Postoperative pancreatic fistula: an international study group (ISGPF) definition

Drain Fluid Amylase as an Early Negative Predictor of Salivary Fistula Following Free Flap Reconstruction

OBJECTIVES

Salivary fistula is a known complication following head and neck free flap reconstruction involving the aerodigestive tract. We sought to examine the association between surgical drain fluid amylase and salivary fistula formation during postoperative hospitalization.

METHODS

Eighty patients who underwent head and neck reconstruction involving the aerodigestive tract at our institution between 2019 and 2023 were included. Amylase concentration (IU/L) was measured from a Jackson-Pratt drain located along the mucosal closure line on postoperative days 1-5.

RESULTS

Twelve patients (15%) developed salivary fistulas. The change in drain amylase concentration between postoperative day 1 and day 2 was found to be significantly higher in those who developed a fistula during postoperative hospitalization. A receiver operating characteristic curve found that a threshold of 15% provided a sensitivity of 58.3% and specificity of 80.6% (area under the curve 0.767) to predict salivary fistula. This threshold remained significant on multivariate analysis (odds ratio 5.35, 95% confidence interval 1.79-24.3) when controlling for prior radiation, perioperative transfusion, and total laryngectomy. When retrospectively applied to our cohort, a cutoff of 15% resulted in a positive predictive value of 35% and a negative predictive value of 91.5%.

CONCLUSION

Change in surgical drain fluid amylase from postoperative day 1 to 2 was associated with fistula formation following free flap reconstruction of the aerodigestive tract. Importantly, a change in amylase of < 15% from postoperative day 1 to 2 was best at identifying patients who are at low risk of developing salivary fistula during postoperative hospitalization, with a negative predictive value of 91.5%.

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.

Multiaction Antimicrobial, Anti-inflammatory, and Prohealing Hydrogel as a Novel Strategy for Preventing Postoperative Pancreatic Fistula

Postoperative pancreatic fistula remains a challenging complication after pancreaticoduodenectomy. Addressing this issue requires effective strategies to promote anastomotic healing. In this study, we developed a novel hydrogel designed to close pancreaticoenteric anastomosis after pancreaticoduodenectomy. The hydrogel-composed of polyvinyl alcohol, chitosan, and dopamine-modified oxidized hyaluronic acid-exhibited excellent antibacterial, anti-inflammatory, and wound healing properties. It was designed to conform well to the anastomotic site for clinical application. The hydrogel demonstrated good biocompatibility, appropriate mechanical strength, low swelling, and strong adhesive properties, meeting specific requirements for pancreaticoenteric anastomosis environments. Moreover, by activating the cell cycle, it promoted cell proliferation and migration, thereby accelerating anastomotic closure. Addition of the potent broad-spectrum antibiotic meropenem further enhanced its antibacterial efficacy, targeting common microbial species involved in delayed healing and fistula formation after pancreatic surgery. In a rat model of pancreatic fistula, the hydrogel effectively sealed the anastomosis, filled potential suture gaps, and exerted antibacterial, anti-inflammatory, and tissue regeneration-promoting effects around the anastomotic site. Therefore, this hydrogel, with its ideal degradation properties, shows promising application prospects in closing pancreaticoenteric anastomosis following pancreaticoduodenectomy, thereby offering an effective solution to reduce complications such as pancreatic fistula after pancreatic surgery.

Machine learning for modeling and identifying risk factors of pancreatic fistula

BACKGROUND

Pancreatic fistula is the most common complication of pancreatic surgeries that causes more serious conditions, including bleeding due to visceral vessel erosion and peritonitis.

AIM

To develop a machine learning (ML) model for postoperative pancreatic fistula and identify significant risk factors of the complication.

METHODS

A single-center retrospective clinical study was conducted which included 150 patients, who underwent pancreatoduodenectomy. Logistic regression, random forest, and CatBoost were employed for modeling the biochemical leak (symptomless fistula) and fistula grade B/C (clinically significant complication). The performance was estimated by receiver operating characteristic (ROC) area under the curve (AUC) after 5-fold cross-validation (20% testing and 80% training data). The risk factors were evaluated with the most accurate algorithm, based on the parameter "Importance" (Im), and Kendall correlation, P < 0.05.

RESULTS

The CatBoost algorithm was the most accurate with an AUC of 74%-86%. The study provided results of ML-based modeling and algorithm selection for pancreatic fistula prediction and risk factor evaluation. From 14 parameters we selected the main pre- and intraoperative prognostic factors of all the fistulas: Tumor vascular invasion (Im = 24.8%), age (Im = 18.6%), and body mass index (Im = 16.4%), AUC = 74%. The ML model showed that biochemical leak, blood and drain amylase level (Im = 21.6% and 16.4%), and blood leukocytes (Im = 11.2%) were crucial predictors for subsequent fistula B/C, AUC = 86%. Surgical techniques, morphology, and pancreatic duct diameter less than 3 mm were insignificant (Im < 5% and no correlations detected). The results were confirmed by correlation analysis.

CONCLUSION

This study highlights the key predictors of postoperative pancreatic fistula and establishes a robust ML-based model for individualized risk prediction. These findings contribute to the advancement of personalized perioperative care and may guide targeted preventive strategies.

Nonalcoholic fatty liver disease following laparoscopic duodenum-preserving pancreatic total head resection vs laparoscopic pancreaticoduodenectomy: A retrospective cohort study

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is characterized by the accumulation of fat in the liver in individuals who do not consume alcohol. Several risk factors influencing the onset of NAFLD after laparoscopic pancreaticoduodenectomy (LPD) have been identified. This study investigated the risk factors associated with the development of fatty liver after laparoscopic duodenum-preserving pancreatic total head resection (LDPPHRt) and LPD.

AIM

To compare the effects of LDPPHRt and LPD on the development of postoperative NAFLD.

METHODS

This retrospective cohort study included 59 patients who were histologically diagnosed with benign or low-grade malignant pancreatic tumors and who underwent laparoscopic pancreatic surgery (LDPPHRt or LPD) between May 2020 and April 2023. Patient data on perioperative and postoperative variables were analyzed and compared. Multivariate logistic regression was used to identify pre-, peri-, and postoperative risk factors for NAFLD, with statistical significance set at P < 0.05.

RESULTS

Of the 59 patients included in the study, 17 (28.8%) developed NAFLD within 6-12 months post-surgery. The incidence of NAFLD was significantly higher in the LPD group compared to the LDPPHRt group (40.0% vs 12.5%, P = 0.022). Multivariable analysis identified the LDPPHRt surgical approach (compared to LPD) as an independent protective factor against the development of postoperative NAFLD, with an odds ratio of 0.208 (95% confidence interval: 0.046-0.931; P = 0.040).

CONCLUSION

Our findings indicate that LDPPHRt is more effective than LPD in reducing the incidence of postoperative NAFLD, which may inform surgical decision-making and optimize patient outcomes after laparoscopic pancreatic surgery.

