[Postoperative chyle leakage after abdominal surgery-Diagnostic and therapeutic strategies]

A postoperative chyle leakage (CL) is caused by intraoperative damage to the main lymphatic vessels or their tributaries. It is characterized by the secretion of a triglyceride-rich fluid, which classically has a characteristic milky appearance in a percutaneous drain. In visceral surgery CLs mostly occur after pancreatic and esophageal surgery but rarely occur after colorectal, liver or gastric surgery. Treatment often consists of a diet rich in medium chain triglycerides (MCT) to reduce the lymphatic flow, while ensuring a sufficient nutrient supply. If the CL does not cease, total parenteral nutrition is usually carried out. A reoperation, lymphography sometimes with percutaneous intervention or short-term irradiation for CL are rarely necessary. A CL frequently results in a prolonged hospital stay and can be accompanied by other complications but is rarely associated with a poorer prognosis.

Chyle leak following root of mesentery dissection in pancreaticoduodenectomy with inferior infracolic superior mesenteric artery first approach

BACKGROUND

The root of mesentery dissection is one of the critical maneuvers, especially in borderline resectable pancreatic head cancer. Intra-abdominal chyle leak (CL) including chylous ascites may ensue in up to 10% of patients after pancreatic resections. Globally recognized superior mesenteric artery (SMA) first approaches are invariably performed. The mesenteric dissection through the inferior infracolic approach has been discussed in this study emphasizing its post-operative impact on CL which is the cornerstone of this study.

AIM

To assess incidence, risk factors, clinical impact of CL following root of mesentery dissection, and the different treatment modalities.

METHODS

This is a retrospective study incorporating the patients who underwent dissection of the root of mesentery with inferior infracolic SMA first approach pancreatoduodenectomy for the ventral body and uncinate mass of pancreas in the Department of Gastrointestinal and General Surgery of Kathmandu Medical College and Teaching Hospital from January 1, 2021 to February 28, 2024. Intraoperative findings and postoperative outcomes were analyzed.

RESULTS

In three years, ten patients underwent root of mesentery dissection with inferior infracolic SMA first approach pancreatoduodenectomy. The mean age was 67.6 years with a male-to-female ratio of 4:5. CL was seen in four patients. With virtue of CL, Clavien-Dindo grade II or higher morbidity was observed in four patients. Two patients had a hospital stay of more than 20 days with the former having a delayed gastric emptying and the latter with long-term total parenteral nutrition requirement. The mean operative time was 330 minutes. Curative resection was achieved in 100% of the patients. The mean duration of the intensive care unit and hospital stay were 2.55 ± 1.45 days and 15.7 ± 5.32 days, respectively.

CONCLUSION

Root of mesentery dissection with lymphadenectomy and vascular resection correlated with occurrence of CL. After complete curative resection, these were managed with total parenteral nutrition without adversely impacting outcome.

Venous resection increases risk of chyle leak after total pancreatectomy for pancreatic tumors

BACKGROUND

Existing research on chyle leak (CL) after pancreatic surgery is mostly focused on pancreaticoduodenectomy and lacks investigation on total pancreatectomy (TP). This study aimed to explore potential risk factors of CL and develop a predictive model for patients with pancreatic tumor undergoing TP.

METHODS

This retrospective study enrolled 90 consecutive patients undergoing TP from January 2015 to December 2023 at Peking Union Medical College Hospital. According to the inclusion criteria, 79 patients were finally included in the following analysis. The LASSO regression and multivariate logistic regression analysis were performed to identify risk factors associated with CL and construct a predictive nomogram. Then, the ROC analysis, calibration curve, decision curve analysis (DCA), and clinical impact curve (CIC) were performed to assess its discrimination, accuracy, and efficacy. Due to the small sample size, we adopted the bootstrap resampling method with 500 repetitions for validation. Lastly, we plotted and analyzed the trend of postoperative drainage volume in CL patients.

RESULTS

We revealed that venous resection (OR = 4.352, 95%CI 1.404-14.04, P = 0.011) was an independent risk factor for CL after TP. Prolonged operation time (OR = 1.473, 95%CI 1.015-2.237, P = 0.052) was also associated with an increased incidence of CL. We included these two factors in our prediction model. The area under the curve (AUC) was 0.752 (95%CI 0.622-0.874) after bootstrap. The calibration curve, DCA and CIC showed great accuracy and clinical benefit of our nomogram. In patients with CL, the mean drainage volume was significantly higher in venous resection group and grade B CL group.

CONCLUSION

Venous resection was an independent risk factor for chyle leak after TP. Patients undergoing vascular resection during TP should be alert for the occurrence of CL after surgery. We then constructed a nomogram consisted of venous resection and operation time to predict the odds of CL in patients undergoing TP.

The impact of lymphangiograpy on chyle leakage treatment duration after pancreatic surgery

PURPOSE

Chyle leakage (CL) is a common complication in pancreatic surgery. Lymphangiography is a therapeutic option for CL in cases of conservative treatment failure. This study investigated the effect of lymphangiography on the healing time of CL.

METHODS

We retrospectively evaluated 283 patients who underwent pancreatic resection between January 2016 and June 2022. The risk factors for CL and the treatment period were evaluated according to whether or not lymphangiography was performed.

RESULTS

Of the 29 patients (10.2%) that had CL, lymphangiography was performed in 6. Malignant disease, the number of harvested lymph nodes, and drain fluid volume on postoperative day 2 were identified as independent risk factors for CL. Lymphangiography was associated with the cumulative healing rate of CL, and patients who underwent lymphangiography had a significantly shorter treatment period. No lymphangiography-related adverse events were observed.

CONCLUSION

Lymphangiography is a feasible and safe treatment option for CL. The CL treatment period after pancreatic surgery was significantly shorter in patients who underwent lymphangiography than in those who did not. Our results suggest that lymphangiography may contribute to early improvement of persistent CL.

Extended lymphadenectomy based on the TRIANGLE for pancreatic head cancer: a single-center experience

BACKGROUND

This study was to compare the safety and efficacy of different lymphadenectomy methods in patients with pancreatic head cancer undergoing pancreaticoduodenectomy (PD).

MATERIAL AND METHODS

A total of 150 patients were included in this study. Patients were divided into Group A (n = 79), Group B (n = 44), and Group C (n = 27) according to the different lymphadenectomy methods. The clinical endpoint was time to progression (TTP) and overall survival (OS). Postoperative complications of different lymphadenectomy methods were compared respectively. TTP and OS of the three groups were compared by Kaplan-Meier curves.

