlled trial of patients undergoing resection for suspected pancreatic head cancer, randomized during surgery to a BA or CWA, stratified by pancreatic consistency and duct diameter. The primary end point was POPF, and secondary outcome measures were adjuvant therapy use, specified surgical complications, quality of life, and survival from the date of randomization. For a 10% POPF reduction, 416 patients were required, 208 per arm (two-sided α = 0·05; power = 80%).

Results

Z-score at planned interim analysis was 0.474 so recruitment was held to 238 patients; 236 patients were analyzed (112 BA and 124 CWA). No significant differences in POPF were observed between BA and CWA, odds ratio (95% confidence interval [CI]) 1·04 (0.58-1.88), P = 0.887, nor in serious adverse events. Adjuvant therapy was delivered to 98 (62%) of 159 eligible patients with any malignancy; statistically unrelated to arm or postoperative complications. Twelve-month overall survival, hazard ratio (95% CI), did not differ between anastomoses; BA 0.787 (0.713-0.868) and CWA 0.854 (0.792-0.921), P = 0.266, nor for the 58 patients with complications, median (IQR), 0.83 (0.74-0.91) compared to 101 patients without complications 0.82 (0.76-0.89) (P = 0.977).

Conclusions

PANasta represents the most robust analysis of BA versus CWA to date.

Pure biliary leak vs. pancreatic fistula associated: non-identical twins following pancreatoduodenectomy

BACKGROUND

Biliary leak (BL) after pancreatoduodenectomy (PD) may have diffrent severity depending on its association with postoperative pancreatic fistula (POPF).

METHODS

Data of 2715 patients undergoing PD between 2011 and 2020 at two European third-level referral Centers for pancreatic surgery were retrospectively reviewed. These included BL incidences, grading, outcomes, specific treatments, and association with POPF.

RESULTS

BL occurred in 6% of patients undergoing PD. Among 143 BL patients, 47% had an associated POPF and 53% a pure BL. Major morbidity (64% vs 36%) and mortality (19% vs 4%) were higher in POPF-associated BL group (all P< 0.01). Day of BL onset was similar between groups (POD 2 vs 3; P = 0.2), while BL closure occurred earlier in pure BL (POD 12 vs 23; P < 0.01). Conservative treatment was more frequent (55% vs 15%; P < 0.01), and the rate of percutaneous and/or trans-hepatic drain placement was lower (30% vs 16%; P = 0.04) in pure BL group. Relaparotomy was more common in POPF-associated BL group (42% VS 17%; P < 0.01) but was performed earlier in pure BL (POD 2 vs 10; P = 0.02).

CONCLUSIONS

Pure BL represents a more benign entity, managed conservatively in half of the cases.

"Impact of Preoperative Biliary Drainage in Patients Undergoing Pancreaticoduodenectomy" - a Prospective Comparative Study from a Tertiary Care Centre in India

Preoperative biliary drainage (PBD) was primarily introduced to reduce perioperative complications following hepato-pancreato-biliary surgeries. There is no proper consensus on the routine use of PBD before pancreaticoduodenectomy (PD). This is a prospective observational study of patients who underwent PD between July 2013 and December 2014. The study group was divided into two groups based on whether a preoperative biliary drainage was performed or not. The intraoperative and postoperative complications were compared among the two groups. A total of 59 patients, predominantly males (64.4%) with a median age of 58 years, were included in study. All except 5 (8.5%) had undergone PD for periampullary malignancy. Thirty-eight patients (64.4%) underwent an upfront PD and the remaining 21 (35.5%) had undergone PBD. Cholangitis was the indication for PBD in all patients. The mean operative time (307.89 ± 52.51 min vs. 314.29 ± 36.273; p value = 0.62) and postoperative complications like delayed gastric emptying (63.2% vs. 61.9%; p value-0.924), postoperative pancreatic fistula (21.1% vs. 33.3%; p value 0.3), post-pancreaticoduodenectomy haemorrhage (5.3% vs. 9.5%; p value-0.611) and mean in-hospital stay were comparable among two groups. Even though the incidence of positive intraoperative bile cultures is significantly higher among the stented group (95.2% vs. 26.3%; p value = 0.0), no significant difference in surgical site infections (47.6% vs. 28.9%; p value 0.152) was noted. The overall mortality was 1.7% (1/59; grade C PPH). This study showed no significant difference in the postoperative complications following PBD despite increase in bile culture positivity. However, notable differences in the spectrum of microbial growths between stented and non-stented groups were observed.

Quality assurance and quality control in surgical oncology

Even though surgery has remained a key component within multi-disciplinary cancer care, the expectations have changed. Instead of serving as a modality to free a patient of a mass at all means and at the risk of high morbidity, modern cancer surgery is expected to provide adequate tumor clearance with lowest invasiveness. This review summarizes the evidence on quality assurance in surgical oncology and gives a comprehensive overview of quality improvement tools.

Impact of Patient Age on Postoperative Short-Term and Long-Term Outcome after Pancreatic Resection of Pancreatic Ductal Adenocarcinoma

(1) Purpose: to evaluate the impact of age on postoperative short-term and long-term outcomes in patients undergoing curative pancreatic resection for PDAC. (2) Methods: This retrospective single-center study comprised 213 patients who had undergone primary resection of PDAC from January 2000 to December 2018 at the University Hospital of Erlangen, Germany. Patients were stratified according the age into two groups: younger (≤70 years) and older (>70 years) patients. Postoperative outcome and long-term survival were compared between the groups. (3) Results: There were no significant differences regarding inhospital morbidity (58% vs. 67%, p = 0.255) or inhospital mortality (2% vs. 7%, p = 0.073) between the two groups. The median overall survival (OS) and disease-free survival (DFS) were significantly shorter in elderly patients (OS: 29.2 vs. 17.1 months, p < 0.001, respectively; DFS: 14.9 vs. 10.4 months, p = 0.034). Multivariate analysis revealed that age was a significant independent prognostic predictor for OS and DFS (HR 2.23, 95% CI 1.58−3.15; p < 0.001 for OS and HR 1.62, 95% CI 1.17−2.24; p = 0.004 for DFS). (4) Conclusion: patient age significantly influenced overall and disease-free survival in patients with PDAC undergoing primary resection in curative intent.

