A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy

Biodegradable internal stent versus no stent for patients at increased risk of pancreatic fistula after pancreaticoduodenectomy: a single-center propensity score matching analysis

Postoperative pancreatic fistula (POPF) is considered the main trigger for further dangerous sequelae following pancreaticoduodenectomy (PD). This study compared the short-term postoperative results of patients at increased risk of POPF undergoing pancreaticojejunal (PJ) anastomosis with and without internal biodegradable stent. Data from a prospectively collected database of patients undergoing PD at increased risk of POPF (ISGPS type B, C, D) between January 2017 and June 2023 were retrieved and analyzed, comparing the postoperative outcomes of those with and without an internal biodegradable stent, using a propensity score matching analysis. In the study period, 183 patients were selected. After matching, a total of 59 with stent (SG) and 59 without (NSG) were compared. The overall POPF rate was 21.2%. No difference was seen between the groups regarding POPF and other postoperative outcomes. A higher rate of biochemical leakage in the SG (53.1% vs 31.9%, p 0.033) was found among patients in the type D class of risk. The present study showed no significant difference in terms of 90-day overall, severe and pancreas-specific postoperative complications among patients at increased risk of POPF who received PJ anastomosis with and without internal biodegradable stent.

Postpancreatectomy acute pancreatitis in pancreaticoduodenectomy and distal pancreatectomy: a retrospective cohort study on risk factors and clinical outcomes

BACKGROUND

Postpancreatectomy acute pancreatitis (PPAP) is a severe complication that can occur following pancreaticoduodenectomy (PD) or distal pancreatectomy (DP). Specific studies focus on the difference of PPAP in PD and DP are lacking.

METHODS

Patients who underwent PD or DP between 2019 and 2024 were retrospectively reviewed. Perioperative parameters and outcomes were collected. PPAP was defined in accordance with the criteria established by the International Study Group for Pancreatic Surgery (ISGPS).

RESULTS

The study cohort comprised 1,017 patients undergoing pancreatic resection: 670 PD and 347 DP. Among PD cases, PPAP occurred in 142 patients (21.19%) and was significantly associated with a higher incidence of postoperative pancreatic fistula (POPF) (82.39% vs. 37.12%, P < 0.0001), particularly in cases of grade B and C POPF (P < 0.0001). In DP cases, PPAP occurred in 17.58% of patients. In PD cases, patients with PPAP experienced increased morbidity (P < 0.0001), including a higher incidence of POPF (91.8% vs. 65.38%, P < 0.0001) and grade B POPF (39.34% vs. 11.54%, P < 0.0001). Compared to patients who had PD, those who had DP experienced a lower incidence of postoperative hyperamylasemia (POH) (30.55% vs. 43.88%, P < 0.0001).

CONCLUSION

PPAP represents a significant postoperative complication following pancreatic resection. Current evidence suggests associations between PPAP and morbidities in PD and DP cases. Notably, PPAP following DP appears to correlate with less severe clinical consequences compared to PD-associated PPAP.

Endoscopic management of postoperative pancreatic fistula after pancreaticoduodenectomy: a single center retrospective analysis

BACKGROUND

Indications and outcomes of endoscopic approaches in treating postoperative pancreatic fistula (POPF) are underinvestigated. The present study aimed to evaluate the outcomes of patients undergoing endoscopic treatment for POPF following pancreaticoduodenectomy (PD).

METHODS

Data of consecutive patients undergoing PD between 2014 and 2024 were retrospectively analyzed. Patients with POPF treated by an endoscopic approach were selected. The primary endpoint was clinical efficacy of the endoscopic approach. Secondary endpoints were variables associated with clinical efficacy of endoscopic treatment.

RESULTS

During the study period, a total of 436 patients underwent PD. Overall POPF rate was 18.4%. Twenty-one patients with POPF underwent endoscopic treatment and composed the study cohort. The median timing for endoscopic treatment was 20 postoperative days (POD). The types of endoscopic treatments performed included: trans-anastomotic intraductal pancreatic stent (23.8%); lumen apposing metal stent (LAMS) through the pancreatico-jejunal (PJ) anastomotic dehiscence (23.8%); large caliber aspirating nose-to-retroperitoneum tube through the PJ anastomosis leak (9.5%); triple metal stenting (enteral + biliary + pancreatic) (9.5%); transgastric LAMS close to pancreatic stump (14.3%); nose-to-retroperitoneum tube into a LAMS placed through PJ dehiscence (9.5%); transgastric LAMS near the pancreatic stump associated with an intraductal pancreatic trans-anastomotic stent (9.5%). Technical and clinical success rate were 100% and 71.4%, respectively. After endoscopic treatment, 19% of patients underwent surgical reoperation and 9.5% died. Timing of endoscopic treatment was the only factor associated with clinical success (POD 20 vs POD 13.5; p = 0.039).

CONCLUSION

Endoscopy can be an effective option for managing POPF after PD with a clinical success rate of 71.4%. Proper patient selection and the timing of intervention are key to achieving good clinical outcomes. Higher success rate was seen for endoscopic treatment performed after the 20th POD.

Validation of a CT-based model for early prediction of post pancreatectomy haemorrhage risk

BACKGROUND

Identification of early predictors of postoperative pancreatic fistula (POPF) related postpancreatectomy hemorrhage (PPH) on contrast-enhanced computed tomography (CT) may help tailoring management after pancreaticoduodenectomy (PD) although no model has been validated so far.

METHODS

A bicentric analysis of consecutive PD performed between 2017 and 2022 was performed. A recently reported CT-based score (CTS) was externally validated. Sensitivity refinements were proposed through a modified-CTS which was internally (development cohort, n=182) and externally validated (validation cohort, n=62). Bootstrap corrected Areas under the curve (AUCs), Sensitivity (Se) and Positive Predictive Value (PVV) were used to evaluate and compare the two scores.

RESULTS

A total of 244 patients (55.1% women; median age: 68 years [IQR: 58.0-75.0], clinically relevant (cr)-POPF: 25.4%, cr-PPH: 13.9%) were included. CTS accurately predicted a cr-PPH with an AUC of 0.83 (1000-boostrap 95% CI: 0.76-0.89). The modified-CTS, made available online (https://stylianostzedakis.shinyapps.io/pph_risk_calculator/), included CTS with 2 supplementary variables selected from a multivariable backward-stepwise regression: Perianastomotic air bubbles, posterosuperior pancreaticojejunal (PJ) anastomosis collection, posterior PJ defect, PJ collection in contact with hepatic or gastroduodenal artery stump and arterial wall irregularities. When compared with the CTS, although modified-CTS AUC [95%CI] were similar in the validation cohort (0.81 [0.62-0.95] vs. 0.87 [0.56-0.96], DeLong p=0.7), Se and PPV for early PPH detection were significantly higher (0.82 [0.75-0.92] vs. 0.71 [0.35-0.75] and 0.95 [0.83-0.99] vs. 0.33 [0.12-0.62], McNemar's p = 0.03).

CONCLUSIONS

With a robust prediction model, early CT-scan after PD seems a valid tool for early identification of high-risk cr-PPH patients.

Predicting postoperative pancreatic fistula after robotic pancreatoduodenectomy using International Study Group on Pancreatic Surgery and fistula risk scores: European multicentre retrospective cohort study

BACKGROUND

Postoperative pancreatic fistula represents the leading cause of morbidity and mortality after robotic pancreatoduodenectomy. Various scores have been proposed to stratify patients based on their postoperative pancreatic fistula risk, including three fistula risk scores, and two International Study Group for Pancreatic Surgery scores. This study compares the performance of these scores in patients undergoing robotic pancreatoduodenectomy.

METHODS

This is a multicentre European retrospective study in consecutive patients receiving robotic pancreatoduodenectomy for all indications (April 2014 to December 2021). The performance of the International Study Group for Pancreatic Surgery 4-tier (A-D) risk score, and its 3-tier (A-C) modification (International Study Group for Pancreatic Surgery 3-tier), fistula risk scores, alternative-fistula risk scores and the updated alternative-fistula risk scores in postoperative pancreatic fistula grade B/C prediction were compared based on their discrimination (area under the curve), calibration and clinical utility, evaluated through decision curve analyses.

RESULTS

Overall, 919 patients undergoing robotic pancreatoduodenectomy were included. The rate of grade B/C postoperative pancreatic fistula was 22.2% (n = 204). The area under the curve for the five scores differed only slightly: International Study Group for Pancreatic Surgery 0.63 (95% confidence interval (c.i.) 0.58 to 0.67), International Study Group for Pancreatic Surgery 3-tier 0.63 (95% c.i. 0.58 to 0.67), fistula risk scores 0.65 (95% c.i. 0.61 to 0.69), alternative-fistula risk scores 0.64 (95% c.i. 0.60 to 0.68) and updated alternative-fistula risk scores 0.65 (95% c.i. 0.60 to 0.69). The International Study Group for Pancreatic Surgery, International Study Group for Pancreatic Surgery 3-tier, fistula risk scores and alternative-fistula risk scores underestimated the risk of postoperative pancreatic fistula. In contrast, the updated alternative-fistula risk score was well-calibrated at low predicted risks, but overestimated postoperative pancreatic fistula risk for high-risk patients. In decision curve analyses, the updated alternative-fistula risk score showed a higher clinical utility compared with the four other risk scores.

CONCLUSION

The clinical utility of the updated alternative-fistula risk score for robotic pancreatoduodenectomy slightly outperformed the four other fistula risk scores, and might be used for patient counselling and patient stratification in clinical practice and research.

Practical Approaches to High-Risk Anastomoses in Robotic Pancreatoduodenectomy

BACKGROUND

Pancreatoduodenectomy (PD) is performed for the treatment of pancreatic head and periampullary tumors and is associated with relatively high postoperative morbidity and mortality. Traditionally conducted as open surgery, PD has evolved with the advent of minimally invasive techniques, including robotic-assisted approaches.