RESULTS

There were no significant differences between the three groups in operative time (P = 0.300), death in the hospital (P = 0.253), postoperative hemorrhage (P = 0.863), postoperative pancreatic fistula (POPF) B/C (P = 0.306), bile leakage (P = 0.215), intestinal fistula (P = 0.177), lymphatic leakage (P = 0.267), delayed gastric emptying [(DGE) (P = 0.283)], ICU stay (P = 0.506), and postoperative hospital stay [(PHS) (P = 0.810)]. Median TTP in Groups B and C was significantly longer than in Group A (log-rank test, A vs B: P = 0.0005, A vs C: P = 0.0001). Median OS between the three groups has no statistical difference (P = 0.1546).

CONCLUSIONS

Extended lymphadenectomy methods based on the TRIANGLE do not increase perioperative complications significantly and can effectively delay tumor progression in patients with pancreatic head cancer.

Prevention, incidence, and risk factors of chyle leak after radical nephrectomy and thrombectomy

BACKGROUND

To define the incidence and risk factors of chyle leak (CL) after radical nephrectomy and thrombectomy and to determine the impact of chyle leak on oncological outcomes.

PATIENTS AND METHODS

A total of 445 patients who underwent radical nephrectomy and thrombectomy between January 2014 and January 2023 were included. CL is defined as the drainage of chyle with a triglyceride level greater than 110 mg/dL after oral intake or enteral nutrition. Multivariate logistic regression analysis was performed to identify the risk factors of postoperative (CL). The Kaplan-Meier curves were used to compare overall survival and cancer-specific survival.

RESULTS

44 patients (9.9%) were diagnosed as (CL). All patients developed CL within 6 days after the operation with a median time of 3 days. In multivariate logistic regression analysis, Mayo grade and side were independent patient-related risk factors. In addition, operation approach, operation time, and number of lymph nodes harvested were independent surgery-related risk factors. Between the CL group and the non-CL group, neither overall survival nor cancer-specific survival showed statistical differences.

CONCLUSION

Based on this retrospective study of renal cell carcinoma and tumor thrombus patients in our center, we found that the risk factors were Mayo grade, side, operation approach, operation time, and number of lymph nodes harvested, and the occurrence of CL significantly prolonged hospital stay, but had no effect on long-term oncological outcomes.

The application of a medium-chain fatty diet and enteral nutrition in post-operative chylous leakage: analysis of 63 patients

Background

Post-operative chylous leakage (CL) is the pathologic leakage of chylomicron fluid after surgery. This retrospective study was performed to evaluate a uniform oral nutrition management strategy on the post-operative CL.

Methods

We retrospectively reviewed patients who developed post-operative CL and received consultation from a clinical nutritionist in seven departments of the Second Affiliated Hospital of Dalian Medical University from May 2020 to April 2022. We designed the oral nutrition intervention program which mainly standardized the type and amount of foods contained in the medium-chain triglyceride (MCT) diet. The influencing factors of curative efficacy were analyzed. Finally, binary logistic regression analysis was conducted to observe the relationship between curative efficacy and potentially predictive variables, including post-operative albumin, post-operative hemoglobin, surgical procedure, and drainage volume at consultation.

Results

Sixty-three patients with post-operative CL were included in this analysis. Of this number, 58 patients were cured successfully without other treatments. Three patients had a significantly prolonged recovery period, and the remaining two cases were treated by reoperation therapy. The leakage volume at the initiation of enteral intervention had no statistically significant difference in seven surgical departments and surgical sites (left, right, median, and bilateral). The length of stay (LOS) of patients with CL after the intervention was not significantly increased in cardiac, hepatobiliary, gastrointestinal, and urological surgeries. Patients with CL had longer LOS than those without CL in gynecology (P=0.044) and thyroid surgery departments (P=0.008). Each unit increase in post-operative hemoglobin would increase the probability of an effective outcome by 8%, which was statistically significant (P = 0.037).

Conclusion

In treating patients with post-operative CL, we recommend the MCT diet and EN as the first option, rather than fasting, parenteral nutrition (PN), or octreotide.

Chyle Leak After Pancreatoduodenectomy: Clinical Impact and Risk Factors in a Nationwide Analysis

OBJECTIVE

The aim of this study was to assess the clinical impact and risk factors of chyle leak (CL).

BACKGROUND

In 2017, the International Study Group for Pancreatic Surgery (ISGPS) published the consensus definition of CL. Multicenter series validating this definition are lacking and previous studies investigating risk factors have used different definitions and showed heterogeneous results.

METHODS

This observational cohort study included all consecutive patients after pancreatoduodenectomy in all 19 centers in the mandatory nationwide Dutch Pancreatic Cancer Audit (2017-2019). The primary endpoint was CL (ISGPS grade B/C). Multivariable logistic regression analyses were performed.

RESULTS

Overall, 2159 patients after pancreatoduodenectomy were included. The rate of CL was 7.0% (n=152), including 6.9% (n=150) grade B and 0.1% (n=2) grade C. CL was independently associated with a prolonged hospital stay [odds ratio (OR)=2.84, 95% confidence interval (CI): 1.85-4.36, P <0.001] but not with mortality (OR=0.3, 95% CI: 0.0-2.3, P =0.244). In multivariable analyses, independent predictors for CL were vascular resection (OR=2.1, 95% CI: 1.4-3.2, P <0.001) and open surgery (OR=3.5, 95% CI: 1.7-7.2, P =0.001). The number of resected lymph nodes and aortocaval lymph node sampling were not identified as predictors in multivariable analysis.

CONCLUSIONS

In this nationwide analysis, the rate of ISGPS grade B/C CL after pancreatoduodenectomy was 7.0%. Although CL is associated with a prolonged hospital stay, the clinical impact is relatively minor in the vast majority (>98%) of patients. Vascular resection and open surgery are predictors of CL.

Therapeutic lymphography for persistent chyle leak after pancreatic surgery

BACKGROUND

Chyle leak is a common complication following pancreatic surgery. After failure of conservative treatment, lymphography is one of the last therapeutic options. The objective of this study was to evaluate whether lymphography represents an effective treatment for severe chyle leak (International study Group on Pancreatic Surgery, grade C) after pancreatic surgery.

METHODS

Patients with grade C chyle leak after pancreatic surgery who received transpedal or transnodal therapeutic lymphography between 2010 and 2020 were identified from a prospectively maintained database. Clinical success of the lymphography was evaluated according to percent decrease of drainage output after lymphography (>50% decrease = partial success; >85% decrease = complete success).

RESULTS

Of the 48 patients undergoing lymphography, 23 had a clinically successful lymphography: 14 (29%) showed partial and 9 (19%) complete success. In 25 cases (52%) lymphography did not lead to a significant reduction of chyle leak. Successful lymphography was associated with earlier drain removal and hospital discharge [complete clinical success: 7.1 days (±4.1); partial clinical success: 12 days (±9.1), clinical failure: 19 days (±19) after lymphography; p = 0.006]. No serious adverse events were observed.

