Serum blood urea nitrogen and serum albumin on the first postoperative day predict pancreatic fistula and major complications after pancreaticoduodenectomy

Albumin and fibrinogen synthesis rates in advanced chronic liver disease

Synthesis of plasma proteins is an important function of the liver that has sparsely been investigated by modern techniques in patients with advanced chronic liver disease (CLD). Twenty-eight well-characterized patients with CLD under evaluation for liver transplantation were included. Albumin and fibrinogen synthesis rates were measured by the flooding dose technique using stable isotope-labeled phenylalanine. Transcapillary escape rate of albumin and plasma volume were assessed by radioiodinated human serum albumin. The absolute albumin synthesis rates were low (65 mg/kg/day, range: 32-203) and were associated with impaired liver function, as reflected by the risk-scores Child-Pugh (P = 0.025) and model for end-stage liver disease (rs = -0.62, P = 0.0005). The fibrinogen synthesis rate (12.8 mg/kg/day, range: 2.4-52.9) was also negatively associated with liver function. The synthesis rates of albumin and fibrinogen were positively correlated. Plasma volume was high (51 ± 9 mL/kg body wt), which contributed to an almost normal intravascular albumin mass despite low plasma concentration. Autoimmune inflammatory etiologies to CLD were associated with higher fibrinogen synthesis. De novo synthesis rates of albumin and fibrinogen in advanced chronic liver failure were negatively correlated to prognostic scores of liver disease. Albumin synthesis rate was low and associated with both liver failure and autoimmune inflammation, whereas fibrinogen synthesis was often normal and positively associated with chronic inflammation. This is different from acute inflammatory states in which both albumin and fibrinogen synthesis rates are high.NEW & NOTEWORTHY Albumin and fibrinogen synthesis were positively correlated, but the high variation indicates that these are probably influenced by different mechanisms. There might be a limited metabolic reserve for the liver to increase both albumin and fibrinogen synthesis in response to longstanding inflammation in CLD and fibrinogen seems to be prioritized.

Clinical Analysis of C-Shaped Embedded Pancreaticojejunostomy in Pancreaticoduodenectomy

Background

Comparing the effects of C-shaped embedded anastomosis and pancreatic duct-jejunal mucosal anastomosis on the incidence of pancreatic fistula after pancreaticoduodenectomy (PD) to find a better pancreaticojejunal anastomosis method that can reduce the occurrence of complications during the operation and benefit the patients.

Methods

A retrospective subresearch method was used to select the clinical data of patients who have undergone pancreaticoduodenectomy in our hospital from December 2019 to March 2021. The indicators to be collected for this study include gender, age, body mass index, preoperative liver function (total bilirubin, alanine aminotransferase, and albumin), preoperative comorbidities (diabetes, chronic pancreatitis), and pancreatic condition (texture, pancreatic duct diameter). The patients were divided into two groups according to the method of pancreaticojejunostomy: C-shaped embedded anastomosis group (n = 38) and pancreatic duct-jejunal mucosal anastomosis group (n = 30). The duration of pancreaticojejunostomy, biliary-enteric anastomosis, gastrointestinal anastomosis, intraoperative blood loss, upper abdominal surgery history, pathological type, intraoperative blood loss, pancreaticojejunostomy time, combined pancreatic fistula, biliary fistula, hemorrhage, and abdominal infection were observed and compared. According to the different methods of pancreaticojejunostomy during operation, they were divided into group A: C-shaped embedded pancreaticojejunostomy group (38 cases), and group B: pancreatic duct-jejunal mucosal anastomosis group (30 cases). The postoperative complications were compared between the two groups, and the observed indicators were analyzed with statistical methods.

Results

The average pancreaticojejunostomy time in group A was 32.13 ± 4.52 min, and the average pancreaticojejunostomy time in group B was 43.23 + 4.31 min. The difference was statistically significant (p < 0.05). Neither group A nor group B had a grade C fistula. The incidence of biochemical fistula in group A was 21.05% (8/38), and the incidence of biochemical fistula in group B was 13.3% (4/30). The difference was not statistically significant (p > 0.05). The incidence of grade B fistula in group A was 5.20% (2/38), and the incidence of grade B fistula in group B was 26.67% (8/30). The difference was statistically significant (p < 0.05). There were no perioperative deaths in the two groups.