A comparison of surgical approaches in the treatment of grade C postoperative pancreatic fistula: A retrospective study

Background

Postoperative pancreatic fistula is one of the most dreaded complications following pancreatic resections with Grade C the most severe. Several possible types of surgical intervention are available but to date, none of them have clearly shown superiority. This study aims to compare different surgical approaches.

Methods

A retrospective analysis of patients who underwent revision surgery for postoperative pancreatic fistula between 2008 and 2020 was performed. Three surgical approaches were compared: open drainage; a disconnection of the pancreaticojejunostomy; and salvage total pancreatectomy. The data of nine monitored parameters were collected. Selected parameters were statistically analyzed and compared.

Results

A total of 54 patients were included. Eighteen patients underwent open drainage, 28 had disconnections of the pancreaticojejunostomy and eight had salvage total pancreatectomy. Statistically significant differences were observed in the time of Intensive Care Unit stay, the number of surgical interventions, 90-day mortality, the number of administered blood transfers and treatment costs. Open drainage showed to be superior in each category. The difference in long-term survival also slightly favored simple drainage.

Conclusion

Open drainage procedure showed to be superior to other types of interventions in most of the monitored parameters. Disconnection of the pancreaticojejunostomy and a salvage total pancreatectomy had similar results, which correlated with the surgical burden of these interventions.

Postoperative Pancreatic Fistula Following Traumatic Splenectomy: A Morbid and Costly Complication

INTRODUCTION

Development of clinically relevant postoperative pancreatic fistula (CR-POPF) in adult splenectomies following trauma occur in 1%-3% of cases. We hypothesized that the use of sutures in splenic hilum ligation compared to staples was associated with a reduced rate of CR-POPF incidence.

METHODS

Adult trauma patients (age ≥17 y) that underwent nonelective splenectomy from 2010 to 2020 were retrospectively evaluated from the trauma registries of all three adult level 1 trauma centers in Indiana. Patients were excluded if they were pregnant, currently incarcerated, expired within 72 h of admission, or had a pancreatic injury diagnosed preoperatively or intraoperatively. A Firth logistic regression using a penalized-maximum likelihood estimate for rare events was used for univariate predictive modeling (SPSS 28.0) of surgical technique on CR-POPF development.

RESULTS

Four hundred nineteen adult splenectomies following trauma were conducted; 278 were included. CR-POPF developed in 14 cases (5.0%). Sutures alone were used in 200 cases: seven developed CR-POPF (3.5%). Staples alone or in combination with sutures were used in 74 cases: seven developed CR-POPF (9.5%). There was no statistically significant difference between the use of sutures alone compared to the use of staples alone (P = 0.123) or in combination (P = 0.100) in CR-POPF incidence.

CONCLUSIONS

Our 10-y retrospective review of CR-POPF finds the complication to be rare but morbid. This study was underpowered to show any difference in surgical technique. However, we do propose a new institutional norm that CR-POPF develop in 5% of splenectomies after trauma and conclude that further study of optimal technique for emergent splenectomy is warranted.

Analysis of preoperative risk factors for early recurrence after curative pancreatoduodenectomy for resectable pancreatic adenocarcinoma

Objectives

To investigate the risk factors for early recurrence after curative pancreatoduodenectomy for resectable pancreatic ductal adenocarcinoma.

Methods

All data were retrospectively collected from patients with resectable pancreatic ductal adenocarcinoma who had undergone pancreatoduodenectomy at the Department of Surgery, Phramongkutklao Hospital, from January 2015 to December 2020. The preoperative and perioperative risk factors were included into the analysis.

Results

In total, 34 patients were included in the study. The median time for recurrence and median survival time were 17 and 20 months, respectively. The 1, 3, and 5 year disease-free survival rates were 59.6%, 23.87%, and 23.87%, respectively, while the 1, 3, and 5 year overall survival rates were 81%, 24.7%, and 12.4%, respectively. Seventeen patients (50%) from a total of 34 patients had recurrence, and ten patients (29.41%) had recurrence within 12 months. The independent preoperative risk factor associated with adverse disease-free survival was tumor size > 4 cm (hazard ratio [HR], 14.34, p=0.022). The perioperative risk factors associated with adverse disease-free survival were pathological lymphovascular invasion (HR, 4.31; p=0.048) and non-hepatopancreatobiliary surgeon (HR, 5.9; p=0.022). Risk factors associated with poor overall survival were microscopical margin positive (R1) resection (HR, 3.68; p=0.019) and non-hepatopancreatobiliary surgeon (HR, 3.45; p=0.031).

Conclusions

Tumor size > 4 cm from the preoperative imaging study was a poor prognostic factor for early recurrence after curative pancreatoduodenectomy for resectable pancreatic adenocarcinoma indicated that they may have radiological occult metastasis, thus, staging laparoscopy may reduce the number of unnecessary laparotomies and avoid missing radiologically negative metastases.

The pancreas-to-muscle signal intensity ratio on T1-weighted MRI as a predictive biomarker for postoperative pancreatic fistula after distal pancreatectomy: a single-center retrospective study

BACKGROUND

Postoperative pancreatic fistula (POPF) is one of the serious complications of pancreatic surgery. When POPF occurs and becomes severe, it causes secondary complications and a longer treatment period. We previously reported a correlation between pancreatic fibrosis and magnetic resonance imaging (MRI) findings, and MRI may have the potential to predict POPF. This study aimed to assess the predictive ability of the pancreas-to-muscle signal intensity ratio on T₁-weighted MRI (SIR on T₁-w MRI) for POPF after distal pancreatectomy (DP).

METHODS

This single-institution retrospective study comprised 117 patients who underwent DP. It was conducted between 2010 and 2021 at the Gifu University Hospital. We statistically analyzed pre-, intra-, and postoperative factors to assess the correlation with POPF.

