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Ciprani D, Capretti G, Sorrentino M, Gramellini M, Famularo S, Casari E, Gavazzi F, Nappo G, Ridolfi C, Zerbi A. Clinical usefulness of routinely performed drain fluid cultures after pancreaticoduodenectomy. A new ally to predict patients' outcomes? Pancreatology 2024; 24:178-183. [PMID: 38171972 DOI: 10.1016/j.pan.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 12/28/2023] [Accepted: 12/29/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Previous studies showed that bacterial contamination of surgical drains was associated with higher morbidity and mortality following pancreaticoduodenectomy (PD). However, there is still no agreement on the routine use of fluid drainage cultures in the management of patients underwent PD. Therefore, we aimed to clarify the role of surgical drain bacterial contamination in predicting patients' postoperative course. METHOD Single-centre study including patients underwent PD at Humanitas Research Hospital (2010-2021). Preoperative, intraoperative and postoperative data were collected. Routinely performed fluid drain cultures on postoperative day (POD) 5 were analyzed and compared among patients throughout the cohort. RESULTS A total of 825 patients were analyzed. Bacterial contamination of surgical drains was observed in 420 (50.9 %) patients and it was found to be associated with a higher rate of B/C grade pancreatic fistula (POPF) (P < 0.001), Clavien-Dindo≥3 (P < 0.001), 30-day mortality (P = 0.011), wound infection (P < 0.001), relaparotomies (P = 0.003) and greater length of hospital stay (LOS) (P < 0.001). Also, E. coli surgical drain contamination was demonstrated to double the risk of B/C grade POPF development (OR = 1.628, 95 % IC = 1.009-2.625, P = 0.046). Finally, preoperative biliary drainage (OR = 2.474, 95 % IC = 1.855-3.298, P < 0.001), age ≥75 years old (OR = 1.492, 95 % IC = 1.077-2.067, P = 0.016) and isolated Roux-en-Y pancreaticojejunostomy (OR = 1.639, 95 % IC = 1.229-2.188, P < 0.001) were identified as risk factors for surgical drains bacterial contamination. CONCLUSION Bacterial contamination of surgical drains predicts the development of B/C grade POPF and other major complications after PD. Therefore, we suggest the routine use of fluid drain cultures following PD.
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Affiliation(s)
- Debora Ciprani
- Pancreatic Surgery Unit, Humanitas Clinical and Research Hospital - IRCCS, Rozzano, Milan, Italy
| | - Giovanni Capretti
- Pancreatic Surgery Unit, Humanitas Clinical and Research Hospital - IRCCS, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Martina Sorrentino
- Pancreatic Surgery Unit, Humanitas Clinical and Research Hospital - IRCCS, Rozzano, Milan, Italy
| | - Marco Gramellini
- Pancreatic Surgery Unit, Humanitas Clinical and Research Hospital - IRCCS, Rozzano, Milan, Italy
| | - Simone Famularo
- Division of Hepatobiliary and General Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Erminia Casari
- Laboratory Medicine, Humanitas Clinical and Research Center, IRCCS, Rozzano, Milan, Italy
| | - Francesca Gavazzi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Hospital - IRCCS, Rozzano, Milan, Italy
| | - Gennaro Nappo
- Pancreatic Surgery Unit, Humanitas Clinical and Research Hospital - IRCCS, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Cristina Ridolfi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Hospital - IRCCS, Rozzano, Milan, Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Hospital - IRCCS, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
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2
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Perri G, Bortolato C, Marchegiani G, Holmberg M, Romandini E, Sturesson C, Bassi C, Sparrelid E, Ghorbani P, Salvia R. Pure biliary leak vs. pancreatic fistula associated: non-identical twins following pancreatoduodenectomy. HPB (Oxford) 2022; 24:1474-1481. [PMID: 35367129 DOI: 10.1016/j.hpb.2022.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 02/23/2022] [Accepted: 03/10/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Biliary leak (BL) after pancreatoduodenectomy (PD) may have diffrent severity depending on its association with postoperative pancreatic fistula (POPF). METHODS Data of 2715 patients undergoing PD between 2011 and 2020 at two European third-level referral Centers for pancreatic surgery were retrospectively reviewed. These included BL incidences, grading, outcomes, specific treatments, and association with POPF. RESULTS BL occurred in 6% of patients undergoing PD. Among 143 BL patients, 47% had an associated POPF and 53% a pure BL. Major morbidity (64% vs 36%) and mortality (19% vs 4%) were higher in POPF-associated BL group (all P< 0.01). Day of BL onset was similar between groups (POD 2 vs 3; P = 0.2), while BL closure occurred earlier in pure BL (POD 12 vs 23; P < 0.01). Conservative treatment was more frequent (55% vs 15%; P < 0.01), and the rate of percutaneous and/or trans-hepatic drain placement was lower (30% vs 16%; P = 0.04) in pure BL group. Relaparotomy was more common in POPF-associated BL group (42% VS 17%; P < 0.01) but was performed earlier in pure BL (POD 2 vs 10; P = 0.02). CONCLUSIONS Pure BL represents a more benign entity, managed conservatively in half of the cases.