Developing a predictive model for delayed healing of esophagojejunal anastomotic fistula following total gastrectomy based on imaging and clinical inflammatory-nutritional status

BACKGROUND

Esophagojejunal anastomotic fistula (EJF) following radical total gastrectomy is a severe perioperative complication in patients with gastric cancer, particularly as delayed fistula healing increases hospitalization costs and leads to poor prognosis. Numerous factors influence the occurrence and progression of EJF, with inflammation and nutritional status being significant contributors to perioperative complications. Therefore, this study aims to investigate the prediction of delayed EJF healing based on postoperative clinical and imaging-related inflammation-nutrition status.

METHODS

We retrospectively collected data on 315 cases of EJF following radical total gastrectomy for gastric cancer from two centers between 2015 and 2023 (training group: center one with 194 cases, validation group: center two with 121 cases). EJF was diagnosed based on clinical presentation, gastrointestinal imaging, or endoscopic findings. The healing time for EJF was defined as the period from diagnosis to the removal of the abdominal drainage tube, and patients were categorized into early healing and delayed healing groups based on the median healing time. Postoperative abdominal computed tomography(CT) scans and clinical characteristics at the time of EJF diagnosis were collected. Univariate and multivariable logistic regression analyses were performed on the training group data to construct a predictive model (nomogram). The model's performance in both the training and validation groups was evaluated using the area under the receiver operating characteristic (ROC) curve (AUC), calibration curves, and decision curve analysis (DCA).

RESULT

The mean healing time for EJF was 16 ± 7 days (median time: 12 days, range: 4-43 days). Postoperative systemic immune-inflammation index (SII) > 521 × 10ˆ9/L, controlling nutritional status score (CONUT) > 4, nutritional support method, visceral fat index (VFI) < 74.42 cm2/m2, and skeletal muscle index (SMI) < 41.25 cm2/m2 were associated with delayed EJF healing times. A comprehensive model was developed, in the validation group, the model demonstrated an AUC of 0.838 (95 % confidence interval (95 % CI): 0.763-0.912). The DCA and calibration curves indicated a strong predictive consistency and clinical utility of the model.

Surgical Management of Solid Pseudopapillary Neoplasm of the Pancreas-an Experience from Tertiary Care Centre

Solid pseudopapillary neoplasm (SPN) is uncommon and constitutes to 1-2% of pancreatic tumours. Owing to its rarity, literature is sparse on its clinicopathological characteristics and surgical outcomes. Our study is a retrospective analysis of prospectively maintained data of patients with histologically proven SPN between January 2012 and December 2019. Patients' demography, clinical presentation, preoperative imaging, operative details, perioperative outcomes, and long-term follow-up were recorded and analyzed. A total of 14 patients were included in the study, all were females with a median age of 19.5 years (range 15-35 years). All presented with pain abdomen. Eight (57.1%) out of 14 patients were correctly diagnosed with contrast-enhanced computed tomography (CECT) abdomen. CECT revealed solid cystic well-encapsulated lesions in 12(85.7%) and homogenous mass lesions without cystic changes in 2 (14.2%) patients. The most common tumour location was head/uncinate process (57.1%). Eight (57.1%) underwent pancreaticoduodenectomy and 6 (42.8%) had undergone distal pancreatectomy. The median size of tumour was 10 cm (4.5-14 cm). The median postoperative stay was 9 days (range 4-20 days). Seven patients (50%) developed postoperative pancreatic fistula (Grade-A-6/7, Grade-B-1/7) and delayed gastric emptying (DGE) was noted in two (14.2%). R0 resection could be achieved in 13 patients (92.8%). Median follow-up period was 49.5 months. One patient had postoperative recurrence after 48 months of surgery. SPN is a rare tumour of pancreas. Surgical resection is associated with acceptable morbidity and is required for potential cure.

Evaluation of the validity of pancreatoduodenectomy for octogenarian patients with biliary tract carcinoma from the perspective of recurrence

OBJECTIVE

To clarify the short- and long-term validity of pancreatoduodenectomy in octogenarian patients with biliary tract carcinoma.

METHODS

We compared 23 and 141 patients aged ≥80 and <80 years, who underwent pancreatoduodenectomy for biliary tract carcinoma (distal cholangiocarcinomas and ampullary carcinomas) and evaluated the relationship between age, clinicopathological factors, and surgical and oncological outcomes, especially in terms of recurrence.

RESULTS

Median overall survival time of distal cholangiocarcinoma and ampullary carcinoma was 92 and 109 months (p = 0.13). Postoperative complications, mortality, and adjuvant chemotherapy rates did not differ between the groups. Although the 5-year recurrence-free survival rate was similar, the 5-year disease-specific survival and overall survival rate were significantly shorter in octogenarians (≥80 years: 43.5, 47.1, and 35.3%; <80 years: 54.1, 69.2, and 63.0%; p = 0.41, 0.016, and 0.034, respectively). The median time from recurrence to death for octogenarian patients was significantly shorter than that of younger patients (3.3 vs. 16.1 months, p < 0.001). At recurrence, the serum albumin level, prognostic nutritional index, controlling nutritional status score, and treatment rate for recurrence were lower in octogenarians. The multivariate analysis identified age ≥80 years (hazard ratio: 3.8), low prognostic nutritional index (hazard ratio: 2.9), high serum carbohydrate antigen 19-9 (hazard ratio: 2.6), and failure to implement treatment after recurrence (hazard ratio: 3.0) as independent risk factors for a short time from recurrence to death. Furthermore, age ≥80 years (odds ratio 0.09) was an independent risk factor for treatment implementation after recurrence.

CONCLUSIONS

Octogenarians had a shorter survival time after recurrence, resulting from low nutritional indices and a reduced rate of treatment implementation at the time of recurrence.

Postoperative nutritional support after pancreaticoduodenectomy in adults

BACKGROUND

Resection of the head of the pancreas is most commonly done by a pancreaticoduodenectomy, known as a Whipple procedure. The most common indication for pancreaticoduodenectomy is malignancy, but can include benign tumours and chronic pancreatitis. Complete surgical resection, with negative margins, provides the best prospect of long-term survival. Pancreaticoduodenectomy involves specific and unique alterations to the digestive system and maintaining nutritional status (optimising outcomes and achieving resumption of a normal diet) in patients with cancer after major surgery is a challenge. Malnutrition is a risk factor following pancreaticoduodenectomy, due to the magnitude of the operation and the frequency of complications. Postoperatively, patients are fed either orally, enterally or parenterally. Oral intake may start with fluids and then progress to solid food, or may be ad libitum. Enteral feeding may be via a nasojejunal tube or feeding tube jejunostomy. Parenteral nutrition can be delivered via a central or peripheral intravenous line, and may provide full nutrition (TPN) or partial nutrition (supplemental PN).

OBJECTIVES

To assess the effects of postoperative nutritional support strategies on complications and recovery in adults after pancreaticoduodenectomy.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, LILACS and CINAHL (from inception to October 2022), ongoing trials registers and other internet databases. We searched previous systematic reviews, relevant publications on the same topic and the references of included studies.