RESULTS

According to the definition and grading of the International Study Group of Pancreatic Fistula (ISGPF), 29 (24.8%) of the 117 patients had POPF grades B and C. In the univariate analysis, POPF was significantly associated with the pancreas-to-muscle SIR on T₁-w MRI, the drainage fluid amylase concentration (D-Amy) levels on postoperative day (POD) 1 and 3, white blood cell count on POD 1 and 3, C-reactive protein level on POD 3, and heart rate on POD 3. In multivariate analysis, only the pancreas-to-muscle SIR on T₁-w MRI (>1.37; odds ratio [OR] 23.25; 95% confidence interval [CI] 3.93-454.03; p < 0.01) and D-Amy level on POD 3 (>737 U/l; OR 3.91; 95% CI 1.02-16.36; p = 0.046) were identified as independent predictive factors.

CONCLUSIONS

The pancreas-to-muscle SIR on T₁-w MRI and postoperative D-Amy levels were able to predict the development of POPF after DP. The pancreas-to-muscle SIR on T₁-w MRI may be a potential objective biomarker reflecting pancreatic status.

Hyperamylasemia grade versus drain fluid amylase: which better predicts pancreatectomy outcomes?

BACKGROUND

The clinical importance of postoperative hyperamylasemia (POHA) grade is unknown. Our objectives were to evaluate the association of POHA grade with clinically relevant postoperative pancreatic fistula (CR-POPF) and compare its prognostic utility against postoperative day 1 drain fluid amylase (DFA-1).

METHODS

Patients who underwent pancreatectomy from January 2019 through March 2020 were identified in the ACS NSQIP pancreatectomy-targeted dataset. POHA grade was assigned using post-operative serum amylase and clinical sequelae. The primary outcome was CR-POPF within 30 days. The association of POHA grade with CR-POPF was assessed using multivariable logistic regression, and c-statistics were used to compare POHA grade versus DFA-1.

RESULTS

POHA occurred in 520 patients at 98 hospitals, including 261 (50.2%) with grade A, 234 (45.0%) with grade B, and 25 (4.8%) with grade C POHA. CR-POPFs were increased among patients with grade B (66.2%, OR 9.28 [5.84-14.73]) and C (68.0%, OR 10.50 [3.77-29.26]) versus grade A POHA (19.2%). POHA-inclusive models better predicted CR-POPF than those with DFA-1 alone (p < 0.002) and models with both predictors outperformed POHA alone (p = 0.039).

CONCLUSION

POHA grade represents a measure of post-pancreatectomy outcomes that predicts CR-POPF and outperforms DFA-1 but must be aligned with new international definitions.

Comparison of splenic vessel preserving distal pancreatectomy and the Warshaw technique for solid pseudopapillary neoplasm in children

PURPOSE

Spleen-preserving distal pancreatectomy (SPDP) such as splenic vessel preservation (SVP) for solid pseudopapillary neoplasms (SPNs) in the body or tail of the pancreas in children prevents post-splenectomy infection and hematologic disorders. However, SVP could be technically challenging, and the Warshaw technique (WT) could be an alternative technique that has been reported to be safe and effective in adults. We, therefore, compared the perioperative outcomes of SVP and WT in pediatric patients.

METHODS

We retrospectively reviewed the medical records of pediatric patients with SPN who underwent SPDP using SVP or WT between November 2002 and November 2018 at a large-sized tertiary referral center.

RESULTS

Twenty-eight patients were included. Sixteen (57.1%) patients underwent SVP and 12 (42.9%) patients underwent WT. There were no significant differences in the baseline characteristics between the two groups. Postoperative complications occurred in 8 patients each in the SVP (50%), and the WT (66.7%) groups. Two (12.5%) in the SVP group and 1 (8.3%) in the WT group required additional intervention. During a median follow-up duration of 49 months, there were no significant differences in the incidence of splenic infarctions or perigastric varices between the two groups.

CONCLUSIONS

There were no significant differences in the surgical outcomes between WT and SVP in pediatric patients with SPN. WT could be a safe and feasible alternative technique for SVP in challenging cases.

Long Term Results of Pancreatectomy With and Without Venous Resection: A Comparison of Safety and Complications of Spiral Graft, End-to-End and Tangential/Patch Reconstruction Techniques

OBJECTIVE

Roughly 10% - 20% of pancreatic cancer patients are candidates for curative intent surgical treatment. In the 2000s, many studies showed similar survival rates comparing pancreatic surgery with or without vein resection and reconstruction. The aim was to identify the best method of venous reconstruction.

METHODS

This was a retrospective cohort study. A total of 1 375 patients undergoing pancreatectomy between 2005 and 2018 were identified. Patients undergoing a combined pancreatic resection and venous reconstruction were included retrospectively. When tumour infiltration to the portal/superior mesenteric vein was detected, excision and reconstruction with tangential suturing/patch, end to end anastomosis, or a spiral graft from the great saphenous vein was performed. Next, 90 day and long term survival and outcomes across reconstruction techniques were analysed.

RESULTS

Overall, 198 patients had venous involvement visible in pre-operative scans or detected during surgery, broken down as follows: 171 (86%) pancreaticoduodenectomy, 12 (6%) total pancreatectomy, and 15 (8%) distal pancreatectomy. In total, 69 (35%) spiral graft reconstructions, 77 (39%) end to end anastomoses, and 52 (26%) tangential/patch reconstructions were performed. Tumour histology revealed pancreatic adenocarcinomas in 162 (82%) patients, intraductal mucinous pancreatic neoplasia in 14 (7%), cholangiocarcinoma in five (3%), neuro-endocrine neoplasia in nine (5%), and eight other diagnoses. Overall, 183 (92%) were malignant and 15 (8%) benign. Two patients died within 90 days, one in hospital and one on post-operative day 38 due to thrombosis of the superior mesenteric vein and intestinal necrosis, a Clavien-Dindo grade 5 complication. In addition, 50 (23%) patients had Clavien-Dindo grade 3 - 4 complications. No differences in complications comparing vein reconstruction techniques or in the long term survival of pancreatectomy patients with or without venous reconstruction were detected.