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Affiliation(s)
- Giampaolo Perri
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Cecilia Bortolato
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy; Division of Surgery, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy.
| | - Marcus Holmberg
- Division of Surgery, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Elisa Romandini
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Christian Sturesson
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Ernesto Sparrelid
- Division of Surgery, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Poya Ghorbani
- Division of Surgery, Department of Clinical Science, Intervention, and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
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3
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Henry AC, Smits FJ, van Lienden K, van den Heuvel DAF, Hofman L, Busch OR, van Delden OM, Zijlstra IJA, Schreuder SM, Lamers AB, van Leersum M, van Strijen MJL, Vos JA, Te Riele WW, Molenaar IQ, Besselink MG, van Santvoort HC. Biliopancreatic and biliary leak after pancreatoduodenectomy treated by percutaneous transhepatic biliary drainage. HPB (Oxford) 2022; 24:489-497. [PMID: 34556407 DOI: 10.1016/j.hpb.2021.08.941] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/02/2021] [Accepted: 08/16/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Complementary to percutaneous intra-abdominal drainage, percutaneous transhepatic biliary drainage (PTBD) might ameliorate healing of pancreatic fistula and biliary leakage after pancreatoduodenectomy by diversion of bile from the site of leakage. This study evaluated technical and clinical outcomes of PTBD for this indication. METHODS All patients undergoing PTBD for leakage after pancreatoduodenectomy were retrospectively evaluated in two tertiary pancreatic centers (2014-2019). Technical success was defined as external biliary drainage. Clinical success was defined as discharge with a resolved leak, without additional surgical interventions for anastomotic leakage other than percutaneous intra-abdominal drainage. RESULTS Following 822 pancreatoduodenectomies, 65 patients (8%) underwent PTBD. Indications were leakage of the pancreaticojejunostomy (n = 25; 38%), hepaticojejunostomy (n = 15; 23%) and of both (n = 25; 38%). PTBD was technically successful in 64 patients (98%) with drain revision in 40 patients (63%). Clinical success occurred in 60 patients (94%). Leakage resolved after median 33 days (IQR 21-60). PTBD related complications occurred in 23 patients (35%), including cholangitis (n = 14; 21%), hemobilia (n = 7; 11%) and PTBD related bleeding requiring re-intervention (n = 4; 6%). In hospital mortality was 3% (n = 2). CONCLUSION Although drain revisions and complications are common, PTBD is highly feasible and appears to be effective in the treatment of biliopancreatic leakage after pancreatoduodenectomy.
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Affiliation(s)
- Anne Claire Henry
- Department of Hepato-Pancreato-Biliary Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein and University Medical Center Utrecht, the Netherlands
| | - F Jasmijn Smits
- Department of Hepato-Pancreato-Biliary Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein and University Medical Center Utrecht, the Netherlands
| | - Krijn van Lienden
- Department of Interventional Radiology, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, the Netherlands
| | - Daniel A F van den Heuvel
- Department of Interventional Radiology, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, the Netherlands
| | - Lieke Hofman
- Department of Hepato-Pancreato-Biliary Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein and University Medical Center Utrecht, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Otto M van Delden
- Department of Interventional Radiology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - IJsbrand A Zijlstra
- Department of Interventional Radiology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Sanne M Schreuder
- Department of Interventional Radiology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Armand B Lamers
- Department of Interventional Radiology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marc van Leersum
- Department of Interventional Radiology, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, the Netherlands
| | - Marco J L van Strijen
- Department of Interventional Radiology, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, the Netherlands
| | - Jan A Vos
- Department of Interventional Radiology, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, the Netherlands
| | - Wouter W Te Riele
- Department of Hepato-Pancreato-Biliary Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein and University Medical Center Utrecht, the Netherlands
| | - I Quintus Molenaar
- Department of Hepato-Pancreato-Biliary Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein and University Medical Center Utrecht, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Hepato-Pancreato-Biliary Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein and University Medical Center Utrecht, the Netherlands.