CONCLUSION

Therapeutic lymphography is a feasible, safe, and effective option for treating grade C chyle leak after pancreatic surgery.

Incidence and risk factors for Chyle leak after pancreatic surgery for cancer: A comprehensive systematic review

BACKGROUND

Chyle leak (CL) is a clinically relevant complication after pancreatectomy. Its incidence and the associated risk factors are ill defined, and various treatments options have been described. There is no consensus, however, regarding optimal management. The present study aims to systematically review the literature on CL after pancreatectomy.

METHODS

A systematic review from PubMed, Scopus and Embase database was performed. Studies using a clear definition for CL and published from January 2000 to January 2021 were included. The PRISMA guidelines were followed during all stages of this systematic review. The MINORS score was used to assess methodological quality.

RESULTS

Literature search found 361 reports, 99 of which were duplicates. The titles and abstracts of 262 articles were finally screened. The references from the remaining 181 articles were manually assessed. After the exclusions, 43 articles were thoroughly assessed. A total of 23 articles were ultimately included for this review. The number of patients varied from 54 to 3532. Incidence of post pancreatectomy CL varied from 1.3% to 22.1%. Main risk factors were the extent of the surgery and early oral or enteral feeding. CL dried up spontaneously or after conservative management within 14 days in 53% to 100% of the cases.

CONCLUSIONS

The extent of surgery is the most common predictor of risk of CL. Conservative treatment has been shown to be effective in most cases and can be considered the treatment of choice. We propose a management algorithm based on the current available evidence.

Learning Curves in Open, Laparoscopic, and Robotic Pancreatic Surgery: A Systematic Review and Proposal of a Standardization

Objective

To depict and analyze learning curves for open, laparoscopic, and robotic pancreatoduodenectomy (PD) and distal pancreatectomy (DP).

Background

Formal training is recommended for safe introduction of pancreatic surgery but definitions of learning curves vary and have not been standardized.

Methods

A systematic search on PubMed, Web of Science, and CENTRAL databases identified studies on learning curves in pancreatic surgery. Primary outcome was the number needed to reach the learning curve as defined by the included studies. Secondary outcomes included endpoints defining learning curves, methods of analysis (statistical/arbitrary), and classification of learning phases.

Results

Out of 1115 articles, 66 studies with 14,206 patients were included. Thirty-five studies (53%) based the learning curve analysis on statistical calculations. Most often used parameters to define learning curves were operative time (n = 51), blood loss (n = 17), and complications (n = 10). The number of procedures to surpass a first phase of learning curve was 30 (20-50) for open PD, 39 (11-60) for laparoscopic PD, 25 (8-100) for robotic PD (P = 0.521), 16 (3-17) for laparoscopic DP, and 15 (5-37) for robotic DP (P = 0.914). In a three-phase model, intraoperative parameters improved earlier (first to second phase: operating time -15%, blood loss -29%) whereas postoperative parameters improved later (second to third phase: complications -46%, postoperative pancreatic fistula -48%). Studies with higher sample sizes showed higher numbers of procedures needed to overcome the learning curve (rho = 0.64, P < 0.001).

Conclusions

This study summarizes learning curves for open-, laparoscopic-, and robotic pancreatic surgery with different definitions, analysis methods, and confounding factors. A standardized reporting of learning curves and definition of phases (competency, proficiency, mastery) is desirable and proposed.

The TRIANGLE operation for pancreatic head and body cancers: early postoperative outcomes

BACKGROUND

Surgical resection is the mainstay of potential cure for patients with pancreatic cancer, however, local recurrence is frequent. Previously, we have described an extended resection technique for pancreatoduodenectomy aiming at a radical resection of the nerve and lymphatic tissue between celiac artery, superior mesenteric artery and mesenteric-portal axis (TRIANGLE operation). Until now, data on postoperative outcome have not been reported, yet.

METHODS

Patients who underwent either partial (PD) or total pancreatoduodenectomy (TP) applying the TRIANGLE procedure were identified. These cohorts were compared to matched historic cohorts with standard resections.

RESULTS

Overall, 330 patients were analysed (PD_TRIANGLE and PD_STANDARD, each n = 108; TP_TRIANGLE and TP_STANDARD, each n = 57). More lymph nodes were harvested in TRIANGLE compared to standard resection (PD: 27.5 (21-35) versus 31.5 (24-40); P = 0.0187, TP: 33 (28-49) versus 44 (29-53); P = 0.3174) and the rate of tumour positive resections margins, R1(direct), dropped. Duration of operation was significantly longer and blood loss higher. Postoperative mortality and complications did not differ significantly.

CONCLUSION

Pancreatoduodenectomy according to the TRIANGLE protocol can be performed without increased morbidity and mortality at a high-volume centre. Long-term survival and quality of life need to be investigated in prospective clinical trials with adequate sample size.

Risk factors and microbial spectrum for infectious complications after pancreaticoduodenectomy

BACKGROUND

Although the mortality of pancreaticoduodenectomy (PD) has decreased, the morbidity especially infections is still a severe challenge. This study aimed to identify the risk factors and microbial spectrum for infectious complications after PD.

METHODS

This retrospective study of 291 consecutive patients who underwent PD between February 2018 and March 2021 was conducted. The clinical data was reviewed and risk factors associated with infectious complications were analyzed. To investigate the microbial spectrum, microorganisms isolated from preoperative bile, drainage fluid and blood were counted.

RESULTS

A total of 110 patients (37.8%) developed postoperative infections. The patients who suffered infections had higher severe complications, prolonged hospitalization and increased expenditures. Three independent risk factors were identified: preoperative biliary drainage (PBD) [odds ratio (OR) 2.082; 95% confidence interval (CI): 1.059-4.091; P=0.033], clinically relevant postoperative pancreatic fistula (CR-POPF) (OR 11.984; 95% CI: 6.556-21.471; P=0.000) and biliary fistula (BF) (OR 3.674; 95% CI: 1.218-11.084; P=0.021). K. pneumoniae and E. faecalis were the most frequently isolated bacteria in preoperative bile and drainage fluid after PD. K. pneumoniae and S. haemolyticus were the most common bacteria in bacteremia patients.

CONCLUSIONS

PBD, POPF and BF are independent risk factors for infectious complications after PD. To lower the incidence of infection, PBD should be performed only in select cases and efforts should be taken to reduce the POPF and BF. The pathogens of bile and drainage fluid should be monitored throughout the hospital stay.