SELECTION CRITERIA

Randomised controlled trials of postoperative nutritional interventions in an inpatient setting for patients undergoing pancreaticoduodenectomy. We specifically looked for studies comparing route or timing rather than nutritional content.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, judged the risk of bias and extracted data. Studies requiring translation were assessed for inclusion, risk of bias and data extraction by an external translator and another author. We used GRADE to evaluate the certainty of the evidence.

MAIN RESULTS

We included 17 studies (1897 participants). Of these, eight studies could be included in a meta-analysis. The route, timing and target of nutritional support varied widely between studies. Enteral feeding (jejunostomy, nasojejunal or gastrojejunostomy) was used in at least 13 studies (one study did not specify the method of enteral route), parenteral nutrition (PN) was used in at least 10 studies (two studies had a control of 'surgeon's preference' and no further details were given) and oral intake was used in seven studies. Overall, the evidence presented in this review is of low to very low certainty. Four studies compared jejunostomy feeding with total parenteral nutrition. When we pooled these four studies, the evidence demonstrated that jejunostomy likely results in a reduced length of hospital stay (mean difference (MD) -1.61 days, 95% confidence interval (CI) -2.31 to -0.92; 3 studies, 316 participants; moderate-certainty evidence). The evidence suggested that there may be no difference in postoperative pancreatic fistula (risk ratio (RR) 0.77, 95% CI 0.41 to 1.47; 4 studies, 346 participants; low-certainty evidence) and that there may be no difference in delayed gastric emptying (RR 0.38, 95% CI 0.04 to 3.50; 2 studies, 270 participants; very low-certainty evidence) or post pancreatectomy haemorrhage (RR 0.36, 95% CI 0.06 to 2.29; 2 studies, 270 participants; very low-certainty evidence), but the evidence is uncertain. There were no data for major and minor complications defined by the Clavien-Dindo classification. Two studies compared nasojejunal feeding with total parenteral nutrition. When the two studies were pooled, the evidence suggested that there may be little to no difference between nasojejunal feeding and TPN in the length of hospital stay (MD 1.07 days, 95% CI -2.64 to 4.79; 2 studies, 242 participants; low-certainty evidence), delayed gastric emptying (RR 1.26, 95% CI 0.83 to 1.91; 2 studies, 242 participants; low-certainty evidence) or post pancreatectomy haemorrhage (RR 1.00, 95% CI 0.62 to 1.62; 2 studies, 242 participants; low-certainty evidence). TPN may slightly improve rates of clinically relevant postoperative pancreatic fistula (RR 2.13, 95% CI 1.21 to 3.74; 2 studies, 242 participants; low-certainty evidence). One study reported on major complications (RR 1.27, 95% CI 0.83 to 1.94; very low-certainty evidence) and minor complications (RR 1.01, 95% CI 0.68 to 1.50; 204 participants; very low-certainty evidence) defined by the Clavien-Dindo classification and there may be little to no difference in effect, but the evidence is uncertain. Two studies compared jejunostomy feeding with oral intake. Of note, one of the studies used a modified surgical technique as part of the intervention. We pooled these studies and found that there may be little to no difference in the length of hospital stay (MD -1.99 days, 95% CI -4.90 to 0.91; 2 studies, 301 participants; very low-certainty evidence) or delayed gastric emptying (RR 0.98, 95% CI 0.33 to 2.88; 2 studies, 307 participants; very low-certainty evidence). One study reported on major complications (RR 1.01, 95% CI 0.44 to 2.34; 247 participants; very low-certainty evidence) and minor complications (RR 0.83, 95% CI 0.59 to 1.15; 247 participants; very low-certainty evidence) defined by the Clavien-Dindo classification, postoperative pancreatic fistula (RR 0.86, 95% CI 0.30 to 2.50; 247 participants; very low-certainty evidence) and post pancreatectomy haemorrhage (RR 2.02, 95% CI 0.52 to 7.88; 247 participants; very low-certainty evidence) and there may be little to no difference in effect on these outcomes, but the evidence is uncertain. No difference in mortality was detected in any of the analyses (Clavien-Dindo Grade V) (very low-certainty evidence).

AUTHORS' CONCLUSIONS

When compared with parenteral nutrition, enteral nutrition by jejunostomy likely results in a decreased length of hospital stay and may lead to no difference in the incidence of postoperative complications. When compared with parenteral nutrition, enteral feeding by nasojejunal tube may result in no difference in the incidence of postoperative complications or length of hospital stay. When compared with oral nutrition, enteral nutrition by jejunostomy feeding may result in no difference in the incidence of postoperative complications or length of hospital stay, but the evidence is very uncertain. Further high-quality research is required and there are several ongoing studies. Given the number of different nutritional interventions available in the postoperative setting, a network meta-analysis would be more appropriate in future.

Obsidian ASG autologous platelet-rich fibrin matrix for the prevention of postoperative pancreatic fistula following pancreatic resection: study protocol for a feasibility trial at the Medical University of Vienna

INTRODUCTION

Postoperative pancreatic fistula (POPF) is the most frequent complication after partial pancreatectomy, which is by definition associated with clinical consequences requiring changes in postoperative management. Despite numerous scientific efforts, effective procedures to prevent POPF are lacking. Obsidian ASG autologous platelet-rich fibrin matrix has been effectively applied to prevent anastomotic leakage following colorectal surgery. This study is the first to investigate the feasibility of using the sealant in pancreatic surgery.

METHODS AND ANALYSIS

25 consecutive patients scheduled for elective formal partial pancreatectomy due to any underlying disease fulfilling the eligibility criteria will be included. Obsidian ASG sealant prepared out of 120 mL of each patient's whole blood will be applied to the pancreatic stump or the pancreatic anastomosis, respectively. The primary endpoint is the feasibility of the procedure, for example, the proportion of patients undergoing successful trial intervention. Secondary endpoints comprise safety and surgical outcome parameters including rate and severity of POPF as well as further pancreas-specific complications as defined by the International Study Group of Pancreatic Surgery during 90 days after surgery. Patients will be matched with a historic collective in a 1:2 ratio to gain first data on efficacy.

ETHICS AND DISSEMINATION

This trial and the associated study protocol (V.1.1.1, date 26 March 2024) were approved by the institution's ethics committee (reference number 2191/2023). All trial procedures are performed in accordance with the International Council for Harmonisation harmonised tripartite guideline on Good Clinical Practice and the ethical principles of the Declaration of Helsinki. After completion of the study, results will be published in due course.

TRIAL REGISTRATION NUMBER

The trial was registered in the German Clinical Trials Register on 6 May 2024 (DRKS-ID: DRKS00034052).

"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.

Whether preoperative biliary drainage leads to better patient outcomes of pancreaticoduodenectomy: a meta-analysis and systematic review

OBJECTIVE

To investigate whether preoperative biliary drainage is beneficial for patients undergoing pancreaticoduodenectomy.