RESULTS

As reported in the literature, minimally invasive PD is becoming a safe and effective alternative surgical approach. Clinically relevant postoperative pancreatic complications, such as fistulas and hemorrhage, remain among the most challenging issues after PD, particularly in high-risk cases. There are several maneuvers that may reduce their incidence and mitigate their postoperative clinical impact.

CONCLUSIONS

In this video, we describe strategies implemented at our center for high-risk PD cases, including some key tips and tricks.

Perioperative and oncologic outcomes after total pancreatectomy and pancreatoduodenectomy for pancreatic head adenocarcinoma-A propensity score-matched analysis from the German Cancer Registry Group

BACKGROUND

To compare perioperative morbidity and mortality in patients receiving pancreatoduodenectomy or total pancreatectomy for pancreatic head adenocarcinoma using German Cancer Registry data.

METHODS

Anonymized pooled data were retrieved from regional cancer registries participating in the German Cancer Registry Group of the Association of German Tumor Centers. Included were patients diagnosed with pancreatic head adenocarcinoma since 2016, receiving curative intent pancreatoduodenectomy or total pancreatectomy. Patients were propensity-score matched according to age, sex, and histopathology. Primary endpoints were 30- and 90-day postoperative mortality. Secondary endpoints were administration of adjuvant chemotherapy, long-term survival, and patterns of cancer recurrence. The data were analyzed using R.

RESULTS

In total, 756 patients per treatment group were matched for further analyses. R0-resection rate was comparable between pancreatoduodenectomy and total pancreatectomy (69.6 vs 73.4%, P = .154). The 30-day (9.5 vs 4.8%, P < .001) and 90-day postoperative mortality (18.0 vs 11.0%, P < .001) rates were significantly lower after pancreatoduodenectomy compared with total pancreatectomy. After pancreatoduodenectomy, more patients received adjuvant chemotherapy (43.6 vs 53.3%, P < .001) and time to adjuvant chemotherapy was shorter (60.1 vs 52.7 days, P = .002) compared with total pancreatectomy. Long-term overall survival was worse after total pancreatectomy (P < .001), also in patients receiving adjuvant chemotherapy (P = .019). The sites of recurrence were comparable between both groups (P = .274).

CONCLUSION

The results of this study show greater perioperative morbidity and mortality after total pancreatectomy compared with pancreatoduodenectomy for pancreatic head malignancy. Also, long-term survival was worse after total pancreatectomy. These results emphasize the role of pancreatoduodenectomy as a standard surgical procedure for pancreatic head adenocarcinoma and suggest that total pancreatectomy should only be performed in selected patients.

AutoFRS: an externally validated, annotation-free approach to computational preoperative complication risk stratification in pancreatic surgery - an experimental study

BACKGROUND

The risk of postoperative pancreatic fistula (POPF), one of the most dreaded complications after pancreatic surgery, can be predicted from preoperative imaging and tabular clinical routine data. However, existing studies suffer from limited clinical applicability due to a need for manual data annotation and a lack of external validation. We propose AutoFRS (automated fistula risk score software), an externally validated end-to-end prediction tool for POPF risk stratification based on multimodal preoperative data.

MATERIALS AND METHODS

We trained AutoFRS on preoperative contrast-enhanced computed tomography imaging and clinical data from 108 patients undergoing pancreatic head resection and validated it on an external cohort of 61 patients. Prediction performance was assessed using the area under the receiver operating characteristic curve (AUC) and balanced accuracy. In addition, model performance was compared to the updated alternative fistula risk score (ua-FRS), the current clinical gold standard method for intraoperative POPF risk stratification.

RESULTS

AutoFRS achieved an AUC of 0.81 and a balanced accuracy of 0.72 in internal validation and an AUC of 0.79 and a balanced accuracy of 0.70 in external validation. In a patient subset with documented intraoperative POPF risk factors, AutoFRS (AUC: 0.84 ± 0.05) performed on par with the uaFRS (AUC: 0.85 ± 0.06). The AutoFRS web application facilitates annotation-free prediction of POPF from preoperative imaging and clinical data based on the AutoFRS prediction model.

CONCLUSION

POPF can be predicted from multimodal clinical routine data without human data annotation, automating the risk prediction process. We provide additional evidence of the clinical feasibility of preoperative POPF risk stratification and introduce a software pipeline for future prospective evaluation.

GRAPHICAL ABSTRACT

The Charlson Comorbidity Index Predicts Clinically Relevant Postoperative Pancreatic Fistula in Patients Undergoing Distal Pancreatectomy Not Pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is a severe complication after pancreatectomy. The preoperative prediction of POPF would benefit patients by providing postoperative management tailored to each patient based on the risk for POPF. The Charlson Comorbidity Index (CCI), which assesses the severity of patient comorbidities, has been associated with postoperative complications in various surgeries. However, its relationship with POPF remains unclear. This study investigates the impact of CCI on the development of POPF.

METHODS

This retrospective study reviewed 597 patients who underwent pancreatectomy from 2010 to 2020, of whom 219 underwent distal pancreatectomy (DP) and 378 underwent pancreaticoduodenectomy (PD). Significant factors were assessed in association with clinically relevant POPF (CR-POPF) using a logistic regression model. K-means clustering was employed based on the body mass index, pancreatic thickness, and CCI score to stratify patients by the risk for CR-POPF.

RESULTS

Higher CCI scores were significantly associated with an increased incidence of CR-POPF, particularly in patients undergoing DP, whereas such association was not observed in patients undergoing PD. Multivariate analysis identified male sex, BMI > 25.95 kg/m2, pancreatic thickness > 9.01 mm, and CCI score > 4 as independent predictors of CR-POPF in the DP group. A predictive model incorporating these factors demonstrated moderate accuracy (AUC = 0.6750) in stratifying patients into high- and low-risk groups for CR-POPF.

CONCLUSION

CCI is a significant predictor of CR-POPF, especially in patients undergoing DP. By integrating CCI with other factors, it was feasible to develop a predictive model with high diagnostic accuracy.

Machine learning-based prediction of postoperative pancreatic fistula after laparoscopic pancreaticoduodenectomy

BACKGROUND

Clinically relevant postoperative pancreatic fistula (CR-POPF) following laparoscopic pancreaticoduodenectomy (LPD) is a critical complication that significantly worsens patient outcomes. However, the heterogeneity of its risk factors and the clinical utility of predictive models remain to be fully elucidated. This study aims to systematically analyze the risk factors for CR-POPF and develop an optimized predictive model using machine learning algorithms, providing an evidence-based approach for individualized risk assessment in patients undergoing LPD.

METHODS

A retrospective study was conducted, including 210 patients with periampullary cancer who underwent laparoscopic pancreaticoduodenectomy (LPD) at the Hepatobiliary Surgery Center, Olympic Stadium Campus, Shandong Provincial Hospital Affiliated to Shandong First Medical University, from January 2017 to January 2024. Patients were classified into the clinically relevant pancreatic fistula (CR-POPF) group (n = 34) and the non-clinically relevant pancreatic fistula (non-CR-POPF) group (n = 176) according to the 2016 criteria of the International Study Group of Pancreatic Surgery (ISGPS). Potential risk factors were identified through intergroup comparisons, and independent risk factors were determined using univariate and multivariate logistic regression analyses. Based on these findings, a predictive model for CR-POPF was developed using machine learning algorithms.

RESULTS

CR-POPF was associated with higher BMI, monocyte levels, platelet count, total bilirubin, AST, ALT, and lower albumin. Pathological diagnosis of ampullary carcinoma and soft pancreatic texture were significantly more common in the CR-POPF group. Multivariate analysis identified soft pancreatic texture as an independent predictor (OR = 4.99, 95% CI: 1.93-12.86). Among all models, the random forest model showed the best performance (AUC = 0.747, sensitivity = 0.917, specificity = 0.574), using only preoperative variables such as age, gender, BMI, hypertension, diabetes, hemoglobin, platelets, AST, and ALT.

CONCLUSION

Soft pancreatic texture was identified as an independent risk factor for postoperative pancreatic fistula following laparoscopic pancreaticoduodenectomy (LPD). The random forest model based on preoperative clinical variables enables individualized risk prediction, offering value for preoperative planning and postoperative care.

Increased risk of postoperative pancreatic fistula in patients with chronic steroid usage undergoing pancreatectomy

PURPOSE

Chronic steroid use may increase the risk of postoperative complications; however, its impact on postoperative outcomes after pancreatectomy has not been fully investigated. This study investigated the impact of chronic steroid use on surgical outcomes, particularly postoperative pancreatic fistulas (POPF).

METHODS

A retrospective analysis of 656 patients who underwent pancreatectomy between 2010 and 2021 was conducted. Patients who had been using steroids for ≥ 1 month at the time of surgery were classified into the steroid group. Postoperative outcomes were compared between the steroid-treated and non-steroid-treated groups.

RESULTS

Of the 656 patients, 17 (2.6%) were in the steroid group, which exhibited a significantly higher POPF rate than the non-steroid group (70.6% vs. 26.3%, p = 0.0002). A multivariate analysis identified chronic steroid use as an independent risk factor for POPF (odds ratio 4.718, 95% confidence interval 1.510-14.742; p = 0.0051). The results were confirmed using a propensity score matching analysis.

CONCLUSION

The risk of POPF was significantly increased after pancreatectomy in patients with chronic steroid use compared to those without chronic steroid use, and chronic steroid use was an independent factor significantly associated with POPF.

Preoperative prediction of postoperative pancreatic fistula after Pancreaticoduodenectomy: Determination and validation of a cut-off value for the Roberts Score

BACKGROUND

POPF after pancreaticoduodenectomy can be life-threatening. For risk stratification, prediction could be key. The aim of this study is to determine and validate a cut-off value for the Roberts Score, which is one of the few purely preoperative multicenter validated predictive models for POPF.

METHODS

582 patients were included. The Youden index determined a cut-off in the exploratory cohort (n ​= ​466). The validation cohort's (n ​= ​116) ability to predict CR-POPF was tested using univariate and multivariate regression analysis.