Preoperative Neutrophil-to-Lymphocyte Ratio may Predict Postoperative Pneumonia in Stage I-III Gastric Cancer Patients After Curative Gastrectomy: A Retrospective Study

BACKGROUND

Several studies have demonstrated that diverse systemic inflammatory-based prognostic parameters predict a poor prognosis in patients with gastric cancer. However, few studies have focused on the relationships between postoperative complications and systemic inflammatory-based prognostic parameters after curative gastrectomy. We investigated the relationships between postoperative complications and these parameters and assessed the clinical utility of the parameters as predictors of postoperative complications in patients with stage I-III gastric cancer.

METHODS

We retrospectively reviewed 300 patients who underwent curative gastrectomy for stage I-III gastric cancer. All postoperative complications were classified as infectious or noninfectious. We evaluated the relationships between postoperative complications and clinical factors, including systemic inflammatory-based prognostic parameters.

RESULTS

In total, 101 patients (33.7%) had postoperative Clavien-Dindo grade II-IV complications, and 54 (18.0%) patients developed infectious complications including pancreatic fistula, pneumonia, anastomotic leak, intra-abdominal abscess, and cholecystitis. The relationships between postoperative complications and systemic inflammatory-based prognostic parameters were evaluated by the areas under the receiver operating characteristic curves. Postoperative pneumonia was identified as the most sensitive complication to the systemic inflammatory-based prognostic parameters. Multivariate analysis revealed that preoperative neutrophil-to-lymphocyte ratio (odds ratio, 14.621; 95% confidence interval, 1.160-184.348; p = 0.038) was an independent predictor of pneumonia.

CONCLUSIONS

Preoperative neutrophil-to-lymphocyte ratio may be a useful predictor of postoperative pneumonia in patients with stage I-III gastric cancer after curative gastrectomy.

Postoperative chylous leak after a laparoscopic low anterior resection: a case report

Chylous leakage is an unusual event after abdominal surgery and even more during colorectal procedures. The management of this complication is already discussed in medical literature. In our case a laparoscopic low anterior resection to an 81-year-old woman with a sigmoid and rectum colon tumor was done. The fourth day after surgery postoperative chylous leakage was diagnosed. It was treated with suspension of oral feeding, total parenteral nutrition and Octreotide with a favorable resolution.

Complications After Pancreaticoduodenectomy

The most common complications after a pancreaticoduodenectomy are delayed gastric emptying, pancreatic fistulae, hemorrhage, chyle leaks, endocrine and exocrine pancreatic insufficiency, and surgical site infections. Understanding the potential complications and recognizing them are imperative to taking great care of these complex patients. Taking care of these patients postoperatively requires a team approach including experienced nursing staff combined with robust gastroenterology and interventional radiology.

Systematic review of the incidence and risk factors for chyle leak after pancreatic surgery

BACKGROUND

The incidence of and risk factors for chyle leak, as defined by the 2017 International Study Group on Pancreatic Surgery, remain unknown.

METHODS

MEDLINE, EMBASE, and Scopus were systematically searched for studies of patients undergoing pancreatectomy that reported chyle leak according to the 2017 International Study Group on Pancreatic Surgery definition. The primary outcomes were the incidence of overall and clinically relevant chyle leak. A random-effects pairwise meta-analysis was used to calculate the incidence of chyle leak.

RESULTS

Thirty-five studies including 7,083 patients were included in the meta-analysis. The weighted incidence of overall chyle leak was 6.8% (95% confidence interval 5.6-8.2), and clinically relevant chyle leak was 5.5% (95% confidence interval 3.8-7.7). Pancreaticoduodenectomy, total pancreatectomy, and distal pancreatectomy were associated with a CL incidence of 7.3%, 4.3%, and 5.8%, respectively. Fourteen individual risk factors for chyle leak were identified from included studies. Younger age, low prognostic nutritional index, para-aortic node manipulation, lymphatic involvement, and post-pancreatectomy pancreatitis were significantly associated with chyle leak, all from individual studies.

CONCLUSION

The incidence of overall chyle leak and clinically relevant chyle leak after pancreatic surgery, as defined by the 2017 International Study Group on Pancreatic Surgery, is 6.8% and 5.5%, respectively. Several risk factors for chyle leak were identified in the present review; however, larger high-quality studies are needed to more accurately define these risks.

Hepatic lymphorrhea following pancreaticoduodenectomy: Preliminary diagnosis and treatment experience from case series of four patients

Introduction

Hepatic lymphorrhea (HL) is an uncommon but potentially life-threatening type of postoperative lymphatic leakage, especially following pancreaticoduodenectomy.

Case presentation

We herein report a case series of four patients with HL following pancreaticoduodenectomy that presented to the department with a severe clinical picture with the discovery in imaging and intraperitoneal fluid's tests. All our patients presented with a condition of Hepatic lymphorrhea secondary to pancreaticoduodenectomy, which were treated successfully with percutaneous hepatic lymphangiography (HLG).

Discussion

Hepatic lymphorrhea is an uncommon but potentially life-threatening complication following pancreaticoduodenectomy. Periportal lymphatic vessels, which was often isolated and dissected especially with extended lymphadenectomy, is potentially damaged and caused resistant chylous leakage. Newly techniques are updated and applied in diagnosis and treatment for this difficult-to-treat complication, one of them is percutaneous Hepatic Lymphangiography (HLG).

Conclusion

HLG with percutaneous access could be effective to identify and terminate the chylous fistula from periportal lymphatic vessels after pancreaticoduodenectomy.

•

Hepatic lymphorrhea is a rare, life-threatening complication of pancreaticoduodenectomy.

•

Periportal lymphatic vessels was a potential location of lymphatic fistula and leakage.

•

This complication can be diagnosed with imaging and intraperitoneal fluid's tests.

•

Hepatic lymphangiography is a minor-invasive therapy to close the lymphatic fistula.

Daily Triglyceride Output Volume as an Early Predictor for Chyle Leak Following Pancreaticoduodenectomy

BACKGROUND/AIM

Useful prophylaxes of chyle leak (CL) after pancreatic surgery have not been established. The aim of the study was to identify an early clinical predictor for CL.

PATIENTS AND METHODS

Fifty-five patients who underwent subtotal stomach preserved pancreaticoduodenectomy (SSPPD) were included. Clinical factors associated with postoperative CL were evaluated.

RESULTS

Eleven patients (20%) developed a CL after SSPPD. Shorter operative time, absent pancreatic fistula, and triglyceride output volume at postoperative day (POD) two were independent risk factors for CL. The receiver operating characteristics curve of the daily triglyceride output volume at POD two indicated a cut-off point of 177 mg (AUC=0.782; p=0.004; 95% CI=0.639-0.925). CL was significantly associated with prolonged postoperative hospital stay in patients who did not develop a pancreatic fistula (p=0.003).

CONCLUSION

Daily triglyceride output volume of >177 mg at POD two may be a predictor of CL following pancreaticoduodenectomy.