Conclusion

According to the results of data analysis, it can be seen that both the two types of pancreaticojejunostomy have good clinical effects, but that in terms of reducing the grade of pancreatic fistula, the C-shaped embedded pancreaticojejunostomy is obviously better and safer. At the same time, the C-shaped embedded pancreaticojejunostomy can shorten the time of pancreaticojejunostomy and is easier to operate, thus worthy of clinical promotion.

Effect of preoperative nutritional supplementation on postoperative outcomes for patients undergoing pancreaticoduodenectomy for cancer: a systematic review protocol

OBJECTIVE

This review aims to present the best available evidence related to the effect of preoperative nutritional supplementation on postoperative outcomes for patients undergoing pancreaticoduodenectomy for cancer.

INTRODUCTION

Pancreaticoduodenectomy surgery is the only curative option for early head of pancreas and periampullary cancers. This complex, high-risk procedure is associated with significant morbidity, making opportunities to improve outcomes paramount. Nutritional supplementation in the preoperative period may enhance the body's ability to withstand the stress of major surgery and reduce postoperative complications.

INCLUSION CRITERIA

This review will consider studies of patients undergoing pancreaticoduodenectomy for cancer who are provided preoperative nutritional supplementation in any form for a minimum of 48 hours. Randomized and quasi-randomized trials that compare any form of preoperative nutritional supplementation to standard care in these patients will be included. Outcome data will include hospital length of stay, mortality, infections, delayed gastric emptying, pancreatic fistula, anastomotic leak, hemorrhage, weight loss, body mass index, serum albumin, lymphocyte levels, and nutrition risk index score.

METHODS

Electronic databases (PubMed, Scopus, CINAHL, and Cochrane Library) and trial registers will be searched for published and unpublished articles. All articles from database inception to present, published in any language will be included. One reviewer will perform the literature search, screen texts for inclusion, and extract data. Two authors will assess methodological quality of the literature using the JBI critical appraisal tool. Authors will be contacted where additional data or clarification is required. Statistical meta-analysis through synthesis and pooling of data for each intervention will be completed where meaningful.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020215307.

A Scoring System for Surgical Site Infection after Pancreaticoduodenectomy Using Clinical Data

Object: To analyze the factors influencing surgical site infection (SSI) after pancreaticoduodenectomy and to establish a scoring system for predicting such infections. Methods: Patients who underwent pancreaticoduodenectomy in the Department of Hepatobiliary Surgery of the Second Affiliated Hospital of Chongqing Medical University from January 2015 to March 2019 were divided randomly into a model group and a test group in a proportion of 3:1. According to whether an SSI occurred after operation, the model group was divided into an incision-infection group and a non-infection group. Univariable analysis and multivariable regression analysis were used to analyze factors related to post-operative incision infection and to establish a clinical predictive scoring system. The scoring system was evaluated for the test group. Results: A total of 236 patients, 177 in the model group and 59 in the test group, were included. In the model group, univariable and logistic regression analysis showed that tumor nature (benign versus malignant), post-operative albumin concentration, pancreatic fistula formation, post-operative cough, and peri-operative blood transfusion were the independent risk factors for incision infection. Then we established a clinical predictive scoring system. In the test group, the area under the receiver operator characteristic curve of the system was 0.768 (p < 0.001, with sensitivity = 59.1% and specificity = 94.6%). Conclusion: The scoring system had good clinical prediction ability and high specificity, so it was worth using in the clinic.

Application of an early oral feeding protocol after pylorus-preserving pancreaticoduodenectomy

PURPOSE

This study evaluates the effect of an enhanced recovery after surgery (ERAS)-based nutrition support protocol on oral intake and weight change in patients who underwent pylorus-preserving pancreaticoduodenectomy (PPPD).

METHODS

A 14-day postoperative nutrition support protocol was developed to initiate oral intake after 1 week of enteral tube feeding and parenteral nutrition (early oral feeding, EOF). Forty-eight patients who underwent PPPD participated in the study (non-EOF, n = 23; EOF, n = 25). General information, nutrition supply route and amount, blood chemistry, and weight changes were tracked.