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Clemente G, De Rose AM, Panettieri E, Ardito F, Murazio M, Nuzzo G, Giuliante F. Pancreatico-Jejunostomy On Isolated Loop After Pancreatico-Duodenectomy: Is It Worthwhile? J Gastrointest Surg 2022; 26:1205-1212. [PMID: 35296957 PMCID: PMC9184425 DOI: 10.1007/s11605-022-05296-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 02/11/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Postoperative morbidity remains a significant problem after pancreatico-duodenectomy. The management of pancreatic stump continues to be a challenge, and many technical solutions have been developed over the years. In this study, we report the results obtained with the use of an isolated loop for pancreatico-jejunostomy in patients with soft pancreas and small pancreatic duct diameter. METHODS Clinical data of patients submitted to pancreatico-duodenectomy in a period of sixteen years (2005-2020) were extracted from a prospective database. Patients with soft pancreas, main duct diameter < 2 mm and reconstruction by pancreatico-jejunostomy on single loop or isolated loop were selected. Primary end-point was the incidence of clinically relevant fistulas in the two groups of patients. Secondary endpoint was the length of postoperative hospital stay. A propensity score matching analysis was used for the statistics. RESULTS Two hundred and twenty-one patients with the above characteristics were found in the database. One hundred and twelve of these received a single-loop reconstruction and 109 an isolated loop reconstruction. Incidence of clinically relevant fistulas was higher in the first group (41% vs 27%; p = 0.023). Postoperative hospital stay was significantly shorter in the second group (21 days vs 15; p < 0.001). These results were confirmed at the propensity score matching. CONCLUSION In patients with soft pancreatic texture and small main duct diameter, pancreatico-jejunostomy on isolated loop is associated with a lower incidence of clinically relevant fistulas than after classic reconstruction. The duration of postoperative hospital stay was significantly reduced, with consequent reduction of cost.
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Affiliation(s)
- Gennaro Clemente
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Agostino Maria De Rose
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Elena Panettieri
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Ardito
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marino Murazio
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gennaro Nuzzo
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Felice Giuliante
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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5
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Li YT, Zhang HY, Xing C, Ding C, Wu WM, Liao Q, Zhang TP, Zhao YP, Dai MH. Effect of Blumgart anastomosis in reducing the incidence rate of pancreatic fistula after pancreatoduodenectomy. World J Gastroenterol 2019; 25:2514-2523. [PMID: 31171894 PMCID: PMC6543243 DOI: 10.3748/wjg.v25.i20.2514] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/02/2019] [Accepted: 05/08/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatic fistula is one of the most serious complications after pancreatoduodenectomy for treating any lesions at the pancreatic head. For years, surgeons have tried various methods to reduce its incidence.
AIM To investigate and emphasize the clinical outcomes of Blumgart anastomosis compared with traditional anastomosis in reducing postoperative pancreatic fistula.
METHODS In this observational study, a retrospective analysis of 291 patients who underwent pancreatoduodenectomy, including Blumgart anastomosis (201 patients) and traditional embedded pancreaticojejunostomy (90 patients), was performed in our hospital. The preoperative and perioperative courses and long-term follow-up status were analyzed to compare the advantages and disadvantages of the two methods. Moreover, 291 patients were then separated by the severity of postoperative pancreatic fistula, and two methods of pancreaticojejunostomy were compared to detect the features of different anastomosis. Six experienced surgeons were involved and all of them were proficient in both surgical techniques.