Successful treatment of intractable chylous ascites after laparoscopic low anterior resection using lymphangiography and embolization with lipiodol: A case report

INTRODUCTION AND IMPORTANCE

Chylous ascites (CA) is an infrequent, intractable complication that may arise after abdominal surgery. Although various attempts at treatment have been adopted, to date, none of them have been consistently effective. We describe the successful treatment of CA using lymphangiography and embolization with lipiodol.

CASE PRESENTATION

A 79-year-old woman underwent laparoscopic surgery for rectum cancer at another hospital. She was discharged on postoperative day (POD) 9; however, she had to be treated and hospitalized for CA three times until POD 76. She visited our hospital to undergo treatment for CA on POD 90 because the previous conservative treatment had not improved her condition. The computed tomography (CT) scans revealed ascites effusion. We performed lymphangiography and embolization with lipiodol two times. Repeated CT on POD 134 showed that the ascites had not increased.

CLINICAL DISCUSSION

Lymphangiography and embolization with lipiodol effectively resolved chylous leakage that occurred after abdominal surgery. Additionally, we compare the features of two groups of cases of CA: one group in which patients were treated by lymphatic intervention and the second in which patients were treated through surgical procedures.

CONCLUSION

We were thus able to demonstrate the clinical effectiveness of lipiodol lymphangiography in treating CA.

Successful minimal invasive treatment of chylous ascites following pancreaticoduodenectomy: A case report and review of literature

Introduction

Chylous ascites is an uncommon but potentially life-threatening type of postoperative lymphatic leakage, especially following pancreaticoduodenectomy.

Case presentation

A 59-year-old man underwent pancreaticoduodenectomy (PD) with extended lymphadenectomy and segmental Superior Mesenteric Vein (SMV) resection for SMV-involved pancreatic ductal adenocarcinoma (PDAC). After 20th postoperative day, patient had a drain output with a milky appearance, and with a triglyceride level was 1.6 mmol/L, and the daily output volume was up to 1500 mL per day. She has been performed Conventional Lymphangiography (CLAG) to identify the broken lymphatic vessels as well as close the leakage. Following two consecutive lymphangiography, the source of chylous leakage was identified from hilar lymphatic system, and injection of Aetoxisclerol 2% into lymphatic vessels to close the leakage was performed. Partial parenteral nutrition with limited fat components or medium-chain triglyceride (MCT) was administered, and the amount of ascites decreased particularly. The drain was removed in 20th day after the second CLAG. He had no symptoms of abdominal distention after drain removal and had been discharged after 37 postoperative days (PODs).

Discussion

Chylous ascites is an uncommon but potentially life-threatening complication following pancreaticoduodenectomy. Portal lymphatic plexus, which was often isolated and dissected especially with extended lymphadenectomy, is potentially damaged and caused resistant chylous leakage. Newly techniques are updated and applied in diagnosis and treatment for this difficult-to-treat complication, one of them is percutaneous transhepatic Conventional Lymphangiography (CLAG).

Conclusion

CLAG with percutaneous transhepatic access could be effective to identify and terminate the chylous fistula from portal lymphatic plexus after pancreaticoduodenectomy.

•

Chylous ascites is a potentially life-threatening type of lymphatic leakage, following pancreaticoduodenectomy.

•

Portal lymphatic plexus was a potential location of lymphatic fistula due to the regularity of isolation and dissection in pancreaticoduodenectomy with extended lymphadenectomy.

•

Conventional Lymphangiography (CLAG) is an invasion to identify the broken lymphatic vessels and close the leakage.

•

Percutaneous transhepatic CLAG is a technique to puncture the portal lymphatic vessels, which could not be approached with other methods.

Postoperative chyle leak after pancreatic surgery - Is treatment effective?

PURPOSE

With increasing soft tissue clearance in pancreatic cancer surgery, postoperative chyle leak (CL) has become a more commonly observed complication. Recently, a new consensus definition was established by the International study group of pancreatic surgery (ISGPS). The aim of the present analysis was to evaluate risk factors and treatment options of patients with CL after pancreatic surgery.

METHODS

Two hundred and twenty-eight patients with serous or chylous drainage after pancreatic surgery were included in this analysis of a prospectively collected database between 01/2014 and 12/2016. Risk factors for CL and treatment options were compared. A subgroup analysis on those patients, who had drain removal despite of persistent CL with respect to the need of subsequent percutaneous drainage or reoperation within three months postoperatively, was performed.

RESULTS

Sixty patients with CL were identified. Of those, 41 patients were treated with medium-chain triglyceride-diet, with a median duration of therapy of 12 days. In patients with CL, the type of treatment had no effect on time to drain removal (P=0.29) and morbidity (P=0.15). Furthermore, morbidity was not increased in patients who had their drains removed despite persistent CL (P=0.84). None of the latter patients had percutaneous drainage or reoperation for CL after removal of the surgical drains.

CONCLUSIONS

Dietary treatment may not be very effective in treating CL. Further research is warranted to explore the effect and necessity of CL treatment.

Delayed post-pancreatectomy hemorrhage and bleeding recurrence after percutaneous endovascular treatment: risk factors from a bi-centric study of 307 consecutive patients

PURPOSE

Delayed post-pancreatectomy hemorrhage (PPH) is still one of the most dreaded complications after pancreatic surgery. Its management is now focused on percutaneous endovascular treatments (PETs).

METHODS

Between 2013 and 2019, 307 patients underwent pancreatic resection. The first endpoint of this study was to determine predictive factors of delayed PPH. The second endpoint was to describe the management of intra-abdominal abscesses (IAA). The third endpoint was to identify risk factors of bleeding recurrence after PET. Patients were divided into two cohorts: A retrospective analysis was performed ("cohort 1," "learning set") to highlight predictive factors of delayed PPH. Then, we validated it on a prospective maintained cohort, analyzed retrospectively ("cohort 2," "validation set"). Second and third endpoints studies were made on the entire cohort.

RESULTS

In cohort 1, including 180 patients, 24 experienced delayed PPH. Multivariate analysis revealed that POPF diagnosis on postoperative day (POD) 3 (p=0.004) and IAA (p=0.001) were independent predictive factors of delayed PPH. In cohort 2, association of POPF diagnosis on POD 3 and IAA was strongly associated with delayed PPH (area under the curve [AUC] 0.80; 95% confidence interval [CI] [0.59-0.94]; p=0.003). Concerning our second endpoint, delayed PPH occurred less frequently in patients who underwent postoperative drainage procedure than in patients without IAA drainage (p=0.002). Concerning our third endpoint, a higher body mass index (BMI) (p=0.027), occurrence of postoperative IAA (p=0.030), and undrained IAA (p=0.011) were associated with bleeding recurrence after the first PET procedure.