CONCLUSION

The spiral graft technique, used when more advanced venous infiltration occurs, does not increase complications, with outcomes mirroring those accompanying shorter venous resections.

Time to Surgery Does Not Affect Overall or Disease-Free Survival of Patients with Primary Resectable PDAC

(1) Background: Delay in therapy for pancreatic ductal adenocarcinoma (PDAC) may contribute to a worse outcome. The aim of this study was to investigate the prognostic value of time from diagnosis to surgery in patients undergoing upfront surgery for primarily resectable pancreatic carcinoma. (2) Methods: This retrospective single-center study included 214 patients who underwent primary resection of PDAC from January 2000 to December 2018 at University Hospital Erlangen. Using a minimum p-value approach, patients were stratified according to time to surgery (TtS) into two groups: TtS ≤ 23 days and TtS > 23 days. Postoperative outcome and long-term survival were compared. (3) Results: Median TtS was 25 days. The best cut-off for TtS was determined as 23 days. There were no differences regarding postoperative outcome or overall survival (OS) and disease-free survival (DFS) (OS: 23.8 vs. 20.4 months, p = 0.210, respectively, and DFS: 15.8 vs. 13.6 months, p = 0.187). Multivariate analysis revealed age, lymph node metastasis, tumor differentiation and resection status as significant independent prognostic predictors for OS and DFS. (4) Conclusions: A delay of surgery > 23 days after first diagnosis does not affect overall or disease-free survival of patients with primary resectable PDAC. However, the psychological impact of a delay to patients waiting for surgery should not be underestimated.

Delayed Gastric Emptying Does Not Influence Cancer-Specific Survival after Pancreatoduodenectomy for Pancreatic Ductal Adenocarcinoma

Background: Delayed gastric emptying (DGE) remains the most frequent complication following pancreatoduodenectomy (PD). The present study investigates the influence of delayed gastric emptying on cancer-specific survival after PD. Methods: We included 267 patients who underwent PD between 2014 and 2021. They were analyzed regarding demographic factors, pre- and perioperative characteristics, surgical complications, and long-term survival. Results: Patients with a higher Charlson Comorbidity Index (CCI) or pre-existing pulmonary disease suffered significantly more from DGE. When experiencing PPH, a prolonged hospital stay, or major overall complications (Clavien-Dindo °III-V) were more common in the DGE group. Tumor size over 3 cm negatively affected survival. Conclusions: DGE has no influence on long-term survival in PDAC patients, although it prolongs hospital stay.

Pancreatic juice outflow in pancreatojejunostomy monitoring with the inter-anastomosis drainage tube; a retrospective observational study

BACKGROUND

Pancreatic fistula remains the biggest problem in pancreatic surgery. We have previously reported a new pancreatojejunostomy method using an inter-anastomosis drainage (IAD) suction tube with Blumgart anastomosis for drainage of the pancreatic juice leaking from the branched pancreatic ducts. This study aimed to evaluate the postoperative outcomes of our novel method, in pancreatojejunostomy and investigate the nature of the inter-anastomosis space between jejunal wall and pancreas parenchyma.

METHODS

This retrospectively study consist of 282 pancreatoduodenectomy cases, including 86 reconstructions via the Blumgart method plus IAD (B + IAD group) and 196 cases reconstructed using the Blumgart method alone (B group). Postoperative outcomes and the amylase value and the volume of the drainage fluids were compared between the two groups. The IAD tube was placed to collect amylase-rich fluid from the inter-anastomosis space during operative procedure between the jejunal wall and pancreatic stump.

RESULTS

The daily IAD drainage volume and the amylase level was significantly higher in patients with a soft pancreas (vs hard pancreas; 16.5 vs. 10.0 mL/day, p = 0.012; 90,900 vs. 1634 IU/L, p < 0.001, respectively). The mean amylase value of IAD collection in 86 cases of B + IAD group was 63,100 IU/L. The incidence of clinically relevant pancreatic fistula grade B and C (23.2% vs. 23.0%, p = 0.55) and the hospital stay was similar between the groups (median 17 vs. 18 days, p = 0.55). In 176 patients with soft pancreas, the incidence of pancreatic fistula grade B and C (33.3% vs. 35.3%, p = 0.67) and the hospital stay was also similar between the groups (median 22.5 vs. 21 days, p = 0.81).

CONCLUSIONS

Positive effect of the IAD method observed in the pilot cases was not reproduced in the current study. IAD tube objectively demonstrated the existence of amylase-rich discharge at the anastomosis site, and countermeasures to eliminate this liquid are highly desired for preventing pancreatic fistula, especially in patients with soft pancreatic texture. Trial registration Retrospectively registered.

Delayed gastric emptying after classical Whipple or pylorus-preserving pancreatoduodenectomy: a randomized clinical trial (QUANUPAD)

PURPOSE

Pylorus-preserving pancreatoduodenectomy (PPPD) has been the gold standard for pancreatic head lesion resection for several years. Some studies have noted that it involves more delayed gastric emptying (DGE) than classical Whipple (i.e., pancreatoduodenectomy with antrectomy). Our working hypothesis was that the classical Whipple has a lower incidence of DGE. We aimed to compare the incidence of DGE among pancreatoduodenectomy techniques.

METHODS

This pragmatic, randomized, open-label, single-center clinical trial involved patients who underwent classical Whipple (study group) or PPPD (control group). Gastric emptying was clinically evaluated using scintigraphy. DGE was defined according to the International Study Group of Pancreatic Surgery (ISGPS) criteria. The secondary endpoints were postoperative morbidity, length of hospital stay, anthropometric measurements, and nutritional status.

RESULTS

A total of 84 patients were randomized (42 per group). DGE incidence was 50% (20/40, 95% confidence interval (95% CI): 35-65%) in the study group and 62% (24/39, 95% CI: 46-75%) in the control group (p = 0.260). No differences were observed between both groups regarding postoperative morbidity or length of hospital stay. Anthropometric measurements at 6 months post-surgery: triceps fold measurements were 12 mm and 16 mm (p = 0.021). At 5 weeks post-surgery, triceps fold measurements were 13 mm and 16 mm (p = 0.020) and upper arm circumferences were 26 cm and 28 cm (p = 0.030). No significant differences were observed in nutritional status.