RESULTS

AUC of Roberts Score for the exploration cohort was 0.768. The identified cut-off of 0.268 was confirmed in the validation cohort (p ​< ​0.001). Higher scores were significantly associated with longer time to drain removal and ICU stay. Multiple logistic regression showed the cut-off as an independent predictor of CR-POPF (p ​= ​0.038).

CONCLUSION

The scoring variables and the cut-off itself were both independent predictors, which may improve the identification of high-risk patients and help to investigate the development of POPF.

Assessment of two different criteria for post-pancreatectomy acute pancreatitis: a single-center retrospective analysis and literature review

BACKGROUND

The significance of postoperative acute pancreatitis (postoperative pancreatitis [POP] as defined by Connor and post-pancreatectomy acute pancreatitis [PPAP] as defined by the International Study Group for Pancreatic Surgery [ISGPS]) has not been determined because of the transition of definitions, a lack of prospective studies and ignorance regarding appropriate management.

METHODS

The incidence of POP/PPAP were retrospectively analyzed. Additionally, the clinicopathological parameters and outcomes were compared between patients with and without POP/PPAP.

RESULTS

Using Connor's criteria, 46% of patients (70/151) showed Grade A POP and 17% (26/151) displayed clinically relevant (CR)-POP. Using ISGPS criteria, the prevalences of postoperative hyperamylasemia and CR-PPAP were 12% (18/151) and 10% (15/151), respectively. The duration of antibiotics and carbapenem were longer in CR-POP (p < 0.001). Total health care cost was significantly higher in CR-POP compared with other grades in Connor's criteria (p = 0.010), whereas no difference was seen in the ISGPS criteria (p = 0.677). The frequencies of complications including pancreatic fistula (Non-POP vs. Grade A POP vs. CR-POP, 22% vs. 36% vs. 81%, p < 0.001), reoperation and length of hospital stay tended to be greater as Connor's grade of POP increased.

DISCUSSION

Connor's definition appeared more closely associated with postoperative worse outcomes than the ISGPS definition.

Enhanced preoperative prediction of pancreatic fistula using radiomics and clinical features with SHAP visualization

Background

Clinically relevant postoperative pancreatic fistula (CR-POPF) represents a significant complication after pancreaticoduodenectomy (PD). Therefore, the early prediction of CR-POPF is of paramount importance. Based on above, this study sought to develop a CR-POPF prediction model that amalgamates radiomics and clinical features to predict CR-POPF, utilizing Shapley Additive explanations (SHAP) for visualization.

Methods

Extensive radiomics features were extracted from preoperative enhanced Computed Tomography (CT) images of patients scheduled for PD. Subsequently, feature selection was performed using Least Absolute Shrinkage and Selection Operator (Lasso) regression and random forest (RF) algorithm to select pertinent radiomics and clinical features. Last, 15 CR-POPF prediction models were developed using five distinct machine learning (ML) predictors, based on selected radiomics features, selected clinical features, and a combination of both. Model performance was compared using DeLong's test for the area under the receiver operating characteristic curve (AUC) differences.

Results

The CR-POPF prediction model based on the XGBoost predictor with the combination of the radiomics and clinical features selected by Lasso regression and RF exhibited superior performance among these 15 CR-POPF prediction models, achieving an accuracy of 0.85, an AUC of 0.93. DeLong's test showed statistically significant differences (P < 0.05) when compared to the radiomics-only and clinical-only models, with recall of 0.63, precision of 0.65, and F1 score of 0.64.

Conclusion

The proposed CR-POPF prediction model based on the XGBoost predictor with the combination of the radiomics and clinical features selected by Lasso regression and RF can effectively predicting the CR-POPF and may provide strong support for early clinical management of CR-POPF.

Ideal outcome after pancreatic resection for neuroendocrine tumors: a nationwide study

BACKGROUND

Pancreatic resections for pancreatic neuroendocrine tumors (pNET) may experience a higher complication rate than for pancreatic ductal adenocarcinoma (PDAC). This study aimed to determine the rate of the novel composite "Ideal Outcome" measure after resection for pNET, using PDAC as reference.

METHODS

This observational cohort study included all consecutive patients after pancreatic resection for pNET and PDAC using the nationwide Dutch Pancreatic Cancer Audit (2014-2021). The primary outcome was Ideal Outcome; absence of postoperative mortality, postoperative pancreatic fistulas (POPF) grade B/C, other major complications, prolonged length of stay, reoperations and readmissions.

RESULTS

In total, 524 pNET and 2851 PDAC resections were included. The rate of Ideal Outcome was lower after resection for pNET (47.7% versus 55.7%; P<0.001) as compared to PDAC. This difference was driven by a lower rate of Ideal Outcome after pancreatoduodenectomy for pNET (37.7% versus 56.3%; P<0.001), with no difference after left pancreatectomy (54.5% versus 52.5%; P=0.598). Among the individual components of Ideal Outcome after pancreatoduodenectomy, the largest difference was a four times higher rate of POPF (32.1% versus 7.9%; P<0.001) after resection of pNET.

CONCLUSION

Patients undergoing pancreatoduodenectomy for pNET have a reduced Ideal Outcome rate compared to patients with PDAC, related to a fourfold increased risk of POPF. This highlights the value of pNET-specific patient counseling and the need for effective POPF mitigation strategies.

Comparison of pancreaticojejunostomy under the theory of mucosal priority healing with duct-to-mucosa anastomosis and invagination pancreaticojejunostomy after pancreaticoduodenectomy: A single-centre case-control study

ObjectiveThe technological aspects of pancreaticoduodenectomy have progressed greatly, but the risk of postoperative complications, especially postoperative pancreatic fistula (POPF), postpancreatectomy haemorrhage (PPH) and mortality, is high. Therefore, we aimed to explore the safety and feasibility of pancreaticojejunostomy (PJ) under the mucosal priority healing theory through a case-control study.MethodsWe have described in detail PJ under the theory of preferential mucosal healing (PM-PJ). In a cohort of patients based on predictors of pancreatic fistula, comparisons were made according to the type of PJ: PM-PJ (n = 312); duct-to-mucosa PJ (DtoM-PJ, n = 116); and invagination PJ (IPJ, n = 109). The primary endpoint was the occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF). The secondary endpoints were PPH, secondary surgery, death 90 days after surgery, and other postoperative complications.ResultsThe incidence rate of CR-POPF in the PM-PJ group was not significantly different from that in the DtoM-PJ group (13.78% vs. 6.9%; p = 0.051) or the IPJ group (13.78% vs. 11.9%; p = 0.623). However, the PM-PJ group exhibited significant reductions in serious postoperative complications (7.4% versus 30.2%; p < 0.001), PPH (1.3% versus 8.4%; p < 0.001), reoperation rates (0.6% versus 9.3%; p < 0.001) and 90-day postoperative mortality rates (0.32% versus 2.6%; p = 0.023). Multivariate LASSO regression analysis revealed that BMI, hypertension, gland texture, duct size, vascular resection and pathological type were independent risk factors for CR-POPF.ConclusionsPM-PJ is safe and reliable. During surgery, there are fewer suture needles and less trauma, which may reduce the incidence of serious complications such as postoperative bleeding and mortality.

Is robotic pancreaticoduodenectomy non-inferior to open pancreaticoduodenectomy in patients with high PD-ROBOSCORE?

INTRODUCTION

Robotic pancreaticoduodenectomy (RPD) is associated with technical challenges that may result in intraoperative and postoperative complications. Some previous reports and the recently published PD-ROBOSCORE describe several factors associated with an increased difficulty. The aim of this study is to investigate whether difficult RPD patients have a better outcome when operated by open approach (OPD).

METHODS

All patients undergoing robotic and open PD from January 2020 to June 2024 with high PD-ROBOSCORE were included. Preoperative pancreatitis and/or cholangitis, and tumor contact with PV-SMV were also analysed. Outcomes of RPD vs OPD were compared.

RESULTS

45 RPD and 57 OPD patients with high PD-ROBOSCORE were considered for this study. Median age was 68.5 years (68 RPD vs 65 OPD; p = 0.25), median BMI was 27 kg/m2 (27 RPD vs 28 OPD; p = 0.13), 65.6% of patients were male (60.0% RPD vs 70.2% OPD; p = 0.15) and median PD-ROBOSCORE was 10 (10 RPD vs 9 OPD, p = 0.145). POPF occurred in 37.2% (40.0% RPD vs 35.1% OPD; p = 0.668), CD ≥ 3 was 25.4% (28.8% RPD vs 22.8% OPD; p = 0.477), median CCI was 20.9 (20.5 RPD vs 20.9 OPD; p = 0.752), reoperation rate was 17.6% (15.5% RPD vs 19.3% OPD; p = 0.496). Hospital stay was 15 days (16 RPD vs 13 OPD; p = 0.583). Of patients developing POPF; 76.3% had soft pancreas, 84.2% had pancreatic duct ≤ 2 mm and 97.2% had BMI ≥ 25.

CONCLUSION

RPD seems to be non-inferior to OPD in patients with increased technical complexity. Most of these complications are related to fistula risk factors (high BMI, soft pancreas and small pancreatic duct) and not directly related with other technical difficulty factors.

Surgical Trends in Chronic Pancreatitis From 2014 to 2021

OBJECTIVES

We analyzed annual surgical trends for benign chronic pancreatitis (CP), studying specifically mortality, morbidity, and pancreatic fistula rates. We also aimed to identify predictors of pancreatic fistula formation.

MATERIALS AND METHODS

For this analysis, we used data from the American College of Surgeons National Surgical Quality Improvement Program from 2014 to 2021. The study included patients who underwent surgery for benign CP. Data collected included patient demographics, preoperative variables, and postoperative outcomes. Data were analyzed with univariate and multivariate analyses, with significance defined as P  ≤ 0.05.

RESULTS

Over the study period, the number of pancreatic surgical procedures increased by 49.3%, although surgery specifically for CP declined by 31.7%. The rate of pancreatic fistula formation decreased 44.9%, and mortality decreased 31.9%. Significant predictors of a pancreatic fistula included no diabetes, preoperative sepsis, soft texture of the pancreatic gland, and greater patient weight.