METHODS

The PubMed, Cochrane Library and the Web of Science were systematically searched for relevant trials that included outcome of pancreaticoduodenectomy with and without preoperative biliary drainage from January 2010 to May 2024. The primary outcomes are postoperative pancreatic fistula and intra-abdominal infection. Data is pooled using the risk ratio or standardized mean difference with 95% confidence interval. The study protocol was registered prospectively with PROSPERO (CRD42022372584).

RESULTS

A total of 39 retrospective cohort studies with 33,516 patients were included in this trial. Compared with no preoperative biliary drainage, the preoperative biliary drainage group had a longer hospital stay (SMD, 0.14). Performing preoperative biliary drainage significantly increases the risk of postoperative pancreatic fistula (RR, 1.09), intra-abdominal infection (RR, 1.09), surgical site infection (RR, 1.84), and sepsis (RR, 1.37). But preoperative biliary drainage lowers risk of bile leak (RR, 0.74).

CONCLUSION

Preoperative biliary drainage before pancreaticoduodenectomy increases the risk of postoperative complications without clear overall benefits. Routine PBD is not recommended for younger patients with mild to moderate jaundice but may be considered for high-risk patients, such as those with severe infections or progressive jaundice. Optimizing preoperative biliary drainage duration and timing may help reduce complications. Further research is needed to refine patient selection and perioperative strategies.

Immunohistochemical Evaluation of the Tumor Immune Microenvironment in Pancreatic Ductal Adenocarcinoma

Background: Pancreatic ductal adenocarcinoma is an aggressive neoplasm with a complex carcinogenesis process that must be understood through the interactions between tumor cells and tumor microenvironment cells. Methods: This study was retrospective with a chronological extension period of 16 years and included 56 cases of pancreatic ductal adenocarcinoma. This study identified, quantified, and correlated the cells of the tumor immune microenvironment in pancreatic ductal adenocarcinoma with major prognostic factors as well as overall survival, using an extensive panel of immunohistochemical markers. Results: Three tumor immunotypes were identified: subtype A (hot immunotype), subtype B (intermediate immunotype), and subtype C (cold immunotype). Patients with immunotype C exhibit considerably higher rates of both pancreatic fistulas and acute pancreatitis. Immunotypes B and C significantly increased the risk of this complication by factors of 3.68 (p = 0.002) and 3.94 (p = 0.001), respectively. The estimated probabilities of fistula formation for each immunotype are as follows: 2.5% for immunotype A, 25% for immunotype B, and 28% for immunotype C. There was a statistically significant difference in median survival times according to tumor immunotype (p < 0.001). Specifically, patients with immunotype C tumors had a median survival time of only 120.5 days, compared to 553.5 days for those with immunotype A and 331.5 for immunotype B tumors. Conclusions: The identification of the immunotype of pancreatic ductal adenocarcinoma can be a predictive factor for the occurrence of complications such as pancreatic fistula as well as for overall survival.

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.

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.

Updates in the Surgical Management of Pancreatic Ductal Adenocarcinoma

Surgical management of pancreas cancer is complex, including the timing of surgery, surgical approach, intraoperative techniques, and postoperative management, which are reviewed in detail in this manuscript. Ultimately, referral to a high-volume pancreatic surgeon or pancreatic surgery center is critical to ensuring appropriate short-term and long-term outcomes.

Outcome following pylorus resecting pancreaticoduodenectomy versus classical Whipple's pancreaticoduodenectomy: a randomised controlled trial

OBJECTIVE

To compare pylorus resecting pancreaticoduodenectomy (PRPD) with classical pancreaticoduodenectomy (classical PD) in terms of short term outcomes.

BACKGROUND

There is some evidence that Pylorus resecting PD (PRPD) is associated with lesser incidence of DGE when compared to pylorus preserving PD (PPPD). However, no study has previously compared PRPD with classical PD.

METHODS

Patients requiring PD were randomly assigned to either PRPD or classical PD after intraoperative assessment to rule out metastases and unresectable disease. Occurrence of DGE was the primary end point.

RESULTS

A total of 154 patients (103 males; Mean age:53.3 ± 12.2 years) were included in the final analysis (PRPD = 78, classical PD = 76). PRPD group had significantly shorter operation [Mean difference: 41 min (95 % CI:18-65)]. There was no significant difference in the incidence of DGE [32 (41.0 %)vs37 (48.7 %); p = 0.339] and clinically significant DGE [22 (28.2 %)vs19 (25.0 %); p = 0.789] between PRPD and classical PD. There was also no difference in the rates of clinically relevant pancreatic fistula [20 (25.6 %)vs22 (28.9 %); p = 0.780], severe morbidity [21 (26.9 %)vs19 (25.0 %); p = 0.930], operative mortality [6 (7.7 %)vs2 (2.6 %); p = 0.157] and median postoperative stay [12 (5-47) days vs 12 (6-56) days; p = 0.861].

CONCLUSION

We found no significant difference in the early postoperative outcomes between PRPD and classical PD. PRPD was found to be significantly faster than the classical PD.

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.

Practical Efficacy and Limitations of the Transpapillary Stent Bridging Technique for Non-postoperative Pancreatic Fistula

BACKGROUND

Non-postoperative pancreatic fistula is usually caused by pancreatic duct disruption due to acute or chronic pancreatitis. Although endoscopic transpapillary drainage and stent bridging to block the disrupted area are traditional treatment approaches, their efficacy remains uncertain. This study aims to evaluate the efficacy of transpapillary drainage for non-postoperative pancreatic fistulas.

METHODS

We evaluated the demographic profiles, fistula characteristics, success rate of stent bridging, and successful clinical outcomes (defined as the absence of symptoms and a continuous reduction of fluid collection, and no need for additional drainage) of 22 patients who underwent transpapillary drainage from January 2013 to September 2024.

RESULTS

Chronic pancreatitis (59%) and acute pancreatitis (27%) were the main etiologies. Proximal and distal pancreatic duct disruptions occurred in nine (41%) and 13 (59%) patients, respectively. The success rate of stent bridging and clinical success rate were 55% and 50%, respectively. Fistula site, type, and stent bridging significantly correlated with clinical success (proximal vs distal: 89% vs. 23%, p = 0.01; complete disruption vs. other types: 0% vs 65%, p = 0.04; successful vs. failed stent bridging: 82% vs. 27%, p = 0.03). Successful stent bridging notably depended on fistula site and type (proximal vs. distal: 89% vs. 31%, p = 0.01; complete disruption vs. other types: 0% vs. 71%, p = 0.01). Among technically successful stent bridging cases, all proximal fistula patients improved clinically, whereas only 25% of distal patients did.

CONCLUSION

Stent bridging demonstrated efficacy primarily in proximal pancreatic fistulas. However, it posed challenges and showed limited efficacy in cases involving distal and complete pancreatic duct disruptions.

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).