CONCLUSION

DGE incidence and severity did not differ between classical Whipple and PPPD. Some anthropometric measurements may indicate a better recovery with PPPD.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03984734.

Redo pancreaticojejunal anastomosis for late-onset complete pancreaticocutaneous fistula after pancreaticojejunostomy

BACKGROUND

Pancreaticojejunal (PJ) anastomosis occasionally fails several months after pancreaticoduodenectomy (PD) with Child reconstruction and can ultimately result in a late-onset complete pancreaticocutaneous fistula (Lc-PF). Since the remnant pancreas is an isolated segment, surgical intervention is necessary to create internal drainage for the pancreatic juice; however, surgery at the previous PJ anastomosis site is technically challenging even for experienced surgeons. Here we describe a simple surgical procedure for Lc-PF, termed redo PJ anastomosis, which was developed at our facility.  METHODS: Between January 2008 and December 2020, six consecutive patients with Lc-PF after PD underwent a redo PJ anastomosis, and the short- and long-term clinical outcomes have been evaluated. The abdominal cavity is carefully dissected through a 10-cm midline skin incision, and the PJ anastomosis site is identified using a percutaneous drain through the fistula tract as a guide, along with the main pancreatic duct (MPD) stump on the pancreatic stump. Next, the pancreatic stump is deliberately immobilized from the dorsal plane to prevent injury to the underlying major vessels. After fixing a stent tube to both the MPD and the Roux-limb using two-sided purse-string sutures, the redo PJ anastomosis is completed using single-layer interrupted sutures. Full-thickness pancreatic sutures are deliberately avoided by passing the needle through only two-thirds of the anterior side of the pancreatic stump.

RESULTS

The redo PJ anastomosis was performed without any intraoperative complications in all cases. The median intraoperative bleeding and operative time were 71 (range 10-137) mL and 123 (range 56-175) min, respectively. Even though a new mild pancreatic fistula developed postoperatively in all cases, it could be conservatively treated within 3 weeks, and no other postoperative complications were recorded. During the median follow-up period of 92 (range 12-112) months, no complications at the redo PJ anastomosis site were observed.

CONCLUSIONS

This research shows that the redo PJ anastomosis for Lc-PF we developed is a safe, feasible, and technically no demanding procedure with acceptable short- and long-term clinical outcomes. This procedure has the potential to become the preferred treatment strategy for Lc-PF after PD.

Does pancreatic duct stent placement lead to decreased postoperative pancreatic fistula rates after pancreaticoduodenectomy? A meta-analysis

PURPOSE

To evaluate the effectiveness of pancreatic duct stent placement for preventing postoperative pancreatic fistula after pancreaticoduodenectomy.

METHODS

PubMed, the Cochrane Central Register of Controlled Trials, Embase and ClinicalTrials.gov databases were searched up to February 26, 2022. Studies comparing outcomes following pancreaticoduodenectomy with or without pancreatic duct stents were included. The primary outcome measured was postoperative pancreatic fistula rate, and secondary outcomes were in-hospital mortality rate, reoperation rate, delayed gastric emptying rate and wound infection rate.

RESULTS

Seven RCTs involving 847 patients met the inclusion criteria. No statistically significant difference between the stent group and non-stent group was detected in the incidence of postoperative pancreatic fistula (RR = 0.85, 95%CI: 0.57-1.26, P = 0.41), in-hospital mortality, reoperation, delayed gastric emptying rate and wound infection. Subgroup analyses revealed that use of an external stent significantly reduced the incidence of pancreatic fistula (RR = 0.61, 95%CI: 0.43-0.86, P = 0.005).

CONCLUSIONS

Our preliminary results from this systematic review and meta-analysis revealed that pancreatic duct stents did not reduce the risk of POPF and other complications after pancreaticoduodenectomy compared with no stents. External stents were associated with a reduced POPF rate compared with no stents. Large-scale RCTs are required to assess the effectiveness and assist in clarifying the real role of pancreatic duct stents with respect to the POPF rates after pancreaticoduodenectomy.

Early Predictive Factors for Postoperative Pancreatic Fistula After Distal Pancreatectomy for Pancreatic Cancer

BACKGROUND/AIM

Postoperative pancreatic fistula (POPF) is the most serious complication of distal pancreatectomy (DP). When POPF occurs and becomes severe, it causes secondary complications and leads to a longer treatment period. This study aimed to identify early predictive factors of POPF after DP for pancreatic cancer (PC).

PATIENTS AND METHODS

This retrospective, single-institution study comprised of 55 patients with PC who underwent DP between 2010 and 2021 at the Gifu University Hospital. We statistically analyzed pre-, intra-, and post-operative factors to identify early predictive factors for POPF.

RESULTS

According to the definition and grading of the International Study Group of Pancreatic Fistula (ISGPF), 12 (21.8%) of 55 patients had POPF grades B and C. In the univariate analysis, POPF was significantly associated with the pancreas-to-muscle signal intensity ratio on T ₁ -weighted magnetic resonance imaging (SIR on T ₁ -w MRI), the drainage fluid amylase (D-Amy) levels on postoperative day 3 (POD3), C-reactive protein (CRP) on POD3, and heart rate on POD3. In multivariate analysis, pancreas-to-muscle SIR on T ₁ -w MRI [>1.37; odds ratio (OR)=17.08; 95% confidence interval (CI)=1.64-598.16; p=0.02], D-Amy levels on POD3 (>1,200 U/l; OR=20.00; 95% CI=1.73-563.83; p=0.02) and heart rate on POD3 (>100 bpm; OR=15.33; 95% CI=1.53-258.45; p=0.02) were identified as independent early predictive factors.

CONCLUSION

Preoperative pancreas-to-muscle SIR on T ₁ -w MRI and postoperative D-Amy levels and heart rate significantly correlated with POPF after DP for PC. Postoperative management based on these predictive factors may improve the postoperative course.