CONCLUSION

Surgery for benign CP decreased substantially despite the established efficacy of surgical intervention for long-term pain management. The concurrent decline in mortality and rates of pancreatic fistula formation suggest advances over the study years in surgical and postoperative care.

Predictive value of postoperative serum lipase level for postoperative pancreatic fistula after pancreaticoduodenectomy

BACKGROUND

The prediction of postoperative pancreatic fistula (POPF) is important. This study aimed to investigate the role of postoperative serum lipase level in predicting POPF.

METHODS

Data from 234 consecutive patients who underwent pancreaticoduodenectomy (PD) were collected. The predictive values of serum amylase and serum lipase during postoperative days (PODs) 1 to 3 for POPF were compared. Subgroup analyses were performed to determine the prognostic value of different levels and durations of elevated serum lipase.

RESULTS

Fifty-six patients developed POPF. The POPF group exhibited increased levels of serum amylase and lipase from PODs 1 to 3 (all P < 0.001). Compared with serum amylase, serum lipase has greater predictive value for POPF. Specifically, serum lipase had the highest area under the receiver operating characteristic curve (AUC) at POD 1 (0.791). Body mass index > 24 kg/m2 [odds ratio (OR) = 2.431, 95% confidence interval (CI): 1.094-5.404, P = 0.029], soft pancreatic texture (OR = 3.189, 95% CI: 1.263-8.056, P = 0.014), serum lipase > 60 U/L at POD 1 (OR = 5.135, 95% CI: 1.257-20.982, P = 0.023), and C-reactive protein > 167 mg/dL at POD 3 (OR = 3.607, 95% CI: 1.431-9.090, P = 0.007) were identified as independent risk factors for POPF. Patients with serum lipase ≤ 60 U/L at POD 1 (n = 104) exhibited lower rates of POPF (3.8% vs. 40.0%, P < 0.001) and severe complications (Clavien-Dindo ≥ IIIa) (4.8% vs. 25.4%, P < 0.001) than those with serum lipase > 60 U/L at POD 1. Moreover, no additional elevation or duration of serum lipase offered any further prognostic value.

CONCLUSIONS

Postoperative serum lipase outperformed serum amylase in the prediction of POPF, and patients with normal serum lipase level at POD 1 had favorable outcomes. A sustained increase in the serum lipase level offers no additional prognostic value.

Risk factors of failure to achieve textbook outcome in patients after pancreatoduodenectomy: a systematic review and meta-analysis

BACKGROUND

Pancreatoduodenectomy (PD) represents one of the most technically demanding surgical procedures, characterized by extensive surgical trauma and high perioperative morbidity. Single outcome measures are insufficient to comprehensively assess the surgical quality of PD. Textbook outcome (TO), as an integrated evaluation system incorporating multiple clinical parameters, offers an objective, reliable, and comprehensive assessment of surgical performance. This systematic review and meta-analysis aimed to identify risk factors associated with failure to achieve textbook outcome (non-TO) following pancreatoduodenectomy.

MATERIALS AND METHODS

We systematically searched international databases (PubMed, Web of Science, EMBASE, and Cochrane Library) and Chinese databases (China National Knowledge Infrastructure, Weipu Chinese Journals Service Platform, Wanfang Data, and SinoMed) for studies on risk factors of failure to achieve textbook outcome after pancreatoduodenectomy from inception to 31 December 2024. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using random-effects or fixed-effects models. Heterogeneity testing, sensitivity analysis, and publication bias assessment were conducted.

RESULTS

Ten studies involving 5238 patients were included in this meta-analysis. Among the 18 factors evaluated, five were significantly associated with failure to achieve textbook outcome after pancreatoduodenectomy: preoperative biliary drainage (OR = 2.09, 95%CI [1.30-3.36], P = 0.002), smaller tumor size (OR = 1.36, 95%CI [1.02-1.81], P = 0.04), soft pancreatic texture (OR = 2.25, 95%CI [1.01-5.02], P = 0.05), small pancreatic duct diameter (OR = 2.30, 95%CI [1.62-3.28], P < 0.00001), and increased intraoperative blood loss (OR = 4.14, 95%CI [1.16-14.83], P = 0.03). The remaining 13 factors showed no significant association with failure to achieve textbook outcome.

CONCLUSION

This meta-analysis identified preoperative biliary drainage, tumor morphological characteristics (including size and texture), pancreatic duct diameter, and intraoperative blood loss as key factors affecting the achievement of textbook outcome after pancreatoduodenectomy. These findings may help surgeons identify high-risk patients for failure to achieve textbook outcome, enabling personalized surgical strategies and optimized perioperative management to improve textbook outcome rates.

"Somatostatin analogues do not reduce the risk of clinically relevant post-operative fistula rates in patients undergoing pancreatic surgery", a systematic review and meta-analysis

BACKGROUND

The impact of Somatostatin Analogues (SSA) on Post-Operative Pancreatic Fistula (POPF) risk reduction lacks clarity and reports are conflicting. The aim of this study was to perform a systematic review and meta-analysis to explore the effect of SSA on POPF rates.

METHODS

A systematic review was performed for studies reporting POPF in relation to SSA use following the consensus by the International Study Group of Pancreatic Fistula (ISGPF) to re-define what constitutes a clinically significant POPF in 2015. The primary outcome was the incidence of clinically relevant POPF among patients who received SSA peri-operatively.

RESULTS

Twenty studies, including 6947 patients, were eligible for inclusion. Overall, SSA use did not significantly lower the risk of developing a POPF(OR 0.89, 95 % CI 0.66-1.20, P = 0.44, I2 = 73 %). Subgroup analysis was performed to determine whether SSA could reduce POPF in high-risk cohorts (soft pancreas, duct <5 mm). SSA did not significantly reduce POPF in the five studies reporting on high-risk cohorts (OR 1.42, 95 % CI 0.60-3.37, P = 0.43, I2 = 73 %). Furthermore, subgroup analysis of both grade B and grade C POPF's did not show any benefit of SSA.

CONCLUSION

SSA prophylaxis does not reduce the incidence of clinically relevant POPR and should not be routinely administered for pancreatic resections.

Intraparenchymal Penicillin G Injection Promotes Wound Healing and Lowers POPF in Pigs After Pancreatic Surgery

Background: Postoperative pancreatic fistula (POPF) is a significant complication following pancreatic surgery, considerably influenced by the texture of the pancreatic tissue. This study aims to explore the potential of Penicillin G (PG) in reducing the severity of POPF in a porcine surgical model. Study Design: After performing distal pancreatectomy with pancreaticojejunostomy (PJ), pigs were administered either normal saline or varying concentrations of PG (0.75, 1.5, and 3.0 mM) at the PJ site. The study estimated POPF by measuring pancreatic hardness, tensile force, fibrosis, and amylase levels in Jackson-Pratt (JP) drain samples. Results: Intraparenchymal PG injection significantly increased pancreatic hardness and tensile force (p < 0.05) while upregulating profibrotic markers like MMP2 and TGF-β1, indicating enhanced fibrosis (p < 0.05). Importantly, these profibrotic changes reverted to baseline levels by POD 14, suggesting reversible fibrosis without lasting consequences. The 0.75 PG and 1.5 PG groups exhibited significantly lower JP amylase levels than the control group on both POD 3 and POD 4 (p < 0.05). Notably, the 0.75 PG group also demonstrated the highest survival rate compared to the 1.5 PG and NS groups (p < 0.05). Conclusions: The intrapancreatic PG injection could effectively reduce the severity of POPF by promoting wound healing through intensified fibrosis around the PJ site.

International multicentre validation of the left pancreatectomy pancreatic fistula prediction models and development and validation of the combined DISPAIR-FRS prediction model

BACKGROUND

Every fifth patient undergoing left pancreatectomy develops a postoperative pancreatic fistula (POPF). Accurate POPF risk prediction could help. Two independent preoperative prediction models have been developed and externally validated: DISPAIR and D-FRS. The aim of this study was to validate, compare, and possibly update the models.

METHODS

Patients from nine high-volume pancreatic surgery centres (8 in Europe and 1 in North America) were included in this retrospective cohort study. Inclusion criteria were age over 18 years and open or minimally invasive left pancreatectomy since 2010. Model performance was assessed with discrimination (receiver operating characteristic (ROC) curves) and calibration (calibration plots). The updated model was developed with logistic regression and internally-externally validated.

RESULTS

Of 2284 patients included, 497 (21.8%) developed POPF. Both DISPAIR (area under the ROC curve (AUC) 0.62) and D-FRS (AUC 0.62) performed suboptimally, both in the pooled validation cohort combining every centre's data and centre-wise. An updated model, named DISPAIR-FRS, was constructed by combining the most stable predictors from the existing models and incorporating other readily available patient demographics, such as age, sex, transection site, pancreatic thickness at the transection site, and main pancreatic duct diameter at the transection site. Internal-external validation demonstrated an AUC of 0.72, a calibration slope of 0.93, and an intercept of -0.02 for the updated model.

CONCLUSION

The combined updated model of DISPAIR and D-FRS named DISPAIR-FRS demonstrated better performance and can be accessed at www.tinyurl.com/the-dispair-frs.

Complexity and Experience Grading to Guide Patient Selection for Minimally Invasive Pancreatoduodenectomy: An International Study Group for Pancreatic Surgery (ISGPS) Consensus

OBJECTIVE

To develop a universally accepted complexity and experience grading system to guide the safe implementation of robotic and laparoscopic minimally invasive pancreatoduodenectomy (MIPD).

BACKGROUND

Despite the perceived advantages of MIPD, its global adoption has been slow due to the inherent complexity of the procedure and challenges to acquiring surgical experience. Its wider adoption must be undertaken with an emphasis on appropriate patient selection according to adequate surgeon and center experience.

METHODS

The International Study Group for Pancreatic Surgery (ISGPS) developed a complexity and experience grading system to guide patient selection for MIPD based on an evidence-based review and a series of discussions.