Postoperative outcomes and their risk factors in left pancreatectomy with and without multivisceral resection

The aim of the present study was to identify risk factors associated with postoperative morbidity and mortality in patients undergoing isolated left pancreatectomy and those undergoing left pancreatic resection as part of a multivisceral resection. We performed a retrospective analysis of 296 adult patients who underwent elective left pancreatectomy from 2005 to 2022 at the University Hospital Erlangen. Patient demographics, pre- and intraoperative findings, along with postoperative outcomes, were collected and tested as predictive factors for various short-term postoperative parameters. Isolated left pancreatectomy (LP) was performed in 173 patients, while 123 patients underwent left pancreatectomy as part of a multivisceral resection (multivisceral LP). Multivisceral LP was associated with a higher rate of major morbidity (27% vs. 17%, p = 0.043) and mortality (7% vs. 2%, p = 0.046) compared to LP. Independent risk factors for major morbidity included the need for intraoperative blood transfusion and oncological lymphadenectomy in the LP group and longer operative time in the multivisceral LP group. CR-POPF was associated with the indication for surgery in the LP group. Independent risk factors for re-surgery included intraoperative blood transfusion in the LP group and ASA III or IV in the multivisceral LP group. Cardiovascular diseases were associated with higher mortality in the LP group, while COPD was the only risk factor for mortality in the multivisceral LP group. Multivisceral left pancreatectomy is associated with worse outcomes compared to isolated left pancreatectomy. In both groups, relevant risk factors predict postoperative complications. Patients with these identified risk factors should receive close monitoring during the postoperative course to anticipate outcomes with an increased risk of complications.

Current and Emerging Treatment Options for Pancreatic Cancer: A Comprehensive Review

Pancreatic ductal adenocarcinoma (PDAC) is one of the leading causes of death worldwide, and its global burden has increased significantly over the past few years. The incidence of pancreatic cancer has also increased in the United States, and most of this increase is attributed to the population's aging process in addition to the rise in the prevalence of risk factors such as obesity, diabetes, smoking, and alcohol intake. Most patients with pancreatic cancer present with advanced unresectable or metastatic disease. Only a few patients present at an early stage with localized disease, and a multidisciplinary approach is required to maximize survival and outcomes. The surgical approach is an option for localized disease, and surgery's safety and efficacy have also been improved in recent years due to the increasing use of minimally invasive surgical techniques. Moreover, systematic chemotherapy has also been used and has had a significant impact on survival. More recently, neoadjuvant therapy has been used for pancreatic cancer along with radiation therapy, optimizing survival among those patients. Targeted therapies have been introduced based on genetic testing in metastatic pancreatic cancer and have shown promising results. Moreover, immune checkpoint inhibitors and targeted agents such as PARP inhibitors and vaccines have emerged with optimal results in terms of survival. To conclude, pancreatic cancer is considered a disease with poor long-term survival; however, recent developments in pharmacotherapy have changed its treatment and have improved outcomes with improved survival. Our review summarizes ongoing therapeutic options for local and metastatic pancreatic cancer. It also summarizes new state-of-the-art therapies that have emerged or are in trials, which can change the pancreatic cancer treatment perspective.

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.

Identification of a pancreatic juice-specific fluorescent probe through 411 probes activated by aminopeptidases/proteases or phosphatases/phosphodiesterases

BACKGROUND

This study is a retrospective review aimed to identify pancreatic juice-specific fluorescent probes to visualize pancreatic juice using a library of 381 aminopeptidase/protease-activatable fluorescent probes and 30 phosphatase/phosphodiesterase probes. In 2013, we developed a fluorescence imaging technique using a chymotrypsin probe to visualize pancreatic juice, linked to postoperative pancreatic fistula (POPF). This probe required addition of trypsin to convert pancreatic chymotrypsinogen to chymotrypsin. Recently we accessed libraries of enzyme-activatable fluorescent probes to find probes that facilitated target-specific imaging.

METHODS

Pancreatic juice and ascitic fluid samples were collected in eight patients undergoing pancreaticoduodenectomy. Reaction rates of pancreatic juice to background ascitic fluids were calculated for these 411 fluorescent probes.

RESULTS

Forty-four fluorescent probes were screened in terms of high reactivity with pancreatic juice. Only one candidate probe targeting ectonucleotide pyrophosphatase/phosphodiesterase (ENPP) 1 was selected for a pancreatic juice-specific fluorescent probe. Inhibitor experiments and Western blotting supported the presence of ENPP1 in the pancreatic juice.

CONCLUSION

ENPP1-targeting fluorescent probe may have the potential to visualize pancreatic juice leakage during surgery. This finding may allow surgeons to suture leaking sites and decide the necessity of prophylactic abdominal drains; however, the role of ENPP1 in pancreatic juice remains to be clarified.

Knowledge of obstetric fistula and contributing factors among reproductive-age women in Ethiopia: a systematic review and meta-analysis

Introduction

Obstetric fistulas are one of the most severe injuries resulting from prolonged, obstructed labor, particularly when timely medical care is unavailable. In Ethiopia, numerous women and girls continue to endure the consequences of obstetric fistula due to contributing factors like early marriage and limited access to skilled healthcare during childbirth. The development of prevention strategies remains challenging, as reports on the knowledge surrounding obstetric fistulas and their causes are inconsistent across the country. To assess the overall, knowledge of reproductive-aged women regarding obstetric fistulas and the contributing factors to its occurrence.

Methods

Studies were systematically searched from May 30 2024 to July 1, 2024, using Web of Science, Scopus, PubMed/Medline, Science Direct, African Journal Online, and the Wiley Online Library. This review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A random-effects meta-analysis was performed with STATA version 11 software to estimate the knowledge, and the results are reported in a forest plot. Simple charts and tables were used to summarize the evidence for the pooled level of knowledge and its determinants.

Results

The pooled knowledge of fistula complications among reproductive-aged women in Ethiopia was 43.3% (95% CI: 35.2, 51.4). Above secondary education level (OR=3.73[2.40, 5.86]), urban residence (OR=3.77 [2.45, 5.80], access to media (OR=2, 82[1.26, 6.33]), and women attended pregnancy conference (OR=3.75[2.35, 5.99]) were determinants of good knowledge of obstetric fistula.

Conclusions

In Ethiopia, only 43.3% of reproductive-age women had good knowledge about obstetric fistulas. Factors that contribute to a higher knowledge include having a secondary education, living in urban areas, access to media, and attending pregnancy-related conferences. To improve knowledge, it is recommended to increase specific education on obstetric fistulas and prevention strategies, particularly for women living in rural areas. Promoting institutional deliveries and providing better health education on how to prevent obstetric fistulas, including pregnancy conferences is essential. Additionally, policymakers and stakeholders should focus on empowering women of reproductive age and addressing the overlooked yet significant public health issue of obstetric fistulas.

Predictive model for pancreatic fistula in minimally invasive surgery for gastric cancer

BACKGROUND

Postoperative pancreatic fistula (POPF) is one of the potentially serious complications after gastrectomy for gastric cancer (GC). Drain amylase level is a predictor of POPF in open and laparoscopic gastrectomy, but no study has focused on minimally invasive surgery (MIS), including robotic gastrectomy (RG). This study assesses the effect of drain amylase levels for POPF in MIS and develop a prediction model in the MIS era.