RESULTS

The enteral tube feeding duration was 2.7 days shorter in the EOF group than in the non-EOF group. Furthermore, the EOF group started oral liquid and soft diets 1.1 and 2.5 days earlier than the non-EOF group, respectively. Compared with the non-EOF group, the EOF group reported a higher energy intake (22.1%; p = 0.001) and protein intake (17.4%; p = 0.000) via oral route. Although cumulative energy and protein intakes were similar in both groups, weight reduction in the EOF group (3.6 ± 0.1%, 2.2 ± 0.7 kg) was significantly less than the non-EOF group (8.2 ± 0.9%, 5.2 ± 0.5 kg). The blood levels of total protein and transferrin increased and prealbumin decreased, regardless of the EOF application. Serum albumin increased significantly only in the EOF group.

CONCLUSION

The EOF protocol developed for post-PPPD patients enables the early initiation and increase in the amount of oral intake while significantly alleviating weight loss.

A Predictive Risk Scoring System for Clinically Relevant Pancreatic Fistula After Pancreaticoduodenectomy

Background

Postoperative pancreatic fistula remains a challenge after pancreaticoduodenectomy (PD). This study aimed to establish a scoring system to predict clinically relevant postoperative pancreatic fistula (CR-POPF) after PD.

Material/Methods

The clinical records of 361 consecutive patients who underwent PD between 2009 and 2017 were reviewed retrospectively. Patients were divided into a study group (225 patients) and a validation group (136 patients). CR-POPF was defined and classified based on the 2016 ISGPS definition and classification system. Univariate and multivariate logistic regression analyses were performed and we thus developed a scoring system based on the regression coefficient of the multivariate logistic regression model. The predictive value was determined using the receiver operating characteristic (ROC) curve.

Results

A predictive scoring system with a maximum of 6 points for CR-POPF was established using the following 4 factors: 1 point for soft pancreatic texture (OR 2.09, 95%CI 1.10–3.98, P=0.025), 1.5 points for main pancreatic duct diameter ≤2.5 mm (OR 2.72, 95%CI 1.23–5.99, P=0.013), 0.5 points for extended lymphadenectomy (OR 1.57, 95%CI 1.13–2.18, P=0.007), 0.5 points for a 25–30 g/L postoperative day 1 serum albumin (OR 1.43, 95%CI 1.02–2.00, P=0.037), and 3 points for postoperative day 1 serum albumin ≤25 g/L (OR 5.12, 95%CI 1.82–14.41, P=0.002). The ROC curve showed that this scoring system was highly predictive for CR-POPF in the validation group (AUC=0.806, 95%CI: 0.735–0.878).

Conclusions

This 6-point risk scoring system will be useful for perioperative risk management of CR-POPF.

Albumin mass balance and kinetics in liver transplantation

Background

In major abdominal surgery albumin is shifted from the circulation, presumably leaking into the interstitial space, contributing to a 30–40% decrease in plasma albumin concentration. During and after liver transplantation exogenous albumin is infused for volume substitution and to maintain plasma albumin concentration. Here we used liver transplantation as a model procedure for the study of albumin mass balance and kinetics during major abdominal surgery with albumin substitution.

Methods

Patients were studied during liver transplantation (n = 16), and until postoperative day 3 (POD 3) (n = 11). Cumulative perioperative albumin shift was assessed by mass balance of albumin and hemoglobin. Synthesis rates of albumin and fibrinogen were estimated by the flooding technique using deuterium-labeled phenylalanine. Albumin distribution was assessed by radioiodinated human serum albumin.

Results

At the end of surgery, 37 ± 17 g of albumin (p < 0.0001) had shifted from plasma, and this amount was stable until POD 3 (48 ± 33 g, p = 0.0017 versus baseline). There was 91 ± 37 g exogenous albumin infused peroperatively and another 47 ± 35 g was infused postoperatively until POD 3. Absolute synthesis rates of albumin and fibrinogen on POD 3 were 239 ± 84 mg/kg body weight/day and 33 mg/kg body weight/day (range 5–161), respectively.

Conclusions

Albumin net leakage from plasma progressed until the end of surgery, and was then unaltered until POD 3. This is in contrast with the normalization of the cumulative albumin shift identified at day 3 after non-transplant major abdominal surgery. Liver synthesis of export proteins was high compared to reference values at the third postoperative day, suggesting rapid recovery of synthesis capacity.

Trial registration

Swedish Medical Product Agency, EudraCT 2015-002568-18. Registered on 15 July 2015.