RESULTS The characteristics of the patients in the two groups showed no significant differences, nor the preoperative information and pathological diagnoses. The operative time was significantly shorter in the Blumgart group (343.5 ± 23.0 vs 450.0 ± 40.1 min, P = 0.028), as well as the duration of pancreaticojejunostomy drainage tube placement and postoperative hospital stay (12.7 ± 0.9 d vs 17.4 ± 1.8 d, P = 0.031; and 21.9 ± 1.3 d vs 28.9 ± 1.3 d, P = 0.020, respectively). The overall complications after surgery were much less in the Blumgart group than in the embedded group (11.9% vs 26.7%, P = 0.002). Patients who underwent Blumgart anastomosis would suffer less from severe pancreatic fistula (71.9% vs 50.0%, P = 0.006), and this pancreaticojejunostomy procedure did not have worse influences on long-term complications and life quality. Thus, Blumgart anastomosis is a feasible pancreaticojejunostomy procedure in pancreatoduodenectomy surgery. It is safe in causing less postoperative complications, especially pancreatic fistula, and thus shortens the hospitalization duration.
CONCLUSION Surgical method should be a key factor in reducing pancreatic fistula, and Blumgart anastomosis needs further promotion.
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Affiliation(s)
- Ya-Tong Li
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Han-Yu Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Cheng Xing
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Cheng Ding
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Wen-Ming Wu
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Quan Liao
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Tai-Ping Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Yu-Pei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Meng-Hua Dai
- Department of General Surgery, Peking Union Medical College Hospital, Beijing 100730, China
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6
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Perrotta de Souza LM, Moreira JP, Fogaça HS, Eulálio JMR, Luiz RR, de Souza HS. Increasing pancreatic cancer is not paralleled by pancreaticoduodenectomy volumes in Brazil: A time trend analysis. Hepatobiliary Pancreat Dis Int 2019; 18:79-86. [PMID: 30583855 DOI: 10.1016/j.hbpd.2018.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 12/04/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Currently, surgical resection represents the only curative treatment for pancreatic cancer (PC), however, the majority of tumors are no longer resectable by the time of diagnosis. The aim of this study was to describe time trends and distribution of pancreaticoduodenectomies (PDs) performed for treating PC in Brazil in recent years. METHODS Data were retrospectively obtained from Brazilian Health Public System (namely DATASUS) regarding hospitalizations for PC and PD in Brazil from January 2008 to December 2015. PC and PD rates and their mortalities were estimated from DATASUS hospitalizations and analyzed for age, gender and demographic characteristics. RESULTS A total of 2364 PDs were retrieved. Albeit PC incidence more than doubled, the number of PDs increased only 37%. Most PDs were performed in men (52.2%) and patients between 50 and 69 years old (59.5%). Patients not surgically treated and those 70 years or older had the highest in-hospital mortality rates. The most developed regions (Southeast and South) as well as large metropolitan integrated municipalities registered 76.2% and 54.8% of the procedures, respectively. LMIM PD mortality fluctuated, ranging from 13.6% in 2008 to 11.8% in 2015. CONCLUSIONS This study suggests a trend towards regionalization and volume-outcome relationships for PD due to PC, as large metropolitan integrated municipalities registered most of the PDs and more stable mortality rates. The substantial differences between PD and PC increasing rates reveals a limiting step on the health system resoluteness. Reduction in the number of hospital beds and late access to hospitalization, despite improvement in diagnostic methods, could at least in part explain these findings.
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Affiliation(s)
- Lucila M Perrotta de Souza
- Department of Internal Medicine, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jessica Pl Moreira
- Institute of Public Health Studies (IESC), Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Homero S Fogaça
- Department of Internal Medicine, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - José Marcus Raso Eulálio
- Department of Surgery, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ronir R Luiz
- Institute of Public Health Studies (IESC), Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Heitor Sp de Souza
- Department of Internal Medicine, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; D'Or Institute for Research and Education, Rio de Janeiro, Brazil.
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7
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Fiorentini G, Tamburrino D, Belfiori G, Crippa S, Partelli S, Falconi M. Which is the best pancreatic anastomosis? MINERVA CHIR 2019; 74:241-252. [PMID: 30665292 DOI: 10.23736/s0026-4733.19.07997-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Postoperative pancreatic fistula is responsible for most of the complications following pancreaticoduodenectomy and several surgical techniques and strategies to prevent it have been suggested. None of these was ever proved to be the safest. Aim of this review is to present existing evidence on the best pancreatic anastomosis.