RESULTS

The ISGPS complexity and experience grading system for MIPD is subclassified into patient-related risk factors and provider experience-related variables. The patient-related risk factors include anatomic (main pancreatic and common bile duct diameters), tumor-specific (vascular contact), and conditional (obesity and previous complicated upper abdominal surgery/disease) factors, all incorporated in an A-B-C classification, graded as no, a single, and multiple risk factors. The surgeon and center experience-related variables include surgeon total MIPD experience (cutoffs 40 and 80) and center annual MIPD volume (cutoffs 10 and 30), all also incorporated in an A-B-C classification.

CONCLUSIONS

This ISGPS complexity and experience grading system for robotic and laparoscopic MIPD may enable surgeons to optimally select patients after duly considering specific risk factors known to influence the complexity of the procedure. This grading system will likely allow for a thoughtful and stepwise implementation of MIPD and facilitate a fair comparison of outcomes between centers and countries.

Postoperative pancreatic fistula risk assessment using digital pathology based analyses at the parenchymal resection margin of the pancreas - Results from the randomized multicenter RECOPANC trial

BACKGROUND

In pancreatic surgery Postoperative pancreatic fistula (POPF) represents the most dreaded complication, for which pancreatic texture is acknowledged as one of the strongest predictors. No consensual objective reference has been defined to evaluate the pancreas composition. The presented study aimed to mine histology data of the pancreatic tissue composition with AI assist and correlate it with clinic-pathological parameters derived from the RECOPANC study.

METHOD

From 320 patients originally included in the RECOPANC multicentric study, after series of exclusions slides of 134 patients were selected of AI-assisted analysis.For each slide tissue training fields were defined. Machine learning was trained to differentiate the tissue compartments: acinar, fibrotic, and adipose tissue, followed by quantification of the tissue area compartments.

RESULTS

Relative fibrotic tissue area revealed as the strongest determinant for the prediction of clinically relevant POPF in multivariable analysis (p = 0.027). The AI assessed amount of fibrotic tissue performed significantly better in prediction of fistula development compared to the surgical palpatory assessment of the pancreatic texture.

CONCLUSION

The present study is the first correlating AI-assisted quantified pancreatic tissue composition and POPF within a multicentric cohort.

The Value of Blood T Cell Frequencies for Risk Prediction of Postoperative Complications in Pancreatic Cancer Surgery

Objective

To quantify and characterize preoperative blood T cells in patients with pancreatic ductal adenocarcinoma (PDAC), who underwent tumor resection, and to determine their relevance as biomarkers for postoperative pancreas-specific complications.

Background

Pancreas-specific complications after pancreatic surgery are associated with a high morbidity and mortality, which both deprive patients of adjuvant chemotherapy. Noninvasive biomarkers for risk prediction of postoperative complications are missing, and the role of blood T cells for preoperative risk stratification is unknown.

Methods

The preoperative frequency of blood T cell subsets was analyzed for 73 patients with PDAC, who underwent proximal pancreatectomy. Patients were screened for postoperative complications such as pancreatic fistula, postpancreatectomy hemorrhage, and postpancreatectomy acute pancreatitis. The frequency of CD8+, conventional CD4+, and regulatory T cells, as well as the differentiation state of each T cell subset in the peripheral blood of patients with PDAC, was analyzed.

Results

Of 73 patients with PDAC, 19.2% developed pancreas-specific complications. The occurrence of postoperative complications was independent of the type of resection performed (Whipple procedure vs pylorus-preserving pancreaticoduodenectomy). Neither the frequency of CD8+, conventional CD4+, and regulatory T cells nor the state of T cell differentiation in the peripheral blood was associated with postoperative pancreas-specific complications. Notably, a significantly lower preoperative bilirubin serum level was observed in patients, who developed postpancreatectomy hemorrhage after proximal pancreatectomy (P =0.001).

Conclusions

A low preoperative bilirubin serum level was associated with a higher risk for postpancreatectomy hemorrhage after proximal pancreatectomy. However, the preoperative blood T cell frequency does not predict postoperative pancreas-specific complications.

Impact of soft pancreas on pancreaticoduodenectomy outcomes and the development of the preoperative soft pancreas risk score

Backgrounds/Aims

Pancreatic texture is difficult to predict without palpation. Soft pancreatic texture is associated with increased post-operative complications, including postoperative pancreatic fistula (POPF), cardiac, and respiratory complications. We aimed to develop a calculator predicting pancreatic texture using patient factors and to illustrate complications from soft pancreatic texture following pancreaticoduodenectomy.

Methods

Data was collected from the 2016 to 2021 American College of Surgeons National Surgical Quality Improvement database including 17,706 pancreaticoduodenectomy cases. Patients were categorized into two cohorts based on pancreatic texture (9,686 hard, 8,020 soft). Multivariable modeling assessed the impact of patient factors on complications, mortality, and pancreatic texture. These preoperative factors were integrated into a risk calculator (preoperative soft pancreas risk score [PSPRS]) that predicts pancreatic texture.

Results

Patients with a soft pancreas had higher rates of postoperative complications compared to those with a hard pancreas (56.5% vs 42.2%; p < 0.001), particularly a threefold increase in POPF rate, and at least a twofold increase in rates of acute kidney injury, deep organ space infection, septic shock, and prolonged length of stay. Female sex (odds ratio [OR]: 1.14, confidence interval [CI]: 1.06-1.22, p < 0.001) and higher body mass index (OR: 1.12, CI: 1.09-1.16, p < 0.001) were independently associated with a soft pancreas. PSPRS ≥6 correctly identified >40% of patients preoperatively as having a hard pancreas (68.9% specificity).

Conclusions

A soft pancreas was independently associated with serious postoperative complications. Our results were integrated into a risk calculator predicting pancreatic texture from preoperative patient factors, potentially enhancing preoperative counseling and surgical decision-making.

Machine learning model-based prediction of postpancreatectomy acute pancreatitis following pancreaticoduodenectomy: A retrospective cohort study

BACKGROUND

The International Study Group of Pancreatic Surgery has established the definition and grading system for postpancreatectomy acute pancreatitis (PPAP). There are no established machine learning models for predicting PPAP following pancreaticoduodenectomy (PD).

AIM

To explore the predictive model of PPAP, and test its predictive efficacy to guide the clinical work.

METHODS

Clinical data from consecutive patients who underwent PD between 2016 and 2024 were retrospectively collected. An analysis of PPAP risk factors was performed, various machine learning algorithms [logistic regression, random forest, gradient boosting decision tree, extreme gradient boosting, light gradient boosting machine, and category boosting (CatBoost)] were utilized to develop predictive models. Recursive feature elimination was employed to select several variables to achieve the optimal machine algorithm.

RESULTS

The study included 381 patients, of whom 88 (23.09%) developed PPAP. PPAP patients exhibited a significantly higher incidence of postoperative pancreatic fistula (55.68% vs 14.68%, P < 0.001), grade C postoperative pancreatic fistula (9.09% vs 1.37%, P = 0.001). The CatBoost algorithm outperformed other algorithms with a mean area under the receiver operating characteristic curve of 0.859 [95% confidence interval (CI): 0.814-0.905] in the training cohort and 0.822 (95%CI: 0.717-0.927) in the testing cohort. According to shapley additive explanations analysis, pancreatic texture, main pancreatic duct diameter, body mass index, estimated blood loss, and surgery time were the most important variables based on recursive feature elimination. The CatBoost algorithm based on selected variables demonstrated superior performance, with an area under the receiver operating characteristic curve of 0.837 (95%CI: 0.788-0.886) in the training cohort and 0.812 (95%CI: 0.697-0.927) in the testing cohort.

CONCLUSION

We developed the first machine learning-based predictive model for PPAP following PD. This predictive model can assist surgeons in anticipating and managing this complication proactively.

The impact of pancreatic duct stent placement on the clinically relevant postoperative pancreatic fistula rate for high-risk anastomoses: a systematic review and meta-analysis

BACKGROUND

To evaluate the impact of pancreatic duct stent outcomes on the prognosis of postoperative pancreatic fistula in patients with high-risk anastomoses.

METHODS

Randomized controlled trials were identified through comprehensive searches in Cochrane Library, Web of Science, Embase, and PubMed databases. Cochrane Collaboration's tool RoB2 was used to evaluate study quality. The presence of non-dilated main pancreatic duct and soft gland texture were used to identify high risk anastomoses. The primary outcome measured was clinically relevant postoperative pancreatic fistula rate. The heterogeneity and sensitivity analyses were performed.

RESULTS

Six studies (n = 476) were included. The pooled data showed no significant difference in the clinically relevant postoperative pancreatic fistula rate between stented and nonstented groups for at least one high-risk factor out of two factors selected (p = 0.234). Patients with non-dilated main pancreatic duct who received stent placement had a lower clinically relevant postoperative pancreatic fistula rate (RR = 0.582, 95%CI = 0.383-0.883, p = 0.011). In contrast, patients with soft pancreatic texture showed no significant difference between two groups (p = 0.879). After removing the study identified by sensitivity analysis as the origin of heterogeneity from general cohorts, the stented group had a lower clinically relevant postoperative pancreatic fistula rate (RR = 0.608, 95%CI = 0.413-0.895, p = 0.012).

CONCLUSIONS

There is a lack of robust evidence to support pancreatic duct stent placement for high-risk anastomoses. Nevertheless, stent implantation may be beneficial for patients with non-dilated pancreatic duct or external stent drainage.

TRIAL REGISTRATION

The protocol was registered in advance with PROSPERO (CRD42023471943).