Perioperative albumin ratio is associated with post-operative pancreatic fistula

BACKGROUND

Despite improvements in surgical techniques and perioperative management, post-operative pancreatic fistula (POPF) remains a serious complication after pancreaticoduodenectomy (PD). The aim of this study was to evaluate the role of perioperative clinical variables of patients, including albumin level, in predicting pancreatic fistula.

METHODS

A total of 86 patients underwent PD for pancreas cancer between 2011 and 2017 at our institution. We prospectively investigated the relation between patient's characteristics and the incidence of clinically relevant (CR)-POPF. Perioperative albumin ratio was defined as post-operative day 1 (POD1) albumin level/preoperative albumin level.

RESULTS

A total of 23 patients (26.7%) developed CR-POPF. At univariate analysis POPF correlated with soft pancreas (P = 0.045), low POD1 albumin (P = 0.02), POD1 and POD3 amylase levels in drainage fluid (P = 0.003 and P = 0.014, respectively) and perioperative albumin ratio (0.58 ± 0.10 versus 0.69 ± 0.12 in patients without POPF; P = 0.003). No significant correlations with POPF were demonstrated for surgical time, serum amylase levels and preoperative albumin levels. At multivariate analysis POD3 amylase level in drainage fluid and perioperative albumin ratio were the only significant independent parameters (P = 0.027 and P = 0.047, respectively).

CONCLUSIONS

Perioperative albumin ratio can predict POPF after PD.

Drainage fluid and serum amylase levels accurately predict development of postoperative pancreatic fistula

AIM

To investigate potential biomarkers for predicting postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD).

METHODS

We prospectively recruited 83 patients to this study. All patients underwent PD (Child’s procedure) at the Division of Hepatobiliary and Pancreas Surgery at the First Bethune Hospital of Jilin University between June 2011 and April 2015. Data pertaining to demographic variables, clinical characteristics, texture of pancreas, surgical approach, histopathological results, white blood cell count, amylase and choline levels in the serum, pancreatic/gastric drainage fluid, and choline and amylase levels in abdominal drainage fluid were included in the analysis. Potential correlations between these parameters and postoperative complications such as, POPF, acute pancreatitis, hemorrhage, delayed gastric emptying, and biliary fistula, were assessed.

RESULTS

Twenty-eight out of the 83 (33.7%) patients developed POPF. The severity of POPF was classified as Grade A in 8 (28%) patients, grade B in 16 (58%), and grade C in 4 (14%), according to the pancreatic fistula criteria. On univariate and multivariate logistic regression analyses, higher amylase level in the abdominal drainage fluid on postoperative day (POD)1 and higher serum amylase levels on POD4 showed a significant correlation with POPF (P < 0.05). On receiver operating characteristic curve analysis, amylase cut-off level of 2365.5 U/L in the abdominal drainage fluid was associated with a 78.6% sensitivity and 80% specificity [area under the curve (AUC): 0.844; P = 0.009]. A cut-off serum amylase level of 44.2 U/L was associated with a 78.6% sensitivity and 70.9% specificity (AUC: 0.784; P = 0.05).

CONCLUSION

Amylase level in the abdominal drainage fluid on POD1 and serum amylase level on POD4 represent novel biomarkers associated with POPF development.

Short and Long-Term Outcomes After Surgical Procedures Lasting for More Than Six Hours

Long-term all-cause mortality and dependency after complex surgical procedures have not been assessed in the framework of value-based medicine. The aim of this study was to investigate the postoperative and long-term outcomes after surgical procedures lasting for more than six hours. Retrospective cohort study of patients undergoing a first elective complex surgical procedure between 2004 and 2013. Heart and transplant surgery was excluded. Mortality and dependency from the healthcare system were selected as outcome variables. Gender, age, ASA, creatinine, albumin kinetics, complications, benign vs malignant underlying condition, number of drugs at discharge, and admission and length of stay in the ICU were recorded as predictive variables. Some 620 adult patients were included in the study. Postoperative, <1year and <5years cumulative mortality was 6.8%, 17.6% and 45%, respectively. Of patients discharged from hospital after surgery, 76% remained dependent on the healthcare system. In multivariate analysis for postoperative, <1year and <5years mortality, postoperative albumin concentration, ASA score and an ICU stay >7days, were the most significant independent predictive variables. Prolonged surgery carries a significant short and long-term mortality and disability. These data may contribute to more informed decisions taken concerning major surgery in the framework of value-based medicine.