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Affiliation(s)
- Guido Fiorentini
- Division of Pancreatic Surgery, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Giulio Belfiori
- Division of Pancreatic Surgery, IRCCS San Raffaele Hospital, Milan, Italy
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8
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Busquets J, Martín S, Fabregat J, Secanella L, Pelaez N, Ramos E. Randomized trial of two types of gastrojejunostomy after pancreatoduodenectomy and risk of delayed gastric emptying (PAUDA trial). Br J Surg 2018; 106:46-54. [PMID: 30507039 DOI: 10.1002/bjs.11023] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 05/14/2018] [Accepted: 09/25/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is the most important cause of an extended hospital stay after pancreatoduodenectomy. Reports suggest that a Roux-en-Y gastroenteric anastomosis may have lower incidence of DGE than a Billroth II reconstruction. The primary aim of this RCT was to compare Billroth II (single loop) and Roux-en-Y (double loop) after pancreatoduodenectomy to determine whether Roux-en-Y reconstruction is associated with a lower incidence of DGE. Secondary endpoints were postoperative complications. METHODS This was a randomized unblinded single-centre trial without masked evaluation of the main outcome. Patients undergoing pancreatoduodenectomy between 2013 and 2015 were randomized to undergo one of two types of gastroenteric anastomosis for reconstruction. RESULTS A total of 80 patients were randomized, 40 in each group. The incidence of DGE was the same in patients undergoing Billroth II or Roux-en-Y gastroenteric anastomosis (both 18 of 40 patients; P = 1·000). The grade of DGE was also similar in the Billroth II and Roux-en-Y groups (grade A, both 10 of 40; grade B, 5 of 40 versus 6 of 40; grade C, 3 of 40 versus 2 of 40; P = 0·962). The mortality rate was 3 per cent, with no significant difference between the two groups. There were no differences in the overall rate of postoperative morbidity, relaparotomy rate or duration of hospital stay. CONCLUSION The incidence and severity of DGE does not differ between single- or double-loop gastroenteric anastomosis performed after pancreatoduodenectomy. Registration number: NCT00915863 (http://www.clinicaltrials.gov).
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Affiliation(s)
- J Busquets
- Unitat de Cirurgia Hepatobiliopancreàtica i Trasplantament Hepàtic, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - S Martín
- Cirurgia General i Digestiva, Hospital Viladecans, Barcelona, Spain
| | - J Fabregat
- Unitat de Cirurgia Hepatobiliopancreàtica i Trasplantament Hepàtic, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - L Secanella
- Unitat de Cirurgia Hepatobiliopancreàtica i Trasplantament Hepàtic, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - N Pelaez
- Unitat de Cirurgia Hepatobiliopancreàtica i Trasplantament Hepàtic, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - E Ramos
- Unitat de Cirurgia Hepatobiliopancreàtica i Trasplantament Hepàtic, Hospital Universitari de Bellvitge, Barcelona, Spain
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9
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Aghalarov I, Herzog T, Uhl W, Belyaev O. A modified single-loop reconstruction after pancreaticoduodenectomy reduces severity of postoperative pancreatic fistula in high-risk patients. HPB (Oxford) 2018; 20:676-683. [PMID: 29456198 DOI: 10.1016/j.hpb.2018.01.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 12/17/2017] [Accepted: 01/03/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Double-loop (DL) reconstruction after pancreaticoduodenectomy (PD), diverting pancreatic from biliary secretions, has been reported to reduce rates and severity of postoperative pancreatic fistula (POPF) compared to single loop (SL) reconstruction at the price of prolonged operative duration. This study investigated the feasibility of a new reconstruction method combining the advantages of DL with the simplicity of SL in patients with high-risk pancreas. METHODS A modified single-loop (mSL) reconstruction was used in patients undergoing PD with a soft pancreatic remnant and a pancreatic duct smaller than 3 mm (n = 50). The loop between the pancreatic and the biliary anastomoses was left longer and a side-to-side jejunojejunal anastomosis was performed between them at the lowest point to promote isolated flow of pancreatic and biliary secretions. Rate and severity of POPF, mortality, duration of surgery, and POPF-associated morbidity were compared to those of 50 matched patients with SL and 25 patients with DL reconstruction. RESULTS Duration of surgery was 57 min longer for DL, but equal for mSL and SL. The POPF rate did not differ between the three groups. The severity of POPF was more pronounced in the SL group (62% grade C: p = 0.011). Mortality and major morbidity were lower and hospital stay shorter in the mSL and DL groups compared to the SL group. CONCLUSIONS The new mSL reconstruction was safer than conventional SL and faster to perform than DL reconstruction in patients with a high-risk pancreas. It did not influence the rate of POPF, but reduced its severity, leading to less major morbidity and mortality.
