Rapid postoperative reduction in prognostic nutrition index is associated with the development of pancreatic fistula following distal pancreatectomy

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 C-Reactive Protein-to-Albumin Ratio Predicts Postoperative Pancreatic Fistula following Pancreatoduodenectomy: A Single-Center, Retrospective Study

Postoperative pancreatic fistula (POPF) following pancreatoduodenectomy (PD) is a potentially lethal complication, and it is clinically important to determine its risk preoperatively. Although C-reactive protein-to-albumin ratio (CAR) is reported to be a prognostic marker for postoperative complications in several cancers, no evidence is currently available regarding the association between preoperative CAR and POPF following PD for periampullary tumors. This study examined whether preoperative CAR could predict POPF following PD. Clinical data were retrospectively retrieved from Ehime University Hospital. The optimal cut-off value for CAR was determined using receiver operating characteristic (ROC) curve analysis. This study enrolled 203 consecutive patients undergoing PD for periampullary tumors. The CAR value was significantly higher in the POPF group than in the non-POPF group (p < 0.001). According to the ROC curve analysis, the optimal cut-off value for CAR was 0.09. Patients with CAR ≥ 0.09 had higher incidence rates of POPF than their counterparts. CAR ≥ 0.09 was a risk factor for POPF in the multivariate logistic regression analysis (odds ratio 34.5, 95% confidence interval 11.75-101.38, p < 0.001). This is the first report demonstrating an association between CAR and POPF following PD. Preoperative CAR is an independent predictive marker for POPF following PD.

Association between the Preoperative C-Reactive Protein-to-Albumin Ratio and the Risk for Postoperative Pancreatic Fistula following Distal Pancreatectomy for Pancreatic Cancer

Postoperative pancreatic fistula (POPF) are major postoperative complications (POCs) following distal pancreatectomy (DP). Notably, POPF may worsen the prognosis of patients with pancreatic cancer. Previously reported risks for POCs include body mass index, pancreatic texture, and albumin levels. Moreover, the C-reactive protein-to-albumin ratio (CAR) is a valuable parameter for prognostication. On the other hand, POCs sometimes lead to a worse prognosis in several cancer types. Thus, we assumed that CAR could be a risk factor for POPFs. This study investigated whether CAR can predict POPF risk in patients with pancreatic cancer following DP. This retrospective study included 72 patients who underwent DP for pancreatic cancer at Ehime University between January 2009 and August 2022. All patients underwent preoperative CAR screening. Risk factors for POPF were analyzed. POPF were observed in 17 of 72 (23.6%) patients. POPF were significantly associated with a higher CAR (p = 0.001). The receiver operating characteristic curve analysis determined the cutoff value for CAR to be 0.05 (sensitivity: 76.5%, specificity: 88.9%, likelihood ratio: 6.88), indicating an increased POPF risk. Univariate and multivariate analysis revealed that CAR ≥ 0.05 was a statistically independent factor for POPF (p < 0.001, p = 0.013). Therefore, CAR has the potential to predict POPF following DP.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND/AIM

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Preoperative neutrophil-to-lymphocyte ratio predicts healing time for postoperative pancreatic fistula after distal pancreatectomy

PURPOSE

Postoperative pancreatic fistula is a serious complication of distal pancreatectomy. Although many studies have described the incidence and risk factors associated with postoperative pancreatic fistula (POPF), few have focused on the healing time. This study investigated the healing time and potential factors associated with the healing time of POPF after distal pancreatectomy (DP).

METHODS

Among 114 patients that underwent DP in our hospital from January 2010 to December 2020, we included 88 that developed POPF. The healing time for a postoperative pancreatic fistula was defined as the interval between the completion of DP and the removal of all drains related to the treatment for POPF. Based on the definition, three cases who required additional treatment after removal of all drains were excluded from this study. Clinical factors associated with the fistula healing times were investigated in the 85 patients.

RESULTS

The average POPF healing time was 11 ± 10 days (median: 6 days, range: 3-57). We found that the neutrophil-to-lymphocyte ratio, a marker of inflammatory and nutritional status, was the only factor independently associated with the POPF healing time; the mean healing time was significantly shorter in patients with neutrophil-to-lymphocyte ratio ≤2.1 (8 ± 6 days) than in those with neutrophil-to-lymphocyte ratio >2.1 (13 ± 12 days; P = .0139).

CONCLUSION

We demonstrated that the neutrophil-to-lymphocyte ratio could independently predict the POPF healing time after DP. These findings suggested that improving the neutrophil-to-lymphocyte ratio might shorten the healing times for POPF after DP.