Prognostic nutritional index predicts clinical outcome in patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

We aimed to investigate whether the prognostic nutritional index (PNI), a combined nutritional-inflammatory score based on serum albumin levels and lymphocyte count, was associated with mortality in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). From September 2011 to November 2014, 309 consecutive patients with STEMI undergoing pPCI were prospectively enrolled. Patients with a combined score of albumin (g/L) + 5 × total lymphocyte count × 10⁹/L ≥ 45 or <45 were assigned a PNI score of 0 or 1, respectively. Of the 309 STEMI patients, 24 (7.74%) died in the hospital, and 15 (4.83%) died during long-term follow-up (median follow-up time, 19.5 [3–36] months). Compared to patients with a PNI of 0, patients with a PNI of 1 had significantly higher in-hospital (14.2% vs. 3.7%; P < 0.001) and long-term follow-up (21.7% vs. 6.9%, P < 0.001) mortality rates. PNI (1/0, HR, 2.414; 95% CI, 1.016 to 5.736; P = 0.046) was a significant independent predictor of mortality in patients with STEMI undergoing pPCI. Moreover, cumulative survival was significantly lower for patients with a PNI of 1 compared to patients with a PNI of 0 (78.3% vs. 93.1%, log-rank P < 0.001). PNI appears useful for the risk stratification of STEMI patients undergoing pPCI.

Blood Urea Nitrogen as a Predictor of Severe Acute Pancreatitis Based on the Revised Atlanta Criteria: Timing of Measurement and Cutoff Points

Background and Aims. This study evaluated the prognostic accuracy of BUN for severe acute pancreatitis (SAP) and in-hospital mortality (IHM) in terms of the best timing for BUN measurement and the optimal BUN cutoff points. Methods. BUN determinants at the time of admission and 24 hrs after hospital admission were recorded and analyzed statistically. The ability of BUN in predicting the SAP and the occurrence of IHM were assessed using the area under the receiver-operating characteristic (ROC) curve. Results. For SAP, AUC of BUN at admission and 24 hrs after hospital admission was 0.75 and 0.80, respectively. For IHM in acute pancreatitis, it was 0.86 at admission and 0.84 after 24 hrs of hospital admission, respectively. The optimal cutoff point of BUN 24 hrs after hospital admission for SAP and at admission for IHM was 8.3 mmol/L and 13.3 mmol/L, respectively. Conclusion. BUN determination after 24 hrs of hospital admission has high accuracy for prediction of SAP while BUN at initial admission has high accuracy for prediction of IHM.

Leakage of albumin in major abdominal surgery

Background

The time course of plasma albumin concentration (P-alb) and cumulative perioperative albumin shift as a measure of albumin extravasation in major abdominal surgery is not well described. Knowledge of these indices of the vascular barrier and vascular content are important for our understanding of fluid physiology during surgery and anesthesia.

Methods

Patients (n = 10) were studied during esophageal or pancreatic surgery. P-alb was repeatedly measured over 72 h, and the mass balance of albumin and hemoglobin were obtained from measures of P-alb, blood hemoglobin and hematocrit.

Results

P-alb decreased rapidly from baseline (32.8 ± 4.8 g/L) until the start of surgical reconstruction (18.7 ± 4.8 g/L; p < 0.001), and was thereafter stable until postoperative day 3. Cumulative perioperative albumin shift increased until 1 h after the end of surgery, when 24 ± 17 g (p < 0.001) had been lost from the circulation.

Conclusions

The rapid fall in P-alb of more than 40 % consistently occurred during the first part of the surgical procedure, but albumin leakage progressed until 1 h after the end of surgery. After the initial drop, P-alb was stable for 72 h.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1283-8) contains supplementary material, which is available to authorized users.

The Standardization of Pancreatoduodenectomy: Where Are We?

Pancreaticoduodenectomy (PD) represents an important challenge for surgeons due to the complexity of the operation, requirement for technical skills and experience, and postoperative management involving important and life-threatening complications. Despite efforts to reduce mortality in high-volume centers, the morbidity rate is still high (approximately 40-50%). The PD standardization process of surgical aspects and preoperative and postoperative settings is essential to permit pancreatic surgeons to communicate in the same language, compare experiences and results, and to improve the short- and long-term outcomes. The aim of this article is to assess the state of the art practices for important matters of debate for PD (the role of mini invasive approach, the definition and the role of mesopancreas, the extent of lymphadenectomy, the different methods of reconstructions, the prophylactic drainage of the abdominal cavity), and to suggest possible future studies.