Textbook outcome following pancreaticoduodenectomy in elderly patients: age-stratified analysis and predictive factors

Despite advancements in pancreatic surgery, managing elderly patients undergoing pancreaticoduodenectomy (PD) remains challenging. Textbook Outcome (TO) serves as a benchmark for surgical success, but its relevance in elderly patients has not been well explored. This study aims to evaluate TO in elderly patients undergoing PD and identify predictors of TO failure. A retrospective analysis was conducted on elderly patients (≥ 70 years) who underwent PD between January 1, 2017, and December 31, 2023 in two international HPB centers. TO achievement rates were assessed and stratified by age groups (70-74, 75-79, ≥ 80). Uni- and multivariate logistic regression analyses were performed to identify risk factors for TO failure. Of 222 patients, 54.5% achieved TO after PD. TO rates decreased with age, with only 35.0% of octogenarians achieving TO, compared to 57.1% in those aged 70-74. Multivariate analysis revealed that age ≥ 80, an ASA score ≥ 2, and histopathologic types other than pancreatic ductal adenocarcinoma or distal cholangiocarcinoma were significant risk factors for failing to achieve TO. Nearly half of elderly patients achieved TO, with a lower likelihood in older age groups, particularly among octogenarians. Higher ASA scores were also associated with lower TO achievement. These findings underscore the importance of a comprehensive preoperative assessment, considering age, to optimize surgical outcomes in elderly patients undergoing PD.

Risk stratification of postoperative pancreatic fistula and other complications following pancreatoduodenectomy. How far are we? A scoping review

PURPOSE

Pancreatoduodenectomy (PD) is a challenging procedure which is associated with high morbidity rates. This study was performed to make an overview of risk factors included in risk stratification methods both logistic regression models and models based on artificial intelligence algorithms to predict postoperative pancreatic fistula (POPF) and other complications following PD and to provide insight in the extent to which these tools were validated.

METHODS

Five databases were searched to identify relevant studies. Calculators, equations, nomograms, and artificial intelligence models that addressed POPF and other complications were included. Only PD resections were considered eligible. There was no exclusion of the minimally invasive techniques reporting PD resections. All other pancreatic resections were excluded.

RESULTS

90 studies were included. Thirty-five studies were related to POPF, thirty-five studies were related to other complications following PD and twenty studies were related to artificial intelligence predication models after PD. Among the identified risk factors, the most used factors for POPF risk stratification were the main pancreatic duct diameter (MPD) (80%) followed by pancreatic texture (51%), whereas for other complications the most used factors were age (34%) and ASA score (29.4%). Only 26% of the evaluated risk stratification tools for POPF and other complications were externally validated. This percentage was even lower for the risk models using artificial intelligence which was 20%.

CONCLUSION

The MPD was the most used factor when stratifying the risk of POPF followed by pancreatic texture. Age and ASA score were the most used factors for the stratification of other complications. Insight in clinically relevant risk factors could help surgeons in adapting their surgical strategy and shared decision-making. This study revealed that the focus of research still lies on developing new risk models rather than model validation, hampering clinical implementation of these tools for decision support.

Preoperative body composition measured by bioelectrical impedance analysis can predict pancreatic fistula after pancreatic surgery

BACKGROUND

Postoperative pancreatic fistula (POPF) remains one of the most severe complications after pancreatic surgery. The methods for predicting pancreatic fistula are limited. We aimed to investigate the predictive value of body composition parameters measured by preoperative bioelectrical impedance analysis (BIA) on the development of POPF.

METHODS

A total of 168 consecutive patients undergoing pancreatic surgery from March 2022 to December 2022 at our institution were included in the study and randomly assigned at a 3:2 ratio to the training group and the validation group. All data, including previously reported risk factors for POPF and parameters measured by BIA, were collected. Risk factors were analyzed by univariable and multivariable logistic regression analysis. A prediction model was established to predict the development of POPF based on these parameters.

RESULTS

POPF occurred in 41 of 168 (24.4%) patients. In the training group of 101 enrolled patients, visceral fat area (VFA) (odds ratio [OR] = 1.077, P = 0.001) and fat mass index (FMI) (OR = 0.628, P = 0.027) were found to be independently associated with POPF according to multivariable analysis. A prediction model including VFA and FMI was established to predict the development of POPF with an area under the receiver operating characteristic curve (AUC) of 0.753. The efficacy of the prediction model was also confirmed in the internal validation group (AUC 0.785, 95% CI 0.659-0.911).

CONCLUSIONS

Preoperative assessment of body fat distribution by BIA can predict the risk of POPF after pancreatic surgery.

Preoperative risk-stratified analysis: External versus internal pancreatic stents in pancreatoduodenectomy

BACKGROUND

Several risk-stratified studies have compared the outcomes of external and internal pancreatic stents in pancreatoduodenectomy (PD), but no resolute standard for a fistula-mitigation strategy exists. The study investigated the efficacy of these stents in a preoperative risk-stratified setting.

METHODS

Data from 285 patients who underwent PD with pancreaticojejunostomy using an external or internal stent from 2015 to 2023 were analyzed. The preoperative pancreatic fistula score (preFRS) was used to classify patients into low-risk (preFRS: 0-5) and high-risk (preFRS: 6-8) groups.

RESULTS

PreFRS accurately predicted the risk of clinically relevant postoperative pancreatic fistula (CR-POPF) as 0% and >40% in patients with preFRS ≤1 and ≥7, respectively. Although no significant difference was observed in postoperative outcomes in low-risk patients, the external stent significantly reduced CR-POPF (21% vs 44%, P = .024) and postpancreatectomy hemorrhage (PPH, 0% vs 19%, P = .02) in high-risk patients, leading to the superiority of the external stent in the entire cohort in terms of CR-POPF (12% vs 24%, P = .033) and PPH (1% vs 11%, P = .013). There were no significant differences in stent-related complications or pancreatic dysfunction. External stent malfunction occurred in 14% and significantly affected CR-POPF development in both low- (20% vs 0%, P < .01) and high-risk groups (60% vs 14%, P = .021).

CONCLUSION

The external pancreatic stent showed a more beneficial effect on CR-POPF and PPH, especially in high-risk patients, without increasing other complications. Risk-stratified strategy and improving stent management might enhance postoperative outcomes.

Prediction of clinically relevant postoperative pancreatic fistula after pancreatoduodenectomy based on multifrequency magnetic resonance elastography

BACKGROUND

Clinically relevant postoperative pancreatic fistula (CR-POPF) is the major complication of pancreatoduodenectomy, and the pancreatic texture is one of the potential affecting factors. Multifrequency magnetic resonance elastography (MRE) is a novel technique for measuring tissue stiffness, but its value in predicting CR-POPF preoperatively has not been well documented.

METHODS

A total of 70 patients who underwent multifrequency MRE before pancreatoduodenectomy between July 2021 and April 2024 were retrospectively recruited into the study. The parameters of MRE, shear wave speed (c) and phase angle (φ), and clinical data were collected. Logistic regression and the receiver operating characteristic curve analyses were used to assess the performance of multifrequency MRE in predicting CR-POPF.

RESULTS

CR-POPF was developed in 14 of 70 patients (20%), all categorized as grade B. The CR-POPF group had significantly lower c (1.339 ± 0.210 m/s) and longer hospital stays (21 [IQR, 15.50-37.75] days) than the no-CR-POPF group. The MRE parameters, c and φ, were moderately correlated with pancreas stiffness (eta2 for φ = 0.189 and eta2 for c = 0.106). Dilated major pancreatic duct (MPD ≥ 3 mm) and higher c were independently associated with a lower risk of CR-POPF in univariant and multivariant analyses (odds ratio [OR] for c, 0.041 [95% CI, 0.002-0.879]; OR for dilated MPD, 0.129 [95% CI, 0.022-0.768]). The area under the curve (AUC) of the predictive model based on c and MPD diameter was 0.786, which was better than the fistula risk score (FRS) (AUC = 0.587) and alternative FRS (AUC = 0.556) in our center, with the DeLong test P = .028 and P = .002, respectively.

CONCLUSION

The MRE parameters were associated with pancreatic stiffness, and c was an independent predictor of CR-POPF after pancreatoduodenectomy.

Positive drain fluid culture on postoperative day one is associated with an increased risk of late postoperative pancreatic fistula after pancreaticoduodenectomy

PURPOSE

To investigate the risk factors for late postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy (PD), with a focus on positive drain fluid culture (DFC) results on postoperative day (POD) 1.

METHODS

Medical records of 198 patients who underwent PD with drain fluid amylase (DFA) on POD 5 < 3x upper limit of normal (ULN) were included. Late POPF was defined as POPF diagnosed post-POD 6, with DFA on POD 5 < 3xULN. Risk factors analyses were performed, with a focus on DFC on POD 1.

RESULTS

Nineteen patients (9.6%) were diagnosed with late POPF. Age > 65 years (OR: 4.019, P = 0.034) and positive DFC on POD 1 (OR: 10.151, P < 0.001) were identified as independent predictors of late POPF. Patients with positive DFC on POD 1 (n = 25) had higher rates of late POPF (44% vs. 4.6%, P < 0.001), postpancreatectomy hemorrhage (20% vs. 5.8%, P = 0.027) and Clavien-Dindo ≥ IIIa complications (44% vs. 6.4%, P < 0.001). The majority of patients (57.9%) with late POPF had positive DFC on POD 1 (11 of 19, 57.9%). The isolates from 11 patients with positive DFC on POD 1 yielded 12 microorganisms, the most prevalent of which were Enterobacter (n = 7), followed by Enterococcus (n = 3) and Staphylococcus (n = 2). Cefmetazole resistance was detected in 66.7% (8 of 12) of the microorganisms.

CONCLUSION

Age > 65 years and positive DFC on POD 1 were independent predictors of late POPF after PD. Positive DFC on POD 1 was associated with a higher rate of complications.

CT Angiography Assessment of Dorsal Pancreatic Artery and Intrapancreatic Arcade Anatomy: Impact on Whipple Surgery Outcomes

BACKGROUND/OBJECTIVES

The aim was to investigate the association between variations in the dorsal pancreatic artery (DPA) and intrapancreatic arcade anatomy with Whipple procedure outcomes and postoperative complications.

METHODS

This retrospective study was conducted with 362 patients who underwent a Whipple procedure at the Department of Gastroenterological Surgery of Adana City Training and Research Hospital between January 2018 and April 2024. All data collected from medical records were compared and statistically analyzed according to the patients' survival status and arcade subtypes.