Day of surgery and mortality after pancreatoduodenectomy: A retrospective analysis of 29 270 surgical cases of pancreatic head cancer from Japan

BACKGROUND/PURPOSE

The day of the week can impact medical treatment outcomes; however, few large-scale, disease-specific studies have focused on the association between the day of the week and mortality in patients after pancreatoduodenectomy for pancreatic head cancer.

METHODS

Data were obtained from the National Clinical Database. Twenty-two clinical variables were adopted for hierarchal logistic regression modeling to determine adjusted odds ratios (ORs) for surgical mortality after elective pancreatoduodenectomy.

RESULTS

The 30-day mortality and surgical mortality rates were 1.0% and 1.7%, respectively (n = 29 720). Surgeries were performed the least on Fridays (13.4%) compared with other weekdays. Crude rates of severe postoperative complications (mean, 14.1%; range, 13.5%-14.8%) and pancreatic fistulas (mean, 10.0%; range, 9.6%-10.3%) remained stable throughout the week. Unadjusted/adjusted ORs did not significantly differ between Friday and Monday (0.868, 95% CI: 0.636-1.173, P = .365, and 0.928, 95% CI: 0.668-1.287, P = .653, respectively), and results were similar for the remaining weekdays. Nineteen independent factors were associated with surgical mortality.

CONCLUSIONS

The rate of perioperative mortality for elective pancreatoduodenectomy is low in Japan, with no evidence of disparities in surgical mortality rates between weekdays.

Can trainees safely perform pancreatoenteric anastomosis? A systematic review, meta-analysis, and risk-adjusted analysis of postoperative pancreatic fistula

BACKGROUND

The complexity of pancreaticoduodenectomy and fear of morbidity, particularly postoperative pancreatic fistula, can be a barrier to surgical trainees gaining operative experience. This meta-analysis sought to compare the postoperative pancreatic fistula rate after pancreatoenteric anastomosis by trainees or established surgeons.

METHODS

A systematic review of the literature was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, with differences in postoperative pancreatic fistula rates after pancreatoenteric anastomosis between trainee-led versus consultant/attending surgeons pooled using meta-analysis. Variation in rates of postoperative pancreatic fistula was further explored using risk-adjusted outcomes using published risk scores and cumulative sum control chart analysis in a retrospective cohort.

RESULTS

Across 14 cohorts included in the meta-analysis, trainees tended toward a lower but nonsignificant rate of all postoperative pancreatic fistula (odds ratio: 0.77, P = .45) and clinically relevant postoperative pancreatic fistula (odds ratio: 0.69, P = .37). However, there was evidence of case selection, with trainees being less likely to operate on patients with a pancreatic duct width <3 mm (odds ratio: 0.45, P = .05). Similarly, analysis of a retrospective cohort (N = 756 cases) found patients operated by trainees to have significantly lower predicted all postoperative pancreatic fistula (median: 20 vs 26%, P < .001) and clinically relevant postoperative pancreatic fistula (7 vs 9%, P = .020) rates than consultant/attending surgeons, based on preoperative risk scores. After adjusting for this on multivariable analysis, the risks of all postoperative pancreatic fistula (odds ratio: 1.18, P = .604) and clinically relevant postoperative pancreatic fistula (odds ratio: 0.85, P = .693) remained similar after pancreatoenteric anastomosis by trainees or consultant/attending surgeons.

CONCLUSION

Pancreatoenteric anastomosis, when performed by trainees, is associated with acceptable outcomes. There is evidence of case selection among patients undergoing surgery by trainees; hence, risk adjustment provides a critical tool for the objective evaluation of performance.

Implications of leukocytosis following distal pancreatectomy splenectomy (DPS) and association with postoperative complications

BACKGROUND

Early identification of complications after distal pancreatectomy splenectomy (DPS) poses challenges, as white blood cell count (WBC) is confounded by physiologic leukocytosis. We examined WBC patterns associated with complications after DPS.

METHODS

Clinicopathologic data were collected for patients who underwent DPS in our system from 2009 to 2016. We examined WBC, temperature, platelet count (PC), and ratios of these variables as potential early indicators of patients at risk of infections or major complications (MCs).

RESULTS

348 patients met study inclusion, of whom 206 (59%) were women and the median patient age was 59 ± 15 years. Infectious and MC rates were 11% and 16%, respectively, with <1% 30-day mortality. Postoperative WBC peaks were higher in patients with infections and MCs compared with no complication (23 vs. 17, p < 0.0001). WBC peak timing occurred postoperative day (POD) 2-3 for uncomplicated cases while peaks occurred POD9 for patients with infections and MCs.

DISCUSSION

These data define patterns of leukocytosis following DPS. Although differences in infection markers were identified for patients with and without complications, no obvious thresholds were identified. Clinical suspicion for complications after DPS remains our best tool for early identification.

Early enteral vs. oral nutrition after Whipple procedure: Study protocol for a multicentric randomized controlled trial (NUTRIWHI trial)

Background

Malnutrition has been shown to be a risk factor for postoperative complications after pancreatoduodenectomy (PD). In addition, patients needing a PD, such as patients with pancreatic cancer or chronic pancreatitis, often are malnourished. The best route of postoperative nutrition after PD remains unknown. The aim of this randomized controlled trial is to evaluate if early postoperative enteral nutrition can decrease complications after PD compared to oral nutrition.

Methods

This multicenter, open-label, randomized controlled trial will include 128 patients undergoing PD with a nutritional risk screening ≥3. Patients will be randomized 1:1 using variable block randomization stratified by center to receive either early enteral nutrition (intervention group) or oral nutrition (control group) after PD. Patients in the intervention group will receive enteral nutrition since the first night of the operation (250 ml/12 h), and enteral nutrition will be increased daily if tolerated until 1000 ml/12 h. The primary outcome will be the Comprehensive Complication Index (CCI) at 90 days after PD.

Discussion

This study with its multicentric and randomized design will permit to establish if early postoperative enteral nutrition after PD improves postoperative outcomes compared to oral nutrition in malnourished patients.