CONCLUSION

POPF diagnosis on POD 3 and intra-abdominal abscesses are independent predictive factors of delayed PPH. Therefore, patients presenting an insufficiently drained POPF leading to intra-abdominal abscess after pancreatic surgery should be considered as a high-risk situation of delayed PPH. High BMI, occurrence of postoperative IAA, and undrained IAA were associated with recurrence of bleeding after PET.

Minimally Invasive Versus open AbdominoThoracic Esophagectomy for esophageal carcinoma (MIVATE) - study protocol for a randomized controlled trial DRKS00016773

BACKGROUND

The only curative treatment for most esophageal cancers is radical esophagectomy. Minimally invasive esophagectomy (MIE) aims to reduce postoperative morbidity, but is not yet widely established. Linear stapled anastomosis is a promising technique for MIE because it is quite feasible even without robotic assistance. The aim of the present study is to compare total MIE with linear stapled anastomosis to open esophagectomy (OE) with circular stapled anastomosis with special regard to postoperative morbidity in an expertise-based randomized controlled trial (RCT).

METHODS/DESIGN

This superiority RCT compares MIE with linear stapled anastomosis (intervention) to OE with circular stapled anastomosis (control) for Ivor-Lewis esophagectomy. It was initiated in February 2019, and recruitment is expected to last for 3 years. For inclusion, patients must be 18 years of age or more with a resectable primary malignancy in the distal esophagus. Participants with tumor localizations above the azygos vein, metastasis, or infiltration into adjacent tissue will be excluded. In an expertise-based approach, the allocated treatment will only be carried out by the single most experienced surgeon of the surgical center for each respective technique. The sample size was calculated with 20 participants per group for the primary endpoint postoperative morbidity according to comprehensive complication index (CCI) within 30 postoperative days. Secondary endpoints include anastomotic insufficiency, pulmonary complications, other intra- and postoperative outcome parameters such as estimated blood loss, operative time, length of stay, short-term oncologic endpoints, adherence to a standardized fast-track protocol, postoperative pain, and postoperative recovery (QoR-15). Quality of life (SF-36, CAT EORTC QLQ-C30, CAT EORTC QLQ-OES18) and oncological outcomes are evaluated with 60 months follow-up.

DISCUSSION

MIVATE is the first RCT to compare OE with circular stapled anastomosis to total MIE with linear stapled anastomosis exclusively for intrathoracic anastomosis. The expertise-based approach limits bias due to heterogeneity of surgical expertise. The use of a dedicated fast-track protocol in both OE and MIE will shed light on the role of the access strategy alone in this setting. The findings of this study will serve to define which approach has the best perioperative outcome for patients requiring esophagectomy.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00016773 . Registered on 18 February 2019.

Association Between Neoadjuvant Chemoradiotherapy and Intractable Serous Ascites After Pancreaticoduodenectomy for Pancreatic Cancer

BACKGROUND

Intractable serous (not chylous) ascites (IA) that infrequently develops early following pancreaticoduodenectomy (PD) for pancreatic cancer is a life-threatening problem. The relationship between neoadjuvant chemoradiotherapy (NACRT) for pancreatic cancer and the incidence of IA following PD has not been evaluated. This study aims to identify the risk factors associated with IA that develops early after PD for pancreatic cancer.

METHODS

We retrospectively identified 94 patients who underwent PD for pancreatic cancer at the Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, Osaka, Japan, from April 2012 to March 2020. Data on 29 parameters were obtained from medical records. Univariate and multivariate analyses were conducted to identify independent risk factors. Levels of serum albumin were compared before and after NACRT to analyze its effect. Survival analysis was also conducted.

RESULTS

Of the 92 patients included in this study, 8 (8.70%) were categorized into the IA group. Multivariate analysis identified NACRT [odds ratio (OR) 27, 95% confidence interval (CI) 1.87-394, p = 0.016)] and hypoalbuminemia (≤ 1.6 g/dl) just after the operation (OR 50, 95% CI 1.68-1516, p = 0.024) as risk factors. The level of serum albumin was significantly decreased following NACRT. The IA group had poorer prognosis than the control group.

CONCLUSIONS

IA is a serious problem that aggravates patient's prognosis. Postoperative lymphatic leak might be a trigger of IA. NACRT was a major risk factor, followed by hypoalbuminemia caused by various reasons. These factors may act synergistically and cause IA.

An Aggressive Approach to Locally Confined Pancreatic Cancer: Defining Surgical and Oncologic Outcomes Unique to Pancreatectomy with Celiac Axis Resection (DP-CAR)

Background:

Modern chemotherapeutics have led to improved systemic disease control for patients with locally advanced pancreatic cancer (LAPC). Surgical strategies such as distal pancreatectomy with celiac axis resection (DP-CAR) are increasingly entertained. Herein we review procedure specific outcomes and assess biologic rationale for DP-CAR.

Methods:

A prospectively maintained single-institution database of all pancreatectomies was queried for patients undergoing DP-CAR. We excluded all patients for whom complete data were not available and those who were not treated with contemporary multi-agent therapy. Data was supplemented with dedicated chart review and outreach for long-term oncologic outcomes.

Results:

Fifty-four patients underwent DP-CAR between 2008–2018. The median age was 62.7 years. 98% received induction chemotherapy. Arterial reconstruction was performed in 17% and concomitant visceral resection in 30%. R0 resection rate was 87%. Postoperative complications were common (43%) with chyle leak being the most frequent (17%). Length of stay was 8 days, readmission occurred in one-third, and ninety-day mortality was 2%. Disease recurrence occurred in 74% during a median follow up of 17.4 months. Median recurrence-free (RFS) and overall survival (OS) were 9 and 25 months, respectively.

Conclusions:

Following modern induction paradigms, DP-CAR can be performed with low mortality, manageable morbidity, and excellent rates of margin-negative resection in high volume settings. The profile of complications of DP-CAR is distinct from pancreaticoduodenectomy and simple distal pancreatectomy. OS and RFS are similar to those undergoing resection of borderline resectable and resectable disease. Improved systemic disease control will likely lead to increasing utilization of aggressive surgical approaches to LAPC.

Early Versus Late Oral Refeeding After Pancreaticoduodenectomy for Malignancy: a Comparative Belgian-French Study in Two Tertiary Centers

BACKGROUND

In the era of fast-track surgery, because pancreaticoduodenectomy (PD) carries a significant morbidity, surgeons hesitate to begin early oral feeding and achieve early discharge. We compared the outcome of two different approaches to the postoperative management of PD in two tertiary centers.