RESULTS

After excluding cases that did not meet the study criteria, a total of 284 patients were included in the study. DPA was visualized in 55.98% (159/284) of patients, while the intrapancreatic arcade was observed in 25% (71/284). The most common origin of the DPA was the splenic artery in 69.2% (n = 110) of patients, followed by the superior mesenteric artery in 17.6% (n = 28). The frequency of intrapancreatic arcade anatomy variations was as follows: type 1: 28.2% (n = 20), type 2: 49.3% (n = 35) and type 3: 22.5% (n = 16). Arcade type 4 anatomy was not detected. Postoperative pancreatic fistula (POPF) complication was found to be statistically significantly higher in patients with type 3 anatomy (p = 0.042). The 90-day mortality and long-term mortality rates did not differ among the groups based on the variations in both DPA and intrapancreatic arcade anatomy types.

CONCLUSIONS

Patients with intrapancreatic arcade type 3 anatomy had a higher risk of POPF complications. Determination of preoperative arcade type by computed tomography (CT) angiography may help to predict the risk of POPF.

Comparison of reconstruction techniques after pancreatoduodenectomy: A single-center retrospective cohort study

BACKGROUND

There is controversy regarding which is the best reconstruction technique after the pancreatoduodenectomy. Currently, there are no studies comparing the three most frequent reconstruction techniques: Whipple + Roux-en-Y gastrojejunostomy (WRYGJ), pyloric-preserving + Billroth II (PPBII), and Whipple + BII (WBII).

METHODS

Between 2012 and March 2023, 246 patients underwent pancreaticoduodenectomy with the following type of reconstruction techniques: (1) WRYGJ: 40 patients; (2) PPBII: 118 patients; and (3) WBII: 88 patients. A retrospective comparative study among these groups was performed.

RESULTS

No significant differences were found among the groups regarding duration of the surgery, the blood volume transfused, or caliber of the Wirsung duct. The size and types of tumors, the degree of differentiation and tumor invasion of the peripancreatic tissue, vascular and neural structures, and lymph nodes were similar among the groups. The rate of R0 resection was lower in WBII (62.5% [55/88]) than in WRYGJ (75% [30/40]) and PPBII (72% [85/118]), but statistically insignificant among the groups (p = 0.232). The incidences of relevant B/C postoperative pancreatic fistula (POPF) were similar among the groups: 7.5% (7/40) in WRYGJ, 17% (20/118) in PPBI, and 26.2% (23/88) in WBII (p = 0.292). In addition, the incidence of B/C delayed gastric emptying (DGE) was higher in WBII (27.3% [24/88]) than in WRYGJ (20% [8/40]) and PPBII (19.5% [23/118]) but statistically insignificance among the groups (p = 0.381). The incidence of medical and surgical complications, intensive care unit and hospital stays, morbimortality at 90 days, and 5-year survival were similar among the groups. Multivariate analysis revealed that POPF grade B/C was a risk factor for DGE grade B/C (odds ratio (OR) = 9.903, 95% confidence interval (CI) = 4.829-20.310; p < 0.001), and a <3-mm Wirsung duct was a risk factor for POPF (OR = 3.604, 95% CI = 1.791-7.254; p < 0.001).

CONCLUSION

No technique was superior to the others. Only relevant POPF B/C was a risk factor for DGE B/C, and <3 mm Wirsung for a POPF.

Achievement of international benchmark outcomes for robotic pancreaticoduodenectomy in a low volume country

BACKGROUND

Recently, there has been an increase in the utilisation of the robotic platform to perform minimally invasive pancreaticoduodenectomy in high volume centres, with the goal of reducing morbidity and improving patient outcomes. This study reports the successful implementation of a robotic pancreaticoduodenectomy (RPD) programme in the relatively low volume setting of Australia, measured against established, internationally accepted benchmarks for low-risk open pancreaticoduodenectomy (OPD).

METHODS

Retrospective review of a prospectively maintained database for consecutive RPD at two Brisbane hospitals was performed, comparing data to internationally established benchmarks for low-risk OPD. A structured RPD programme was implemented by two surgeons across a study period spanning May 2017 to December 2023.

RESULTS

Over the study period, seventy-two consecutive RPDs were performed, with 79 % for malignancy. Perioperative outcomes for transfusions, conversion rate, postoperative fistula rate, morbidity, mortality and oncological outcomes were all within established benchmark cutoffs for low-risk open pancreaticoduodenectomy (OPD), although operative time exceeded the benchmark value by 0.7hrs.

CONCLUSION

A carefully implemented RPD programme in the low volume Australian setting is feasible, with high quality outcomes achievable when compared to established benchmarks for low-risk OPD and to reported RPD series published by high volume pioneering centres.

Updating the paradigm of prophylactic abdominal drainage following pancreatoduodenectomy

BACKGROUND

Prophylactic abdominal drainage (PAD) is considered a routine procedure after pancreatoduodenectomy (PD) to prevent and detect severe complications at an early stage. However, the drainage itself may cause adverse consequences. Thus, the optimal strategy of PAD after PD remains controversial.

METHODS

The present paper summarizes the latest research on the strategies of PAD following PD, mainly focusing on 1) the selective placement of PAD, 2) the optimal drainage types, 3) the early removal of drainage (EDR), and 4) novel strategies for PAD management.

RESULTS

Accurate stratifications based on the potential risk factors of clinically relevant-postoperative pancreatic fistula (CR-POPF) facilitates the selective placement of PAD and the implementation of EDR, with postoperative outcomes superior or similar to routine PAD placement. Both active and passive drainage methods are feasible in most patients after PD, with similar prognostic outcomes. Novel predictive models with accurate, dynamic, and individualized performance further guide the management of PAD and afford a better prognosis.

CONCLUSIONS

Evidence-based risk stratification of CR-POPF aids in the management of PAD in patients undergoing PD. Novel dynamic and individualized PAD strategies might be the next hotspot in drain-relevant explorations.

The proinflammatory status, based on preoperative interleukin-6, predicts postpancreatectomy acute pancreatitis and associated postoperative pancreatic fistula after pancreaticoduodenectomy

BACKGROUND AND AIM

Early predictors of morbidity after pancreaticoduodenectomy (PD) can guide tailored postoperative management. Preoperative inflammatory data in patients who underwent PD remained poorly studied in investigating the clinical significance of predicting postpancreatectomy acute pancreatitis (PPAP) and PPAP-associated postoperative pancreatic fistula (POPF).

METHODS

The clinical data of 467 patients receiving PD between January 2020 and December 2022 were retrospectively reviewed. Preoperative inflammatory data were stratified according to PPAP, and independent risk factors were analyzed. Multivariate logistic regression and subgroup analyses were conducted to compare risk factors of PPAP-associated POPF and non-PPAP-associated POPF.

RESULTS

PPAP occurred in 17.6% of patients. The incidence of other complications increased following PPAP. Among the preoperative inflammatory factors, only interleukin-6 (IL-6) increased (P < 0.001), leading to a higher incidence of PPAP and POPF (P < 0.001; P = 0.002). The area under the curve of IL-6 in predicting PPAP was 0.71 (0.65-0.77; P < 0.001). Abnormal preoperative IL-6 levels (odds ratio [OR]: 5.01; P < 0.001), soft pancreatic texture (OR: 2.15; P = 0.007), and pathology (OR: 2.03; P = 0.012) were independent risk factors for PPAP. The subgroup analysis showed that increased IL-6 (OR: 1.01; P = 0.006) and soft pancreatic texture (OR: 2.05; P = 0.033) resulted in a higher risk of PPAP-associated POPF, while increased IL-8 (OR: 1.01; P = 0.007), older age (OR: 1.05; P = 0.008), and higher body mass index (OR: 1.12; P = 0.021) correlated with non-PPAP-associated POPF.

CONCLUSION

PPAP is common after PD; a high preoperative IL-6 level can predict its occurrence, in addition to associated POPF, which could be due to a preoperative proinflammatory status.

The impact of externalized pancreatic stents in our practice: A comparison of outcomes after pancreaticoduodenectomy in two time periods

BACKGROUND

Postoperative pancreatic fistula is a severe complication of pancreaticoduodenectomy. Using an externalized pancreatic stent is a potential mitigation strategy not previously studied in Latin America.

METHODS

Pancreaticoduodenectomies performed in a single center between 2006 and 2019 were retrospectively analyzed. Clinical variables were collected with a 90-day follow-up according to stent intervention: externalized stent (ES), internal stent (IS), or no stent. Before and after ES implementation (2016) periods were also compared.

RESULTS

Out of 237 patients, 77 (32.5 ​%) had an ES, 24 (10.1 ​%) an IS, and 136 (57.4 ​%) none. No difference was found in the overall incidence of POPF. The use of an ES was associated with less type C POPF, despite having an increased risk for fistula development. PD performed after 2016 were also associated with a reduced incidence of type C POPF, surgical reintervention requirement, POPF-associated mortality, and intrahospital stay.

CONCLUSIONS

The use of an ES is a low-cost intervention that can mitigate POPF severity in high-risk patients.

Hospital charge and resource use analysis of extended-spectrum penicillin antibiotic therapy after pancreatoduodenectomy in intermediate- and high-risk patients

BACKGROUND

We previously reported that an extended antibiotic mitigation pathway following pancreatoduodenectomy in patients with intermediate-/high-risk glands is associated with 83 % lower odds of clinically relevant postoperative pancreatic fistula (CR-POPF). We now describe associations between the pathway, resource utilization, and hospital charges.

METHODS

We performed a retrospective cohort study of patients who underwent elective pancreatoduodenectomy with soft gland texture and fistula risk score (FRS) ≥3 who received standard or extended antibiotics. Hospital charges and resource utilization within 90 days of surgery were compared by CR-POPF status and antibiotic pathway.