How Does Outcomes Research Help Advance Our Knowledge of Patient Outcomes in Hepatopancreaticobiliary Surgery?

Randomized controlled trials have historically been regarded as the gold standard of modern clinical research tools, allowing us to elucidate the efficacy of novel therapeutics in an unparalleled manner. However, when attempting to generalize trial results to broader populations, it becomes apparent that the unexplained outcome variability exists among treatment recipients, suggesting that randomized controlled trials harbor inherent limitations. Herein, we explore the benefits of health services (outcomes) research utilization in addressing variation in patient outcomes following surgical intervention in the non-randomized setting, with a specific focus on hepatopancreaticobiliary surgery outcomes. To achieve this, we have constructed a framework that outlines the complex interactions existing between therapeutic, patient, and provider factors that subsequently lead to variation in outcomes. By exploring examples in the current literature, we have highlighted the areas where the knowledge is currently lacking and can be further strengthened through the application of outcomes research. Furthermore, we have attempted to demonstrate the utility of alternative study designs in the investigation of novel clinical questions currently unanswered in the field of hepatopancreaticobiliary surgery.

Albumin Kinetics in Patients Undergoing Major Abdominal Surgery

Background

The drop in plasma albumin concentration following surgical trauma is well known, but the temporal pattern of the detailed mechanisms behind are less well described. The aim of this explorative study was to assess changes in albumin synthesis and transcapillary escape rate (TER) following major surgical trauma, at the time of peak elevations in two well-recognized markers of inflammation.

Methods

This was a clinical trial of radiolabeled human serum albumin for the study of TER and plasma volume. Ten patients were studied immediately preoperatively and on the 2nd postoperative day after major pancreatic surgery. Albumin synthesis rate was measured by the flooding dose technique employing incorporation of isotopically labelled phenylalanine.

Results

Fractional synthesis rate of albumin increased from 11.7 (95% CI: 8.9, 14.5) to 15.0 (11.7, 18.4) %/day (p = 0.027), whereas the corresponding absolute synthesis rate was unchanged, 175 (138, 212) versus 150 (107, 192) mg/kg/day (p = 0.21). TER was unchanged, 4.9 (3.1, 6.8) %/hour versus 5.5 (3.9, 7.2) (p = 0.63). Plasma volume was unchanged but plasma albumin decreased from 33.5 (30.9, 36.2) to 22.1 (19.8, 24.3) g/L. (p<0.001).

Conclusion

Two days after major abdominal surgery, at the time-point when two biomarkers of generalised inflammation were at their peak and the plasma albumin concentration had decreased by 33%, we were unable to show any difference in the absolute synthesis rate of albumin, TER and plasma volume as compared with values obtained immediately pre-operatively. This suggests that capillary leakage, if elevated postoperatively, had ceased at that time-point. The temporal relations between albumin kinetics, capillary leakage and generalised inflammation need to be further explored.

Trial Registration

clinicaltrialsregister.eu: EudraCT 2010-08529-21 ClinicalTrials.gov NCT01194492

Urea

Urea is generated by the urea cycle enzymes, which are mainly in the liver but are also ubiquitously expressed at low levels in other tissues. The metabolic process is altered in several conditions such as by diets, hormones, and diseases. Urea is then eliminated through fluids, especially urine. Blood urea nitrogen (BUN) has been utilized to evaluate renal function for decades. New roles for urea in the urinary system, circulation system, respiratory system, digestive system, nervous system, etc., were reported lately, which suggests clinical significance of urea.

Risk factors and outcomes of postoperative pancreatic fistula after pancreatico-duodenectomy: an audit of 532 consecutive cases

BACKGROUND

Pancreatic fistula (PF) remains the most challenging complication after pancreaticoduodenectomy (PD). The purpose of this study was to identify the risk factors of PF and delineate its impact on patient outcomes.

METHODS

We retrospectively reviewed clinical data of 532 patients who underwent PD and divided them into PF group and no PF group. Risk factors and outcomes of PF following PD were examined.