METHODS

This single-institutional retrospective study, conducted from January 2011 to December 2021, included 1,353 who underwent standard MIS for GC. We placed a drain in all patients undergoing MIS gastrectomy and measured the drain amylase level on the first postoperative day (D1Amy). The predictive accuracy of D1Amy for POPF was assessed. Additionally, the entire cohort was randomly categorized into the training (1,048 patients) and validation sets (305 patients) to establish the nomogram.

RESULTS

Of the 1353 patients, 530 underwent a robotic approach. POPF and intraabdominal infectious complications of Clavien-Dindo classification grade ≥ II were observed in 80 (5.9%) and 145 (10.7%) patients, respectively. Median D1Amy was 812 U/L. The receiver operating characteristic analysis of D1Amy for POPF revealed an area under the curve (AUC) of 0.888. Multivariate analysis revealed age, tumor location, splenectomy, and D1Amy as significant risk factors for POPF. The AUC of the nomogram was 0.8960, validated with AUC of 0.9259.

CONCLUSIONS

We revealed the utility of D1Amy in predicting POPF in MIS gastrectomy. Furthermore, the nomogram, incorporating D1Amy and other clinical factors, was additionally used as a predictive model for POPF.

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.

Comparison of surgical outcomes between single-layer and double-layer pancreaticojejunostomy after pancreaticoduodenectomy: a meta-analysis

INTRODUCTION

Postoperative pancreatic fistula (POPF) is the most severe complication after pancreaticoduodenectomy (PD), and this study investigates the effects of single-layer and double-layer pancreaticojejunostomy (PJ) on POPF.

EVIDENCE ACQUISITION

Four electronic databases were systematically searched until March 2024: PubMed, Web of Science, Embase, and Cochrane Library. Statistical analysis was performed using Review Manager (RevMan) software. Mean difference (MD) or odds ratios (OR) with 95% confidence intervals (CI) were used to indicate continuous or dichotomous variables, respectively. Ten studies were included, comprising 1811 patients.

EVIDENCE SYNTHESIS

Compared to the double-layer PJ group, the single-layer PJ group had a similar POPF rate (OR=0.73; P=0.28) and grade C POPF rate (OR=0.55; P=0.12), but a lower grade B POPF rate (OR=0.50; 95% CI: 0.31-0.81; P=0.005). The clinically relevant POPF (CR-POPF) rate was lower in the single-layer PJ group (OR=0.47; 95% CI: 0.31-0.73; P<0.001), especially in the 2017 International Study Group of Pancreatic Surgery (ISGPS) criteria subgroup (OR=0.44; 95% CI: 0.27-0.73; P=0.001), the China subgroup (OR=0.41; 95% CI: 0.26-0.64; P<0.001), and the minimally invasive subgroup (OR=0.40; 95% CI: 0.22-0.74; P=0.003).

CONCLUSIONS

Compared with double-layer PJ, single-layer PJ after PD might reduce the incidence of CR-POPF.

Clinical characteristics and treatment outcomes of patients with insulinoma-a single center's experience of 76 cases over a 10-year period

Objective

Insulinoma is a rare pancreatic neuroendocrine neoplasm caused by pancreatic beta cell tumor or beta cell proliferation resulting in excessive insulin secretion. Due to its rarity, surgical analysis and summary studies on patients with insulinoma are few and the sample size is limited.

Methods

In this study, we retrospective the cumulative experiences including demographics, clinical characteristics, detailed surgical reports and postoperative outcome of 76 patients diagnosed with insulinoma from 2010 to 2020 at the First Affiliated Hospital of Xi'an Jiaotong University.

Results

Our cohort consisted of 48 females and 28 males with an average diagnosis age of 52 years. Loss of consciousness (68 %), sweating (59 %), vertigo (56 %) are three most shown symptoms. The average time from symptom onset to diagnosis of insulinoma was 33.4 month. When CT combined with MRI was used, the diagnostic rate was as high as 96.87 %. Of the 76 patients, 48.68 % of preoperative tumors were in the head/neck, and the remaining 51.32 % were in the body/tail. Most of the patients received surgery for enucleation (65.79 %). The duration of surgery was 216 ± 105 min. The incidence of postoperative pancreatic fistula was 53.95 %. Postoperative pancreatic hemorrhage occurred in 6 patients (7.89 %), all of whom were pancreatic head/neck surgery patients. The incidence of pancreatic fistula, bleeding and major complications after the operation of pancreatic head/neck insulinoma was higher than that of pancreatic body/tail insulinoma.

Conclusion

CT combined with MRI can localize insulinoma in most patients. As a parenchyma-sparing pancreatectomy, enucleation is the procedure of choice if possible. The incidence of postoperative hemorrhage should be more vigilant after the surgery of pancreatic head/neck insulinoma. The intraoperative suture of high-risk vessels prone to bleeding should be performed if necessary.

Abdominal aortic calcification volume as a preoperative prognostic predictor for pancreatic cancer

PURPOSE

Atherosclerosis and cancer may progress through common pathological factors. This study was performed to investigate the association between the abdominal aortic calcification (AAC) volume and outcomes following surgical treatment for pancreatic cancer.

METHODS

The subjects of this retrospective study were 194 patients who underwent pancreatic cancer surgery between 2007 and 2020. The AAC volume was assessed through routine preoperative computed tomography. Univariate and multivariate analyses were performed to evaluate the impact of the AAC volume on oncological outcomes.

RESULTS

A higher AAC volume (≥ 312 mm3) was identified in 66 (34%) patients, who were significantly older and had a higher prevalence of diabetes and sarcopenia. Univariate analysis revealed several risk factors for overall survival (OS), including male sex, an AAC volume ≥ 312 mm3, elevated carbohydrate antigen 19-9, prolonged operation time, increased intraoperative bleeding, lymph node metastasis, poor differentiation, and absence of adjuvant chemotherapy. Multivariate analysis identified an AAC volume ≥ 312 mm3, prolonged operation time, lymph node metastasis, poor differentiation, and absence of adjuvant chemotherapy as independent OS risk factors. The OS rate was significantly lower in the high AAC group than in the low AAC group.

CONCLUSION

The AAC volume may serve as a preoperative prognostic indicator for patients with pancreatic cancer.

Combined division of the splenic vessels and pancreatic parenchyma during laparoscopic distal pancreatectomy is a safe alternative to separate division: a single-institution retrospective study

BACKGROUND

Limited data exists regarding the safety and outcomes of combined division of the splenic vessels with the pancreatic parenchyma during laparoscopic distal pancreatectomy (LDP). This study aims to evaluate the combined division technique.

METHODS

Patients who underwent LDP for pancreatic cancer from April 2011 to December 2022 were retrospectively reviewed and categorized into the following groups: combined (CV) versus separate (SV) division of the splenic vein; combined (CA) versus separate (SA) division of the splenic artery; and combined (CAV) versus separate (SAV) division of the splenic artery and vein, with or without the pancreatic parenchyma.