Lower geriatric nutritional risk index predicts postoperative pancreatic fistula in patients with distal pancreatectomy

Postoperative pancreatic fistula (POPF) is a common complication following pancreatic resection. It leads to increased medical costs, and longer hospital stays. However, the risk factors of POPF are still unclear, and therefore, this urgent clinical issue should be resolved. The geriatric nutritional risk index (GNRI) is tool to assess the nutritional status using body weight, and serum albumin value, particularly in elderly patients. On the other hand, POPF is associated with body mass index (BMI). Thus, the present study aimed to investigate whether GNRI can predict the risk of POPF in patients after distal pancreatectomy (DP). We conducted a retrospective cohort study involving 37 patients who were treated at the Department of Digestive Surgery, Kawaguchi Municipal Medical Center between January 2007 and June 2018. All patients were subjected to nutritional screening using GNRI, and were followed up after DP for postoperative complications including POPF. In addition, risk factors of POPF, and patient's height, BMI, and preoperative laboratory values were analyzed. POPF was observed in 7 of the 37 (19%) patients. Those with a POPF had significantly lower GNRI values than those without POPF (P<0.001). Receiver operating characteristic curve analysis was performed to determine a cut-off value of GNRI, which indicated an increased risk of POPF. This value was determined as 96 (sensitivity: 71.4%, specificity: 86.7%, likelihood ratio: 5.36). Univariate analysis confirmed that a GNRI of <96 was significantly associated with POPF (P=0.005), and a multivariate logistic regression analysis revealed that a GNRI of <96 was significant independent predictor of POPF (P=0.005), suggesting its utility for assessing the risk of POPF following DP.

The influence of nutritional status on the incidence of postoperative complications in patients following distal pancreatectomy

INTRODUCTION

Malnutrition is a common problem in hospitalised patients. The immunological, inflammatory, and nutritional status of patients significantly influences the postoperative outcome.

AIM

To assess and analyse the influence of the nutritional status on postoperative complications in patients following distal pancreatectomy.

MATERIAL AND METHODS

The analysis included 50 patients operated in a large centre of gastrointestinal surgery. The clinicopathological parameters were analysed, and the nutritional status was assessed. The prognostic nutritional index (PNI) was calculated as 10 × serum albumin (g/dl) + 0.005 × total lymphocyte count (per mm3). The immunological parameters, neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), and lymphocyte/monocyte ratio (LMR) were calculated. Patients were divided into two groups according to the presence of early postoperative complications: those without postoperative complications and those with postoperative complications.

RESULTS

Early postoperative complications were observed in 15 (30.0%) patients undergoing distal pancreatectomy. Postoperative pancreatic fistula (POPF) was the most frequent complication noted in 11 (22%) patients. Significantly higher Nutritional Risk Screening (NRS) 2002 (p = 0.005) and lower PNI (median value: 56 vs. 41, p = 0.0003) were noted in patients with postoperative complications. In laboratory results, the significantly lower total lymphocyte count (median value: 2.4 vs. 1.4 per mm3, p = 0.01) and serum level of albumin (median value: 4.7 vs. 3.3 g/dl, p = 0.0003) were noted in the complications group.

CONCLUSIONS

Nutritional status significantly influences the incidence of postoperative complications in patients following distal pancreatectomy. Assessment of nutritional status using PNI calculation should be the standard management of patients before surgical treatment.

Clinical significance of preoperative nutritional parameter and patient outcomes after pancreatectomy: A retrospective study at two academic institute

Backgrounds/Aims

Preoperative nutritional status has been reported to influence patient outcomes after pancreatectomy. The Prognostic Nutritional Index (PNI) is a useful parameter to reflect the outcomes of patients undergoing gastrointestinal surgery. Therefore, the relationship between the PNI and clinicopathological factors, surgical data, and postoperative morbidity were retrospectively evaluated at two academic institutes in a cohort study.

Methods

Curative pancreatectomy was performed on 222 patients at the University of Nagasaki between 1995 and March 2015, and 101 at the University of Miyazaki between April 2015and March 2018. The PNI was calculated using preoperative albumin and total cholesterol levels.

Results

The mean PNI in our series was 39.2±5.4 and the prevalence of PNIs less than 40 was observed in 134 patients (44%). The PNI was not significantly different between normal, hard, and fatty architecture of the pancreatic parenchyma. The PNIs were significantly negatively correlated with higher age (p<0.01), but not with gender, co-morbidity, or habits. The PNI was significantly correlated with levels of hemoglobin, prothrombin activity, choline esterase, total protein, albumin and cholesterol (p<0.01), and with postoperative total protein and albumin levels (p<0.05). Although the preoperative PNI tended to be lower in patients with total postoperative complications, no significant differences for each complication were observed.