RESULTS

PF was found in 65 (12.2%) cases, of whom 11 were classified into ISGPF grade A, 42 grade B, and 12 grade C. Clinically serious postoperative complications in the PF versus no PF group were mortality, abdominal bleeding, bile leak, intra-abdominal abscess and pneumonia. Univariate and multivariate analysis showed that blood loss ≥ 500 ml, pancreatic duct diameter ≤ 3 mm and pancreaticojejunostomy type were independent risk factors of PF after PD.

CONCLUSIONS

Blood loss ≥ 500 ml, pancreatic duct diameter ≤ 3 mm and pancreatico-jejunostomy type were independent risk factors of PF after PD. PF was related with higher mortality rate, longer hospital stay, and other complications.

The gastric/pancreatic amylase ratio predicts postoperative pancreatic fistula with high sensitivity and specificity

This article aims to identify risk factors for postoperative pancreatic fistula (POPF) and evaluate the gastric/pancreatic amylase ratio (GPAR) on postoperative day (POD) 3 as a POPF predictor in patients who undergo pancreaticoduodenectomy (PD).POPF significantly contributes to mortality and morbidity in patients who undergo PD. Previously identified predictors for POPF often have low predictive accuracy. Therefore, accurate POPF predictors are needed.In this prospective cohort study, we measured the clinical and biochemical factors of 61 patients who underwent PD and diagnosed POPF according to the definition of the International Study Group of Pancreatic Fistula. We analyzed the association between POPF and various factors, identified POPF risk factors, and evaluated the predictive power of the GPAR on POD3 and the levels of serum and ascites amylase.Of the 61 patients, 21 developed POPF. The color of the pancreatic drain fluid, POD1 serum, POD1 median output of pancreatic drain fluid volume, and GPAR were significantly associated with POPF. The color of the pancreatic drain fluid and high GPAR were independent risk factors. Although serum and ascites amylase did not predict POPF accurately, the cutoff value was 1.24, and GPAR predicted POPF with high sensitivity and specificity.This is the first report demonstrating that high GPAR on POD3 is a risk factor for POPF and showing that GPAR is a more accurate predictor of POPF than the previously reported amylase markers.

Analysis of risk factors for postoperative pancreatic fistula following pancreaticoduodenectomy

AIM: To explore the morbidity and risk factors of postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy.

METHODS: The data from 196 consecutive patients who underwent pancreaticoduodenectomy, performed by different surgeons, in the General Hospital of the People’s Liberation Army between January 1^st, 2013 and December 31^st, 2013 were retrospectively collected for analysis. The diagnoses of POPF and clinically relevant (CR)-POPF following pancreaticoduodenectomy were judged strictly by the International Study Group on Pancreatic Fistula Definition. Univariate analysis was performed to analyze the following factors: patient age, sex, body mass index (BMI), hypertension, diabetes mellitus, serum CA19-9 level, history of jaundice, serum albumin level, blood loss volume, pancreatic duct diameter, pylorus preserving pancreaticoduodenectomy, pancreatic drainage and pancreaticojejunostomy. Multivariate logistic regression analysis was used to determine the main independent risk factors for POPF.

RESULTS: POPF occurred in 126 (64.3%) of the patients, and the incidence of CR-POPF was 32.7% (64/196). Patient characteristics of age, sex, BMI, hypertension, diabetes mellitus, serum CA19-9 level, history of jaundice, serum albumin level, blood loss volume, pylorus preserving pancreaticoduodenectomy and pancreaticojejunostomy showed no statistical difference related to the morbidity of POPF or CR-POPF. Pancreatic duct diameter was found to be significantly correlated with POPF rates by univariate analysis and multivariate regression analysis, with a pancreatic duct diameter ≤ 3 mm being an independent risk factor for POPF (OR = 0.291; P = 0.000) and CR-POPF (OR = 0.399; P = 0.004). The CR-POPF rate was higher in patients without external pancreatic stenting, which was found to be an independent risk factor for CR-POPF (OR = 0.394; P = 0.012). Among the entire patient series, there were three postoperative deaths, giving a total mortality rate of 1.5% (3/196), and the mortality associated with pancreatic fistula was 2.4% (3/126).

CONCLUSION: A pancreatic duct diameter ≤ 3 mm is an independent risk factor for POPF. External stent drainage of pancreatic secretion may reduce CR-POPF mortality and POPF severity.

Is routine drainage necessary after pancreaticoduodenectomy?