RESULTS

Among the 80 patients included, 44 underwent CV and 36 underwent SV. Operative time and major morbidity were significantly lower in CV compared with SV. Similar findings were observed in CAV versus SAV, as well as lower blood loss in CAV. Operative time was significantly lower in CA versus SA. Pancreatic fistula and postpancreatectomy hemorrhage rates showed no significant differences between groups. No patient developed splenic arteriovenous fistula in follow-up.

CONCLUSION

Combined division of the splenic vessels with the pancreatic parenchyma during LDP is safe and associated with improved outcomes compared with separate division.

Colitis-Induced Pancreatic Fistula with Pancreatic Ascites

Introduction

Although cases of severe pancreatitis causing fistula formation into the colon have been documented, the reverse process of colitis causing a pancreatic fistula remains undocumented.

Case Presentation

We present the case of a 79-year-old male with severe colitis resulting in perforation and pericolonic abscess formation adjacent to the pancreas, which resulted in an internal pancreatic fistula and pancreatic ascites. After 2 paracenteses, our patient ultimately underwent endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and pancreatic duct stent placement. The patient clinically improved and was ultimately discharged.

Conclusion

Follow-up ERCP was performed 2 months after discharge and showed no contrast extravasation, illustrating closure of the previous pancreatic fistula. Ultimately, our case demonstrates that cases of severe colitis may contribute to adjacent pancreatic fistula and ascites formation.

Impact of patient age on outcome of minimally invasive versus open pancreatoduodenectomy: a propensity score matched study

BACKGROUND

Pancreatoduodenectomy in elderly patients may be associated with increased postoperative mortality, but studies in minimally invasive pancreatoduodenectomy (MIPD) are scarce.

METHODS

International multicenter retrospective study including patients aged >60 years undergoing MIPD (robot-assisted and laparoscopic) and open pancreatoduodenectomy (OPD), were categorized by age: 60-69, 70-79, and 80+ years. In each category, propensity score matching (PSM) was performed (1:1 ratio) between MIPD and OPD. Primary outcome was 30-day/in-hospital mortality.

RESULTS

Among 3820 patients, we matched 1468 patients aged 60-69, 1154 patients aged 70-79, and 196 patients aged 80+ years. In patients aged 60-69 and 70-79 years, MIPD was associated with longer operative time, less blood loss and a longer length of stay. Major morbidity was higher after MIPD with similar 30-day/in-hospital mortality. The R0 resection rate was higher after MIPD. In patients aged 80+ years, besides a longer operative time in MIPD, outcomes were comparable between both groups.

CONCLUSION

This study found no evidence that increasing age worsens mortality of MIPD. MIPD was associated with longer operative time, higher rate of major morbidity, prolonged length of stay versus less blood loss and a higher R0 resection in patients aged 60-69 and 70-79 years. These differences continue in patients aged 80+ years, but became less evident.

Topical application of Glauber's salt accelerates the absorption of abdominal fluid after pancreatectomy

BACKGROUND

Abdominal fluid collection (AFC) is one of the most common complications after pancreatic surgery, yet there are few recommendations on how to manage it. Most cases of AFC only require observation, while others may require more invasive techniques. Unfortunately, there are no drugs that effectively promote the absorption of AFCs. The aim of this study was to evaluate the potential efficacy of Glauber's salt solution for promoting the absorption of AFCs after pancreatectomy.

METHODS

This study included 196 patients who underwent pancreatomy and had AFCs on at least 2 cross-sectional follow-up CT images between 2020 and 2022. AFCs were defined as effusion with a diameter ≥ 3 cm and located around the pancreatic resection margin. We retrospectively investigated the relationship between Glauber's salt concentration and clinical variables.

RESULTS

The rate of clinically significant pancreatic fistula (grades B + C) was significantly higher in the control group (62.8% vs. 40.7%, P = 0.014). The median maximum diameter of the AFC was smaller, and the median time for the AFC to decrease to 30 mm in diameter was shorter in the Glauber's salt group than in the control group (41.9 mm vs. 53.5 mm, P = 0.008; 35.5 d vs. 100 d, P < 0.001). According to the multivariate analysis, percutaneous drainage and the application of Glauber's salt were found to be independent risk factors for AFCs decreasing to less than 30 mm in diameter (HR = 2.338, 95% CI = 1.524-3.585, P < 0.001; HR = 1.853, 95% CI = 1.327-2.589, P < 0.001). Additionally, patients with a maximum postoperative temperature exceeding 38.5 °C exhibited enhanced AFC absorption (hazard ratio (HR) = 1.850, 95% CI = 1.268-2.701; P = 0.001).

CONCLUSIONS

Topical application of Glauber's salt solution after pancreatic surgery can promote the absorption of AFCs.

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.

Meta-analysis of routine abdominal drainage versus no drainage following distal pancreatectomy: Does the best available evidence overcome "HPB surgeon's paranoia"?

AIMS

To evaluate comparative outcomes of routine abdominal drainage versus no drainage after distal pancreatectomy (DP).

METHODS

A systematic search of MEDLINE, CENTRAL and Web of Science and bibliographic reference lists were conducted (last search: 20th April 2024). All comparative studies reporting outcomes of DP with routine abdominal drainage and no drainage were included and their risk of bias were assessed. Overall perioperative complications, clinically-relevant postoperative pancreatic fistula (CR-POPF), delayed gastric emptying (DGE), postoperative haemorrhage, surgical site infections (SSIs), need for radiological intervention, reoperation, re-admission, and postoperative mortality were the evaluated outcome parameters.

RESULTS

Eight comparative studies (2 randomised and 6 observational) reporting 8164 patients who underwent DP with (n = 6394) or without (n = 1770) routine abdominal drainage were included. Routine abdominal drainage was associated with significantly higher rates of CR-POPF (OR 2.87; 95 % CI 2.34-3.52, p < 0.00001), radiological intervention (OR 1.33; 95 % CI 1.10-1.61, p = 0.0003), SSIs (OR 2.47; 95 % CI 1.29-4.72, p = 0.006) or re-admission (OR 1.54; 95 % CI 1.30-1.82, P < 0.00001) compared to no use of drain. However, there was no significant difference in C-D III or higher postoperative morbidities (OR 1.25; 95 % CI 0.98-1.60, p = 0.08), DGE (OR 1.17; 95 % CI 0.81-1.67, p = 0.41), reoperation (OR 1.11; 95 % CI 0.80-1.54, P = 0.53), postoperative haemorrhage (OR 0.59; 95 % CI 0.18-2.00, P = 0.40), or mortality (RD 0.0; 95 % CI -0.01-0.01, p = 0.76) between two groups.

CONCLUSIONS

The meta-analysis of best available evidence indicates safety of "no drain policy" in distal pancreatectomy considering its lower risk of CR-POPF, re-intervention and hospital re-admission. More randomised evidence is required to overcome the "HPB surgeon's paranoia".