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Affiliation(s)
- Ilgar Aghalarov
- Department of Surgery, St. Josef Hospital, Ruhr University of Bochum, Germany
| | - Torsten Herzog
- Department of Surgery, St. Josef Hospital, Ruhr University of Bochum, Germany
| | - Waldemar Uhl
- Department of Surgery, St. Josef Hospital, Ruhr University of Bochum, Germany
| | - Orlin Belyaev
- Department of Surgery, St. Josef Hospital, Ruhr University of Bochum, Germany.
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10
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Number of acinar cells at the pancreatic stump predicts pancreatic fistula after pancreaticoduodenectomy. Surg Today 2018; 48:790-795. [DOI: 10.1007/s00595-018-1656-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 03/13/2018] [Indexed: 12/28/2022]
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11
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Abstract
BACKGROUND Pancreatic anastomosis is the Achilles heel of pancreatic surgery. Despite substantial progress in surgical techniques the rate of postoperative pancreatic fistulas remains very high. For this reason various supportive measures to secure pancreatic anastomoses are of continuing interest. OBJECTIVE This review presents the newest evidence-based data on supportive measures designed to secure a pancreatic anastomosis. MATERIAL AND METHODS The most recent meta-analyses, randomized controlled trials and the largest retrospective studies on the role of pancreatic duct stenting, double loop reconstruction, autologous patches and drainage in pancreaticoduodenectomy were taken into account. The value of somatostatin analogues, perioperative nutrition and fluid management is critically discussed. RESULTS The existing body of evidence on supportive measures is insufficient and remains controversial. The use of somatostatin analogues, drainages and restrictive perioperative fluid management has proven effective. In contrast, routine stenting of the pancreatic duct cannot be recommended. Other approaches, such as double loop reconstruction and use of autologous patches lack sufficient evidence. CONCLUSION Meticulous surgical technique and surgeon experience remain the cornerstones of performing a safe pancreatic anastomosis; however, some additional supportive measures seem to have significant potential and should be further investigated in large and well-designed prospective clinical trials.
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Affiliation(s)
- O Belyaev
- Klinik für Allgemein- und Viszeralchirurgie, St. Josef-Hospital, Ruhr-Universiät Bochum, Gudrunstr. 56, 44791, Bochum, Deutschland.
| | - W Uhl
- Klinik für Allgemein- und Viszeralchirurgie, St. Josef-Hospital, Ruhr-Universiät Bochum, Gudrunstr. 56, 44791, Bochum, Deutschland
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12
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Oguro S, Yoshimoto J, Imamura H, Ishizaki Y, Kawasaki S. Three hundred and sixty-eight consecutive pancreaticoduodenectomies with zero mortality. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2017; 24:226-234. [PMID: 28103418 DOI: 10.1002/jhbp.433] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Only a limited number of reports have documented zero mortality in consecutive pancreaticoduodenectomy series. The aim of this study is to review and verify our management aiming to eliminate mortality after pancreaticoduodenectomy. METHODS Three hundred and sixty-eight consecutive patients undergoing pancreaticoduodenectomy between 2002 and 2015 were retrospectively reviewed. During this period, in order to enhance the safety of pancreaticoduodenectomy, we have used a consistent strategy consisting of early ligation of the inferior pancreatoduodenal artery, mucosal sutureless pancreaticojejunostomy combined with external pancreatic duct stenting, conditional two-stage pancreaticojejunostomy, jejunal decompression using tube jejunostomy, application of an omental flap to cover the stump of the gastroduodenal artery, and careful postoperative drain management. RESULTS Major postoperative complications (Clavien-Dindo grade ≥ IIIa) occurred in 20 patients (5%). Grade A/B/C pancreatic fistula was observed in 49/29/4 patients (13%/8%/1%), respectively. Reoperation and readmission was necessary in five and four patients (1% and 1%), respectively. There was no in-hospital or 90-day mortality. CONCLUSIONS To achieve zero mortality in pancreaticoduodenectomy, it is crucial to incorporate various strategies to minimize the degree of surgical invasiveness and the damage caused by pancreatic fistula with a meticulous approach to perioperative management.
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Affiliation(s)
- Seiji Oguro
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Jiro Yoshimoto
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Hiroshi Imamura
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Yoichi Ishizaki
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Seiji Kawasaki
- Department of Hepatobiliary-Pancreatic Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
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