METHODS

Of patients having undergone PD for malignancy from 2008 to 2017, 100 patients who received early postoperative oral feeding (group A) were compared to 100 patients from another center who received early enteral feeding and a delayed oral diet (group B). Surgical indication and approach and type of pancreatic anastomosis were similar between both groups. Postoperative outcomes were retrospectively reviewed.

RESULTS

Patient characteristics were similar between both groups, except significantly more neoadjuvant treatment in group A (A = 20% vs. B = 9%, p < 0.01). Mortality rates were 3% and 4% in groups A and B, respectively (p = 0.71). The rate of severe postoperative morbidity was significantly lower in group A (13% vs. 26%, p = 0.02), resulting in a lower reoperation rate (p < 0.01). Delayed gastric emptying and clinically relevant pancreatic fistula were similar between both groups but chyle leaks were more frequent in group A (10% vs. 3%, p = 0.04). The median hospital stay was shorter in group A (16 vs. 20 days, p < 0.01).

CONCLUSION

In the present study, early postoperative oral feeding after PD was associated with a shorter hospital stay and did not increase severe postoperative morbidity or the rate of pancreatic fistula. However, it resulted in more chyle leaks and did not prevent delayed gastric emptying.

Successful management of chylous ascites after pancreatoduodenectomy using etilefrine: a case report

An 84-year-old woman underwent subtotal stomach pancreatoduodenectomy (PD) for distal cholangiocarcinoma. Over 1000 ml of serous ascites, which appeared milky after starting a high-protein, low-fat, middle-chain triglyceride diet, was discharged from the inserted drain. On postoperative day (POD) 13, she underwent right hemicolectomy for transverse colonic volvulus, which occurred on POD 9 and was refractory to conservative therapies. Following second surgery, the chylous ascites (CA) amount continued to increase. Octreotide, albumin and diuretics were administered, but the amount of ascites did not decrease. Etilefrine was administered on POD 19; the ascites amount gradually decreased. The drain was removed 3 days after etilefrine administration. She had no symptoms of abdominal distention after drain removal. Etilefrine’s effectiveness for chylothorax after esophagectomy and CA after distal pancreatectomy has been reported. We present a case of CA successfully treated by etilefrine following PD. Our case highlights etilefrine’s usefulness for CA following PD.

Chyle leakage after robotic and open pancreaticoduodenectomy

BACKGROUND

Chyle leakage is a well-known but poorly characterized complication after pancreaticoduodenectomy (PD). No study examined the chyle leakage after robotic PD (RPD).

METHODS

Data regarding chyle leakage were prospectively collected and analyzed from patients undergoing RPD or open PD (OPD).

RESULTS

The study included 118 RPD and 165 OPD. Overall chyle leakage rate was 12.0%, with 13.6% for RPD and 10.9% for OPD. Chyle leakage was eventually resolved in all patients through conservative treatment. The drainage volumes were significantly higher in chyle leakage group from postoperative days (PODs) 1-7, with a median of 240 mL on POD 1 and POD 7, as compared to 160 mL on POD 1 and 70 mL on POD 7 for those without chyle leakage. The number of lymph nodes involved and resected and pancreatic head adenocarcinoma affected the risk of developing chyle leakage, whereas the surgical approach used (RPD or OPD) did not.

CONCLUSIONS

Chyle leakage after PD is not rare, and it can eventually be resolved through conservative treatment. The extent and radicality of the surgery probably have a significant effect on the risk of developing chyle leakage, but the surgical approach used does not.

Relationship Between Early Oral Intake Post Pancreaticoduodenectomy and Chyle Leakage: A Retrospective Cohort Study

BACKGROUND

Early oral intake is strongly recommended according to the enhanced recovery after surgery (ERAS) guidelines because it can reduce complications and improve recovery. However, early oral intake has been indicated to be associated with chyle leakage (CL) after pancreatic surgery, which may lead to worsening of existing malnutrition and impeded recovery. This study investigated the relationship between early oral intake and CL and identified risk factors for CL to reduce its occurrence and promote recovery after pancreaticoduodenectomy.

MATERIALS AND METHODS

All patients who underwent pancreaticoduodenectomy between June 2014 and June 2018 were identified retrospectively. Patients were divided into the early-oral-intake and control groups according to whether they had early oral intake according to ERAS protocols. CL and other clinicopathological characteristics were recorded. Univariable and multivariable analyses assessed CL risk factors.

RESULTS

Early oral intake improved recovery, leading to a shorter postoperative hospital stay for the early-oral-intake group in comparison to that of the control group [13.6 (range, 12-68) vs. 17.8 (range, 14-83) days; p = 0.047] without increasing the incidence of CL and other complications. CL was diagnosed significantly earlier in the early-oral-intake group than in the control group [4.6 (range 3-5) vs. 6.7 (range 3-9) days; p = 0.001]. Early oral intake did not increase the grade severity (p = 0.845) or the costs (p = 0.241) or prolong postoperative hospital stays (p = 0.611). A primary diagnosis of malignancy, para-aortic lymph node dissection, lymphatic invasion, lymph node metastases, the number of harvested nodes, and the number of positive nodes were significantly associated with CL (p < 0.05), whereas early oral intake was not (p = 0.525). Multivariate analyses demonstrated that para-aortic lymph node dissection (p = 0.039) and the number of harvested nodes (p = 0.001) were independent risk variables.

CONCLUSION

This study provides significant evidence that early oral intake after pancreaticoduodenectomy is not associated with CL. The identification of the independent risk factors for CL can help prevent it.

Optimizing the outcomes of pancreatic cancer surgery

Pancreatic cancer is likely to become the second most frequent cause of cancer-associated mortality within the next decade. Surgical resection with adjuvant systemic chemotherapy currently provides the only chance of long-term survival. However, only 10-20% of patients with pancreatic cancer are diagnosed with localized, surgically resectable disease. The majority of patients present with metastatic disease and are not candidates for surgery, while surgery remains underused even in those with resectable disease owing to historical concerns regarding safety and efficacy. However, advances made over the past decade in the safety and efficacy of surgery have resulted in perioperative mortality of around 3% and 5-year survival approaching 30% after resection and adjuvant chemotherapy. Furthermore, owing to advances in both surgical techniques and systemic chemotherapy, the indications for resection have been extended to include locally advanced tumours. Many aspects of pancreatic cancer surgery, such as the management of postoperative morbidities, sequencing of resection and systemic therapy, and use of neoadjuvant therapy followed by resection for tumours previously considered unresectable, are rapidly evolving. In this Review, we summarize the current status of and new developments in pancreatic cancer surgery, while highlighting the most important research questions for attempts to further optimize outcomes.

Management of chylous ascites following pancreaticobiliary surgery

Background

Chyle leak is an uncommon form of ascites occurring due to the accumulation of lipid‐rich lymph into the peritoneal cavity. Traumatic injury to the lymphatic system due to pancreaticobiliary surgery can lead to this phenomenon.