Conclusions

Although the preoperative PNIs reflect the perioperative nutritional status, its predictive usefulness for postoperative complications could not be significantly confirmed.

Correlation of serum albumin and prognostic nutritional index with outcomes following pancreaticoduodenectomy

BACKGROUND

Pancreaticoduodenectomy (PD) is a complex surgical procedure with a high morbidity rate. The serious complications are major risk factors for poor long-term surgical outcome. Studies have reported an association between early postoperative prognostic nutritional index (PNI) and prediction of severe complications after abdominal surgery. However, there have been no studies on the use of early postoperative PNI for predicting serious complications following PD.

AIM

To analyze the risk factors and early postoperative PNI for predicting severe complications following PD.

METHODS

We retrospectively analyzed 238 patients who underwent PD at our hospital between January 2007 and December 2017. The postoperative complications were classified according to the Dindo-Clavien classification. Grade III-V postoperative complications were classified as serious. The risk factors for serious complications were analyzed by univariate analysis and multivariate logistic regression analysis.

RESULTS

Overall complications were detected in 157 of 238 patients (65.9%) who underwent PD. The grade III-V complication rate was 26.47% (63/238 patients). The mortality rate was 3.7% (9/238 patients). Multivariate logistic regression analysis revealed that preoperative serum albumin [odds ratio (OR): 0.883, 95% confidence interval (CI): 0.80-0.96; P < 0.01] and PNI on postoperative day 3 < 40.5 (OR: 2.77, 95%CI: 1.21-6.38, P < 0.05) were independent factors associated with grade III-V postoperative complications.

CONCLUSION

Perioperative albumin is an important factor associated with serious complications following PD. Low early postoperative PNI (< 40.5) is a predictor for serious complications.

Simplicity and Safety: Minimized Pancreatic Fistula Rate after Distal Pancreatectomy through Pancreas Stump Sutured Fish-Mouth Closure

Pancreatic stump leak after distal pancreatectomy (DP) is a major determinant for impaired postoperative recovery. Factors influencing pancreatic fistula (PF) occurrence remain of interest. Prospectively collected data from an academic surgical oncology practice were examined for predictors of PF. Seventy-five of 294 pancreatectomy patients underwent DP (26%). There were 33 men and 42 women, with a median age of 61 years (range: 18–85 years). Underlying conditions included cancer (60%) and benign processes (40%). Resections were comprising open DP (64%), laparoscopic DP (21%), and open multivisceral resections (15%). Of 21 cases with postoperative complications (28%, no death), six were PFs (8%, 2 grade A and 4 grade B). The median length of stay was six days (4–24). The PF rate was 2.0 per cent in 50 patients after sutured fish-mouth closures, but 20 per cent in cases using other techniques including stapling ( P = 0.007); no other variable was linked to PF occurrence. Length of stay was linked to complications, resection extent, malignancy, and transfusions (all at P < 0.02), but not to PF. PF rate after DP in this experience is unaffected by splenic vessel resection but seems to be minimized through a sutured fish-mouth closure technique.

Risk factors of postoperative pancreatic fistula in patients after distal pancreatectomy: a systematic review and meta-analysis

Postoperative pancreatic fistula (POPF) is a common complication following distal pancreatectomy (DP). However, the risk factors of this complication in patients after DP still remain controversial. The aim of our study is to estimate the association between potential risk factors and POPF. Relevant articles published up to June 21, 2016 were identified via PubMed, EMBASE, Web of Science, and The Cochrane Library. Studies that examined the risk factors of POPF following DP were enrolled. 20 articles (2070 patients) were finally included in this study. The pooled data suggested that patients with soft pancreas, higher Body Mass Index (BMI), blood transfusion, elevated intraoperative blood loss, and longer operative time had a decreased risk for POPF. However, age, gender, malignant pathology, types of stump closure, octreotide therapy, history of diabetes and chronic pancreatitis, splenectomy, multiorgan resection, main duct ligation, preoperative serum albumin levels, PGA felt wrapping, and extended lymphadenectomy could not be regarded as risk factors for POPF. Our analytic data demonstrated that pancreas texture, BMI, blood transfusion, intraoperative blood loss, and operative time were clinical predictor for POPF. This study may assist surgeons to screen patients with high risk of POPF and select appropriate treatment measures.