Clinical trial registration

https://clinicaltrials.gov/(NCT05042882) Registration date: September 2021.

Association of a Modified Blumgart Anastomosis With the Incidence of Pancreatic Fistula and Operation Time After Laparoscopic Pancreatoduodenectomy: A Cohort Study

OBJECTIVE

To explore the association between a modified Blumgart anastomosis technique and the operative time and surgical complications.

METHODS

This is a retrospective cohort study that analyzed the data of patients who underwent laparoscopic pancreaticoduodenectomy from January 2015 to March 2021. The primary outcome was to explore the association between the modified Blumgart anastomosis technique and operative time.

RESULTS

A total of 282 patients were enrolled. There were 177 cases of pancreatic duct-to-mucosa anastomosis in the traditional surgery group, and 105 cases of the modified three-step Blumgart anastomosis in the modified group. There were no statistically significant differences in the general and intraoperative characteristics found between the two groups (P > 0.05). The surgical method was an independent predictor of operative time. Overall complications postsurgery were less common in the modified group than in the traditional group. The incidence of postoperative pancreatic fistula was higher in the traditional group than in the modified group (45 cases (25.4%) and 11 cases (10.5%), respectively). Fourteen cases (7.9%) in the traditional group and four case (3.8%) in the modified group had postoperative pancreatic fistula of grades B + C. The two groups had statistically significant differences (P < 0.05). The results of the linear regression showed that the type of surgical method was associated with operation time (95% CI, -73.074 to -23.941, β: -0.438, P < 0.001).

CONCLUSION

This modified three-step Blumgart pancreaticojejunostomy was associated with the operation time.

Enhanced recovery in elderly patients undergoing pancreatic resection: A retrospective monocentric study

Enhanced recovery after surgery (ERAS) pathway for pancreas has demonstrated its value in clinical practice. However, there is a lack of specific evidence about its application in elderly patients. The aim of the present study was to assess the impact of age on compliance and postoperative outcomes. Patients ≥70 years old that underwent pancreatic resection within an ERAS pathway between 2012 and 2018 were included, and divided into three groups: 70-74, 75-79, and ≥80 years old. Compliance with ERAS items, length of stay, mortality, and complications were analyzed. 114 patients were included: 49, 37, and 28 patients aged 70-74, 75-79, and ≥80 years, respectively. Overall compliance to ERAS items between groups was not different (66%, 66%, and 62%, P = .201). No significant difference was observed in terms of median length of stay (14, 17, and 17 days, P = .717), overall complications (67%, 78%, and 71%, P = .529), major complications (26%, 32%, and 39%, P = .507), or mortality (0%, 3%, and 4%, P = .448) with increasing age. Application of an ERAS pathway is feasible in elderly patients with pancreatic resection. Increasing age was neither associated with poorer compliance nor worse postoperative outcomes.

A proposal of drain removal criteria in hepatobiliary resection

BACKGROUND

Standardized criteria for the drain removal in hepatobiliary resection are lacking. We evaluated the outcomes of delayed removal policy in this extended surgery.

METHODS

Patients undergoing hepatectomy with biliary reconstruction between 2012 and 2018 were retrospectively reviewed. The drains were removed on postoperative day (POD) 7 when the drainage fluid was grossly serous, biochemically normal, and negative for bacterial contamination as assessed by Gram staining; additionally, no abnormal fluid collection was confirmed by computed tomography. Clinically relevant abdominal complications (CRACs), including biliary leakage, pancreatic fistula or intra-abdominal abscess, served as the primary outcome measure.

RESULTS

Among 374 study patients, surgical drains were removed in 166 (44.3%) patients who met the criteria. Of these patients, 16 (9.6%) patients required additional drainage afterwards due to CRAC. Drains were retained and exchanged in 208 (55.6%) patients who did not meet the criteria. Of them, exchanged drains were soon removed in 34 patients due to no signs of CRAC. The diagnostic ability of the criteria revealed 0.916 sensitivity, 0.815 specificity, and 0.866 accuracy.

CONCLUSION

The four findings on POD 7 worked well as criteria for drain removal, and these criteria may be helpful in drain management after hepatobiliary resection.

Perianastomotic Irrigation With Passive Drainage Dramatically Decreases POPF Rate After High-risk Pancreaticoduodenectomy

Objective

To assess whether prophylactic irrigation and passive drainage of pancreatico-jejunal anastomosis could reduce leak and mortality rates after high-risk pancreaticoduodenectomies.

Background

Postoperative pancreatic fistula (POPF) is a life-threatening complication following pancreaticoduodenectomy. Several risk factors have been proposed likewise potential mitigation strategies. Regarding the latter, surgical drain policy remains a "hot topic." We propose an innovative approach to mitigate POPF and POPF-related mortality following high-risk pancreaticoduodenectomies.

Methods

One hundred fifty-seven patients undergoing pancreaticoduodenectomy between January 2012 and November 2021 were included in the study. Subjects with main pancreatic duct ≤ 3 mm and soft parenchyma were classified as high-risk for POPF development. Since August 2015, high-risk patients received prophylactic irrigation and drainage of the perianastomotic area. These patients were compared with risk-matched historical controls.

Results

We identified 73 high-risk patients. Of these, the 47 subjects receiving prophylactic perianastomotic irrigation showed significantly lower POPF rates (12.7% vs 69.2%, P < 0.001). Multivariate regression analysis confirmed the significant association between irrigation drainages and POPF (odds ratio 0.014, P = 0.01). Although not significant, mortality was lower in the irrigation group (4.2% vs 13.0%, P = 0.340). However, none of the fatalities in the irrigation-drainage group were POPF-related. No significant difference in length of hospital stay was observed between the 2 groups (18.0 vs 21.0 days, P = 0.091).

Conclusions

Irrigation and drainage of the perianastomotic area represents a powerful approach to reduce POPF and, potentially, mortality after high-risk pancreaticoduodenectomies.