Method

We retrospectively evaluated the data of 159 patients of pancreticobiliary surgery from January 2012 to December 2016. Five patients (5/137, 3.6%) sustained a chylous leak following pancreaticoduodenectomy and one patient (1/22, 4.5%) sustained a chylous leak following Roux‐en‐Y hepaticojejunostomy for postcholecystectomy biliary stricture.

Results

Average daily output was 441 mL (range: 150–800 mL/day), and total duration of output was 16.5 days (range: 4–35 days). Mean hospital stay increased to 19.1 days (range: 10–40 days). All the patients were successfully managed conservatively with a combination of customized enteral feeds, supplemental parenteral nutrition, and octreotide. One patient required additional percutaneous drainage.

Conclusion

Chyle leak can be successfully treated with conservative management but at the cost of increased hospital stay.

Clinical and experimental studies of intraperitoneal lipolysis and the development of clinically relevant pancreatic fistula after pancreatic surgery

Background

Visceral obesity is one of the risk factors for clinically relevant pancreatic fistula after pancreatic resection. The objective of this study was to evaluate the impact of intraperitoneal lipolysis on postoperative pancreatic fistula.

Methods

The degree of intraperitoneal lipolysis was investigated by measuring the free fatty acid concentration in drain discharge in patients after pancreatic resection. An experimental pancreatic fistula model was prepared by pancreatic transection, and the impact of intraperitoneal lipolysis was evaluated by intraperitoneal administration of triolein (triglyceride) with, or without orlistat (lipase inhibitor).

Results

Thirty-three patients were included in the analysis. The free fatty acid concentration in drain discharge on postoperative day 1 was significantly associated with the development of a clinically relevant pancreatic fistula (P = 0·004). A higher free fatty acid concentration in drain discharge was associated with more visceral adipose tissue (P = 0·009). In the experimental model that included 98 rats, intraperitoneal lipolysis caused an increased amount of pancreatic juice leakage and multiple organ dysfunction. Intraperitoneal administration of a lipase inhibitor reduced lipolysis and prevented deterioration of the fistula.

Conclusion

Intraperitoneal lipolysis significantly exacerbates pancreatic fistula after pancreatic resection. Inhibition of lipolysis by intraperitoneal administration of a lipase inhibitor could be a promising therapy to reduce clinically relevant postoperative pancreatic fistula.

Chyle leak after pancreatic surgery: validation of the International Study Group of Pancreatic Surgery classification

BACKGROUND

Chyle leak is an uncommon complication after pancreatic surgery. The chyle leak incidence, definition, diagnosis, and treatment had been reported heterogeneously so far. Recently a consensus definition and grading system was published by the International Study Group for Pancreatic Surgery. This study aims to evaluate the differences in the clinical and economic burden of chyle leak applying the new definition.

METHODS

All data from patients who underwent pancreatic surgery for any disease from January 2014 to December 2016 were retrieved from the institutional prospective database. The 2017 International Study Group for Pancreatic Surgery definition and classification were applied. The classification was validated analyzing the differences in major complications, length of stay, and hospitalization costs.

RESULTS

A total of 945 patients was the final population. A chyle leak was reported in 43 patients (4.5%). Grade A chyle leak occurred in 10 patients (23.3%), Grade B chyle leak in 31 patients (72.1%), and Grade C chyle leak in 2 patients (4.6%). Chyle leak occurred as unique postoperative complication in 29 cases (67.4%). The economic analysis showed that the average costs of the 3 grades were 2,806, 7,150 and 15,684 euros respectively (P < .001). Furthermore, the length of stay, the rates of septic events, and major complications were significantly different among the 3 grades (P = .008, P = .004, and P < .001, respectively). Of note, we did not find any intraoperative factor associated with chyle leak.

CONCLUSION

The present study confirms the validity of the International Study Group for Pancreatic Surgery classification of chyle leak. The 3 grades of chyle leak proposed identify reliably clinical and economical differences among the chyle leak cases.

The TRIANGLE operation - radical surgery after neoadjuvant treatment for advanced pancreatic cancer: a single arm observational study

BACKGROUND

Neoadjuvant therapy is an important strategy for locally advanced pancreatic cancer (PDAC) as resection rates increase with modern chemotherapy regimens even in patients with arterial tumor encasement. The aim of this study is the description of technique and initial outcomes of a new type of radical and arterial-sparing resection after neoadjuvant treatment for locally advanced PDAC.

METHODS

The surgical technique and perioperative results of a new type of operation are described, comprising radical tumor removal by sharp dissection along the celiac axis and the superior mesenteric artery with complete dissection of all soft tissue between both - arteries and superior mesenteric/portal vein (TRIANGLE operation).

RESULTS

15 patients underwent artery-preserving tumor removal without mortality, 7/15 patients showed postoperative complications and an R0 resection was achieved in 6/15 patients. Functional outcome was good in 11/15 patients despite the extended approach of dissection.

CONCLUSION

After neoadjuvant therapy for locally advanced PDAC, surgical exploration should be attempted in patients with stable disease or remission to clarify true vascular infiltration. In case of absent viable tumor, the described technique allows to perform radical surgery without arterial resection in this subgroup of patients.

Extended pancreatic transection for secure pancreatic reconstruction during pancreaticoduodenectomy

Backgrounds/Aims

Pancreaticoduodenectomy (PD) is associated with various surgical complications including healing failure of the pancreaticojejunostomy (PJ). This study intended to ensure blood supply to the pancreatic stump through extended pancreatic transection (EPT).

Methods

This study assessed whether EPT reduces PJ-associated complications and whether EPT is harmful on the remnant pancreatic function. The EPT group included 19 patients undergoing PD, pylorus-preserving PD (PPPD) or hepatopancreaticoduodenectomy. The propensity score matched control group included 45 patients who had undergone PPPD. Pancreatic transection was performed at the level of the celiac axis in the EPT group, by which the pancreatic body was additionally removed by 3 cm in length comparing with the conventional pancreatic transection.

Results

A small invagination fissure suspected as the embryonic fusion site was identified at the ventro-caudal edge of the pancreatic body in all patients undergoing EPT. A sizable fissure permitting easy separation of the pancreatic parenchyma was identified in 15 of 19 patients (78.9%). The incidence of significant postoperative pancreatic fistula was significantly lower in the EPT group than in the control group (p=0.047). There was no significant increase in the postoperative de novo diabetes mellitus in EPT group (p=0.60).

Conclusions

The EPT technique contributes to the prevention of major pancreatic fistula without impairing remnant pancreatic function. EPT is feasible for routine clinical application or at least in patients with any known risk of PJ leak.