With the development of imaging technology and surgical techniques, pancreatic resections to treat pancreatic tumors, ampulla tumors, and other pancreatic diseases have increased. Pancreaticoduodenectomy, one type of pancreatic resection, is a complex surgery with the loss of pancreatic integrity and various anastomoses. Complications after pancreaticoduodenectomy such as pancreatic fistulas and anastomosis leakage are common and significantly associated with patient outcomes. Pancreatic fistula is one of the most important postoperative complications; this condition can cause intraperitoneal hemorrhage, septic shock, or even death. An effective way has not yet been found to avoid the occurrence of pancreatic fistula. In most medical centers, the frequency of pancreatic fistula has remained between 9% and 13%. The early detection and routine drainage of anastomotic fistulas, pancreatic fistulas, bleeding, or other intra-abdominal fluid collections after pancreatic resections are considered as important and effective ways to reduce postoperative complications and the mortality rate. However, many recent studies have argued that routine drainage after abdominal operations, including pancreaticoduodenectomies, does not affect the incidence of postoperative complications. Although inserting drains after pancreatic resections continues to be a routine procedure, its necessity remains controversial. This article reviews studies of the advantages and disadvantages of routine drainage after pancreaticoduodenectomy and discusses the necessity of this procedure.

Serum amylase on the night of surgery predicts clinically significant pancreatic fistula after pancreaticoduodenectomy

OBJECTIVES

Drainage after pancreaticoduodenectomy (PD) remains controversial because the risk for uncontrolled postoperative pancreatic fistula (POPF) must be balanced against the potential morbidity associated with prolonged and possibly unnecessary drainage. This study investigated the utility of the level of serum amylase on the night of surgery [postoperative day (PoD) 0 serum amylase] to predict POPF.

METHODS

A total of 185 patients who underwent PD were studied. Occurrences of POPF were graded using the International Study Group on Pancreatic Fistula (ISGPF) classification. Receiver operating characteristic (ROC) analysis identified a threshold value of PoD 0 serum amylase associated with clinically significant POPF (ISGPF Grades B and C) in a test cohort (n = 45). The accuracy of this threshold value was then tested in a validation cohort (n = 140).

RESULTS

Overall, 43 (23.2%) patients developed clinically significant POPF. The threshold value of PoD 0 serum amylase for the identification of clinically significant POPF was ≥ 130 IU/l (P = 0.003). Serum amylase of <130 IU/l had a negative predictive value of 88.8% for clinically significant POPF (P < 0.001). Serum amylase of ≥ 130 IU/l on PoD 0 and a soft pancreatic parenchyma were independent risk factors for clinically significant POPF.

CONCLUSIONS

Postoperative day 0 serum amylase of <130 IU/l allows for the early and accurate categorization of patients at least risk for clinically significant POPF and may identify patients suitable for early drain removal.

Morbidity and mortality after pancreaticoduodenectomy in patients with borderline resectable type C clinical classification

BACKGROUND

We previously described the clinical classification of patients with resectable pancreatic tumor anatomy but marginal performance status (PS) or reversible comorbidities as "borderline resectable type C" (BR-C). This study was designed to analyze the incidence and risk factors for post-pancreaticoduodenectomy (PD) morbidity/mortality in a multi-institutional cohort of BR-C patients.

METHODS

Elective PDs were evaluated from the 2005-10 ACS-NSQIP database. BR-C was defined as age ≥ 80, poor PS, weight loss > 10 %, pulmonary disease, recent myocardial infarction/angina, stroke history, and/or preoperative sepsis. Variables associated with 30-day postoperative major complications (PMC) and mortality were analyzed.

RESULTS

A total of 3,033/8,266 (36.7 %) patients were BR-C. BR-C patients were more likely to suffer PMC (31.3 vs. 26.2 %) and mortality (4.1 vs. 2.3 %). BR-C patients with PMC suffered 50 % higher mortality versus non-BR-C patients with PMC (11.5 vs. 7.7 %) (all p < 0.001). For BR-C patients, multivariate analysis identified the following risk factors for PMC or mortality: albumin < 3.5 g/dL, dyspnea, preoperative sepsis, age ≥ 80, poor PS, anesthesia score ≥ 4, and intraoperative transfusion ≥ 4 units.

CONCLUSIONS

Nationwide, one third of patients undergoing PD are medically borderline. These BR-C patients are at higher risk for and less able to be rescued from PMC. Surgeons should identify and optimize comorbidities and utilize prehabilitation to address functional deficits before elective PD.