Postoperative arterial lactate levels can predict postoperative pancreatic fistula following pancreaticoduodenectomy: A single cohort retrospective study

BACKGROUND

/Objectives: Postoperative pancreatic fistula (POPF) is a serious complication after pancreaticoduodenectomy (PD). Thus, identification of the risk factors for POPF is urgently needed. In this study, we aimed to identify whether arterial lactate (LCT) levels following PD might be a marker of the potential risk of POPF.

METHODS

Between September 2009 and December 2020, 151 patients who underwent elective PD were retrospectively enrolled. Patient characteristics, perioperative clinicopathological variables, postoperative blood biochemistry data were analyzed in univariable and multivariable analyses. Pancreatic fistula of Grade B and C was considered as POPF.

RESULTS

Patients were divided into the POPF group (n = 33, 21.9%) and non-POPF group (n = 118, 78.1%). Higher body mass index (p = 0.017), increased estimated blood loss (p = 0.047), soft textured pancreas (p = 0.007), smaller main pancreatic duct (p = 0.016), higher LCT levels (p < 0.001), higher aspartate aminotransferase levels (p = 0.023) and higher procalcitonin levels (p = 0.024) were significantly associated with POPF. Receiver operating characteristic curve analysis revealed that 2.1 mmol/L was the optimal cut-off value of LCT (sensitivity = 78.8%, specificity = 61.2%) for predicting POPF occurrence. Univariate and multivariate analyses confirmed that an LCT of ≥2.1 mmol/L was independently associated with the risk of POPF following PD (odds ratio = 6.78, 95% confidence interval = 2.22-20.74; p = 0.001).

CONCLUSIONS

Higher LCT is a predictive marker for POPF following PD.

A fast-track surgery programme leads to timelier treatment and higher resection rates in pancreatic cancer

BACKGROUND

The aim was to perform a propensity-matched comparison of patients with pancreatic cancer undergoing surgery, with and without biliary stenting and an intention to treat analysis of long-term survival between the two groups.

METHODS

This was an observational study of a cohort of consecutive patients presenting with obstructive jaundice and undergoing pancreatoduodenectomy for pancreatic and periampullary malignancies between November 2015 and May 2019.

RESULTS

In this study of 216 consecutive operable patients, 70 followed the fast-track pathway and 146 had pre-operative biliary drainage. All 70 patients in the FT group and 122 out of 146 in the PBD group proceeded to surgery (100% and 83.6% respectively, p = 0.001). Interval time from diagnostic CT scan to surgery and from MDT decision to treat to surgery was shorter in the FT group, (median 8 vs 43 days p < 0.001 and 3 vs 36 days p < 0.001 respectively) as was the overall time from diagnostic CT to adjuvant treatment (88 vs 121 days p < 0.001). Postoperative outcomes including complications, readmission and mortality rates were comparable in the two groups. There was no difference in survival.

CONCLUSION

For a person with pancreatic cancer who is proceeding to surgery, the best approach is to avoid pre-operative biliary drainage.

Robotic Distal Gastrectomy Reduces Drain Amylase Values in Patients With a Small Pancreas-left Gastric Artery Angle

PURPOSE

Pancreatic fistula is a severe complication after laparoscopic distal gastrectomy (LDG). We previously evaluated the pancreas-left gastric artery angle (PLA) as a risk indicator for developing a pancreatic fistula after LDG. This study evaluated the incidence of pancreatic fistula with robotic distal gastrectomy (RDG) in comparison to LDG from the view of the PLA.

MATERIALS AND METHODS

An association between the PLA and the incidence of pancreatic fistula in 165 patients who underwent either RDG (n=45) or LDG (n=120) was investigated retrospectively.

RESULTS

RDG patients had significantly lower drain amylase values (postoperative day 2) than LDG patients. As opposed to LDG patients, drain amylase values were similar for patients with small (PLA <62 degrees) and large (PLA ≥62 degrees) PLA in RDG patients.

CONCLUSION

Robotic surgery may reduce the risk of postoperative pancreatic fistula in patients with a small PLA.

Insight of pancreatic cancer: recommendations for improving its therapeutic efficacy in the next decade

Pancreatic cancer is one of the most malignant digestive system tumors. The effectiveness of pancreatic cancer treatment is still dismal, and the 5-year survival rate is only about 10%. Further improving the diagnosis and treatment of pancreatic cancer is the top priority of oncology research and clinical practice. Based on the existing clinical and scientific research experience, the review provides insight into the hotspots and future directions for pancreatic cancer, which focuses on early detection, early diagnosis, molecular typing and precise treatment, new drug development and regimen combination, immunotherapy, database development, model establishment, surgical technology and strategy change, as well as innovation of traditional Chinese medicine and breakthrough of treatment concept.

Enucleation Is a Feasible Procedure for Well-Differentiated pNEN-A Matched Pair Analysis

The extent of surgical resection in the treatment of pancreatic neuroendocrine neoplasms (pNEN) is still controversial. This study aimed to evaluate the outcomes of enucleation for well-differentiated non-functional (nf) pNEN. Patients undergoing enucleation (2001−2020) were analyzed. Clinicopathological parameters, perioperative outcomes and survival were assessed. The analysis was performed as a nested case-control study and matched-pair analysis with formal resection. Sixty-one patients undergoing enucleation were identified. Compared to patients undergoing formal resection, enucleation was associated with a significantly shorter median length of operative time (128 (IQR 95−170) versus 263 (172−337) minutes, p < 0.0001) and a significantly lower rate of postoperative diabetes (2% versus 21%, p = 0.0020). There was no significant difference in postoperative pancreatic fistula rate (18% versus 16% type B/C, p = 1.0), Clavien−Dindo ≥ III complications (20% versus 26%, p = 0.5189), readmission rate (12% versus 15%, p = 0.6022) or length of hospital stay (8 (7−11) versus 10 (8−17) days, p = 0.0652). There was no 30-day mortality after enucleation compared to 1.6% (n = 1) after formal resection. 10-year overall survival (OS) and disease-free survival (DFS) was similar between the two groups (OS: 89% versus 77%, p = 0.2756; DFS: 98% versus 91%, p = 0.0873). Enucleation presents a safe surgical approach for well-differentiated nf-pNEN with good long-term outcomes for selected patients.