RESULTS

A total of 34 patients received extended antibiotics and 53 received standard antibiotics. In patients with CR-POPF, patients who received extended antibiotics had lower likelihood of surgical or percutaneous reintervention (75.0 % vs. 100.0 %, p = 0.022). Ninety-day postoperative charges associated with CR-POPF were higher than no CR-POPF ($60,527 vs. $25,631, p = 0.028). Our risk-based model predicted a $15,825 decrease in hospital charges per patient receiving extended antibiotics.

CONCLUSIONS

CR-POPF is associated with higher 90-day hospital charges. Extended antibiotic therapy following pancreatoduodenectomy in patients with soft gland texture and FRS ≥3 is associated with fewer reinterventions in patients who develop CR-POPF. These outcomes will be formally tested in a randomized controlled trial (NCT05753735).

The impact of chronic obstructive pulmonary disease on risk for complications after pancreatoduodenectomy - a single centre cohort study

BACKGROUND

The association between chronic obstructive pulmonary disease (COPD) and risk for postoperative complications after pancreatic surgery has not been clarified. The aim of this study was to investigate if COPD is associated with increased risk for postoperative complications after pancreatoduodenectomy.

METHODS

All patients aged ≥18 years undergoing pancreatoduodenectomy from 2008 to 2019 at a high-volume tertiary centre for pancreatic cancer surgery were included. COPD was defined as an established diagnosis according to the International Statistical Classification of Diseases. The primary outcome was Clavien-Dindo-score (CD)≥ IIIa.

RESULTS

Out of 1009 available patients, 57 (5.6 %) had a diagnosis of COPD. There was no association between COPD and CD≥ IIIa (25.5 % vs. 29.8 % p-value 0.471). COPD was associated with an increased risk for postoperative pancreatic fistula (POPF) (odds ratio [OR] 3.06, 95 % confidence interval 1.62-5.89; p < 0.001). The 12 months mortality rate was higher among patients with COPD compared to patients without COPD, although not statistically significant (28.07 % vs., 18.17 %, p-value = 0.063).

CONCLUSION

COPD was associated with increased risk for POPF. These results imply that among patients deemed fit enough to undergo surgery, COPD should be thoroughly evaluated in the risk stratification.

Italian survey about intraperitoneal drain use in distal pancreatectomy

Intraperitoneal prophylactic drain (IPD) use in distal pancreatectomy (DP) is still controversial. A survey was carried out through the Italian community of pancreatic surgeons using institutional emails, Twitter, and Facebook accounts of the Italian Association for the Study of the Pancreas (AISP) and the Italian Association of Hepato-biliary-pancreatic Surgery (AICEP). The survey was structured to learn surgeons' practice in using IPD through questions and one clinical vignette. Respondents were asked to report their regrets for omission and commission regarding the IPD use for the clinical scenario, eliciting a scale between 0 (no regret) and 100 (maximum regret). The threshold model and a multilevel mixed regression were built to identify respondents' attitudes. One hundred six surgeons completed the survey. Sixty-three (59.4%) respondents confirmed using at least 1 drain, while 43 (40.6%) placed 2 IPDs. Only 13 respondents (12.3%) declared a change in IPD strategy in patients at high risk of clinically relevant postoperative pancreatic fistula (CR-POPF), while 9 (9.4%) respondents changed their strategy in low-risk POPF situations. Thirty-five (35.5%) respondents declared they would remove the IPD within the third postoperative day (POD) in the absence of CR-POPF suspicion. The median omission regret, which proved to be the wrong decision, was 80 (50-100, IQR). The median regret due to the commission of IPD, which turned out to be useless, was 2.5 (1-20, IQR). The CR-POPF probability threshold at which drainage omission was the less regrettable choice was 7% (1-35, IQR). The threshold to perceive drain omission as the least regrettable choice was higher in female surgeons (P < 0.001), in surgeons who modulated the strategies based on the risk of CR-POPF, and in high volume centers (p = 0.039). The threshold was lower in surgeons who performed minimally invasive distal pancreatectomy (P < 0.001), adopted a closed system (P < 0.001), placed two IPDs (P < 0.001), or perceived the IPD as important to prevent reintervention (p = 0.047). Drain management after DP remains very heterogeneous among surgeons. The regret model suggested that IPD omission could be performed in low-risk patients (7% of CR-POPF), leading to low regret in the case of the wrong decision, making it an acceptable clinical decision.

Robotic Pancreaticoduodenectomy for Pancreatic Head Tumour: A Single-Centre Analysis

Background: The robotic approach is an appealing way to perform minimally invasive pancreaticoduodenectomy. We compare robotic cases' short-term and oncological outcomes to a historical cohort of open cases. Methods: Data were collected in a prospective database between 2016 and 2024; complications were graded using the ISGPS definition for the specific pancreas-related complications and the Clavien-Dindo classification for overall complications. Furthermore, the Comprehensive Complication Index was calculated. All patients undergoing pancreaticoduodenectomy were included, except those with acute or chronic pancreatitis, vascular tumour involvement or multi-visceral resections. Only the subset of patients with malignancy was regarded for the oncologic outcome. Results: In total, 100 robotic and 102 open pancreaticoduodenectomy cases are included. Equal proportions of patients have a main pancreatic duct ≤3 mm (p = 1.00) and soft consistency of the pancreatic remnant (p = 0.78). Surgical time is longer for robotic pancreaticoduodenectomy (p < 0.01), and more patients have delayed gastric emptying (44% and 28.4%, p = 0.03). In the robotic group, the number of patients without any postoperative complications is higher (p = 0.02), and there is less chyle leak (p < 0.01). Ninety-day mortality, postoperative pancreatic fistula, and postpancreatectomy haemorrhage are similar. The lymph node retrieval and R0 resection rates are comparable. Conclusions: In conclusion, after robotic pancreaticoduodenectomy, remembering all cases during the learning curve are included, less chyle leak is observed, the proportion of patients without any complication is significantly larger, the surgical duration is longer, and more patients have delayed gastric emptying. Oncological results, i.e., lymph node yield and R0 resection rate, are comparable to open pancreaticoduodenectomy.

Pancreaticoduodenectomy with pancreaticogastrostomy and an external pancreatic stent in risky patients: a propensity score-matched analysis

BACKGROUND

There is an ongoing debate about the most appropriate method for reconstructing the pancreas after a pancreaticoduodenectomy (PD). This study assessed the impact of pancreaticogastrostomy (PG) with an external pancreatic stent on postoperative outcomes following PD in high-risk patients.

PATIENTS AND METHODS

This study involves a propensity score-matched analysis of high-risk patients who underwent PD with PG reconstruction. The primary outcome measure was the occurrence of Postoperative Pancreatic Fistula (POPF). Secondary outcomes included operative time, intraoperative blood loss, length of hospital stay, re-exploration rate, as well as postoperative morbidity and mortality rates.

RESULTS

The study included 78 patients; 26 patients underwent PD with Pancreatogastrostomy (PG) and an external pancreatic stent, while 52 underwent PG without a pancreatic stent. Blood loss and operative time did not significantly differ between the two groups. The overall postoperative morbidity was higher in the group without a stent than in the stented group (34.6% vs. 15.4%, P = 0.06). No patient in the pancreatic stent group developed a clinically relevant POPF; however, in the non-stented group of PG, 17.3% developed POPF. There were no cases of hospital mortality in the stented group. However, in the non-stented group, two hospital mortality happened (one case was due to the systemic inflammatory response syndrome (SIRS) secondary to POPF grade C, and the other was due to pulmonary embolism.

CONCLUSION

PG with an external pancreatic stent results in fewer clinically relevant pancreatic fistulas, a decrease in postoperative morbidities, and a non-existent mortality rate in high-risk patients.

An improved invagination pancreaticojejunostomy technique associated with a lower incidence of pancreatic fistula: A single-center study

PURPOSE

This study compared the incidence of postoperative pancreatic fistula (POPF) between standard invagination pancreaticojejunostomy (PJ) and an improved PJ technique after pancreaticoduodenectomy and evaluated the clinical utility of the improved PJ procedure.

METHODS

Clinical and postoperative data of 363 patients who underwent pancreaticoduodenectomy at the First Affiliated Hospital of Soochow University from February 2018 to October 2021 were analyzed retrospectively. In our cohort, 155 patients underwent the improved PJ technique (group A), and 208 underwent standard invagination PJ (group B). Data on demographic characteristics, pathological nature, intraoperative factors, and postoperative complications, including POPF, were collected and analyzed.

RESULTS

There were no significant between-group differences in demographic characteristics (p > 0.05). The improved PJ technique was associated with a significantly lower incidence of clinically relevant POPF (CR-POPF) in the total cohort (11.6 % vs. 26.4 %, p < 0.001) and in the subgroup with high fistula risk scores (16.0 % vs. 38.6 %, p < 0.001).

CONCLUSION

The improved invagination PJ technique reduces the incidence of CR-POPF and improves prognosis.

Cross-sectional imaging of pancreatic leak: a pictorial review

Pancreatic leaks occur when a disruption in the pancreatic ductal system results in the leakage of pancreatic enzymes such as amylase, lipase, and proteases into the abdominal cavity. While often associated with pancreatic surgical procedures, trauma and necrotizing pancreatitis are also common culprits. Cross-sectional imaging, particularly computed tomography, plays a crucial role in assessing postoperative conditions and identifying both early and late complications, including pancreatic leaks. The presence of fluid accumulation or hemorrhage near an anastomotic site strongly indicates a pancreatic fistula, particularly if the fluid is connected to the pancreatic duct or anastomotic suture line. Pancreatic fistulas are a type of pancreatic leak that carries a high morbidity rate. Early diagnosis and assessment of pancreatic leaks require vigilance and an understanding of its imaging hallmarks to facilitate prompt treatment and improve patient outcomes. Radiologists must maintain vigilance and understand the imaging patterns of pancreatic leaks to enhance diagnostic accuracy. Ongoing improvements in surgical techniques and diagnostic approaches are promising for minimizing the prevalence and adverse effects of pancreatic fistulas. In this pictorial review, our aim is to facilitate for radiologists the comprehension of pancreatic leaks and their essential imaging patterns.