A single-center prospective analysis of the impact of glucose metabolism on pancreatic fistula onset after pancreaticoduodenectomy for periampullary tumors

BACKGROUND

Glucose impairment notably affects the postoperative course of gastrointestinal surgeries. However, evidence on its impact on clinically relevant pancreatic fistulas(CR-POPFs) after pancreaticoduodenectomy(PD) is lacking. This study evaluates if and how preoperative glucose metabolism affects the development of CR-POPF after PD.

METHODS

One hundred and ten consecutive PDs were included. Patients underwent preoperative metabolic profiling using the Oral Glucose Tolerance Test(OGTT) and the hyperinsulinemic euglycemic clamp procedure. Accordingly, patients were categorized as normal glucose tolerant (NGT), impaired glucose tolerant (IGT), diabetic (DM), and longstanding-DM. Receiver operating characteristics(ROC) analyses were performed to determine the values of metabolic features in prediction of CR-POPF.

RESULTS

The CR-POPF rate was 36.3 ​%(40 patients). NGT patients had a higher CR-POPF rate (51.7 ​%) compared to IGT(45.2 ​%), DM (15.8 ​%), and longstanding-DM (25.8 ​%) (p ​= ​0.03). CR-POPF patients had lower median fasting glucose levels (p ​= ​0.01) and higher c-peptide values at all OGTT time points (p ​< ​0.05). Fasting glucose and c-peptide levels had high diagnostic accuracy for CR-POPF (AUC>0.8) and were independent risk factors for CR-POPF (OR: 24.7[95%CI: 3.7-165.3] for fasting glucose; OR: 19.9[95%CI: 3.2-125.3] for c-peptide).

CONCLUSION

Normoglycemia and normal beta cell function may be risk factors for CR-POPF after PD. Fasting glucose and c-peptide levels effectively predicted CR-POPF development following PD.

CLINICALTRIALS GOV IDENTIFIER

NCT02175459.

Risk factors and prevention of pancreatic fistula after laparoscopic gastrectomy for gastric cancer

Following laparoscopic gastrectomy (LG), one of the critical complications that can arise is a pancreatic fistula (PF). The inability to promptly prevent, diagnose, and manage this condition can lead to severe complications and potentially be life-threatening for the patient. The incidence of PF post-LG in gastric cancer treatment is related to factors such as surgical approach, surgical instruments, characteristics of the pancreas itself, tumor stage, and the surgeon's experience. Currently, the diagnosis of postoperative PF is mainly based on the definition and diagnostic criteria consensus established by the International Study Group of Pancreatic Surgery. Gastrointestinal surgeons should be aware of the risk factors for PF, perform LG for gastric cancer with great care and precision, avoid pancreatic injury, and actively work to reduce the risk of postoperative PF.

Personalized nutrition after discharge for pancreatic surgery: A study protocol

Background: Pancreatic cancer has an increasing incidence and prevalence trend. Its prognosis is negatively affected by poor/altered nutritional status. Therefore, nutritional interventions play a critical/pivotal role at any stage. Despite being included in the prehabilitation items of Enhanced Recovery After Surgery (ERAS) protocols for pancreatic surgery, nutritional recommendations concerning early post-discharge period are lacking. Aim: To assess the acceptability and feasibility of a personalized and standardized food plan for patients following pancreatic surgery. A secondary aim is to determine if adherence to a personalized food plan is linked to improved postoperative outcomes. Methods: A prospective monocentric cohort study will be performed, including 180 patients undergoing pancreatic surgery. Body composition, nutritional, muscular, and hydro-electrolyte status will be assessed with bio-impedance analysis (BIA). Patients will receive a personalized nutritional plan after discharge for the following 45 days. Summary: Detailed nutritional indications have been formulated with broad consensus for the pre-operative (prehabilitation) and postoperative period. No previous study has specifically formulated or validated a nutritional intervention focused on the early post-discharge period. The results of this study might contribute to paving the way for future research and to broaden nutritional recommendations within the ERAS protocol.

Simpler and safer anastomosis by pancreaticogastrostomy using a linear stapler after pancreaticoduodenectomy

Postoperative pancreatic fistula (POPF) remains a major and serious problem after pancreaticoduodenectomy (PD). In its presence, pancreatic juice may leak from the main duct or branches of the pancreatic stump. To prevent this, we have applied a newly modified anastomosis of pancreaticogastrostomy (PG) using a linear stapler (stapled PG). Clinical records of 30 consecutive patients who underwent PD were reviewed between 2013 and 2023 at our community hospital. Regarding procedures, 12 stapled PGs and eighteen pancreaticojejunostomies (PJs) were performed after PD, from 2018 to 2023 and from 2013 to 2017, respectively. The pancreas was transected for long compression by a linear stapler, involving: pre-compression for 5 min, stapling for 5 min, and dissection for 5 min. After removal of the staples at the main duct opening of the pancreatic stump, PG anastomosis was performed. The outer layer was anastomosed by a straight single row pancreas-transfixing suture with the posterior gastric wall, and inner layer duct-to-mucosa anastomosis was also performed in a radial axis manner. Anastomosis of PJ was conducted without using a linear stapler. POPF was defined as a clinical manifestation of POPF (grade B/C) based on the ISGPF (International Study Group of Pancreatic Fistula) criteria. None of the 12 patients who had undergone stapled PG developed clinically relevant POPF, whereas 5 (27%) patients who had received PJ developed POPF. Three patients showed POPF grade B and 2 patients exhibited POPF grade C. Stapled PG after PD may reduce clinically relevant POPF. Because our sample size was small, the further accumulation of cases is required to validate this method.

Drainage for fluid collections post pancreatic surgery and acute pancreatitis: similar but different?

Postoperative pancreatic fistulas (POPFs) are common adverse events that occur after pancreatic surgery. Endoscopic ultrasonography (EUS)-guided drainage (EUS-D) is a first-line treatment, similar to that for pancreatic fluid collection (PFCs) after acute pancreatitis. However, some POPFs do not develop fluid collections depending on the presence or location of the surgical drain, whereas others develop fluid collections, such as postoperative fluid collections (POPFCs). Although POPFCs are similar to PFCs, the strategy and modality for POPF management need to be modified according to the presence of fluid collections, surgical drains, and surgical type. As discussed for PFCs, the indications, timing, and selection of interventions or stents for EUS-D have not been fully elucidated for POPFs. In this review, we discuss the management of POPFs and POPFCs in comparison with PFCs due to acute pancreatitis and summarize the topics that should be addressed in future studies.

Iatrogenic transmesenteric defect mimicking a Petersen's space hernia after open pancreatic necrosectomy

Complications of acute pancreatitis can be disastrous if appropriate treatment is not initiated. Pancreatic necrosis can occur without the presence of symptoms; however, in some cases, it can be accompanied by organic failure, abscess, pseudocyst, fistulas, and pancreatic exocrine disfunction. The surgical treatment of pancreatic necrosis can be managed with open surgical debridement of necrotic tissue. Hence, complications after surgery can appear even in patients without clinical background; complications mostly appear if the surgical technique is not done properly. We present a case of a 47-year-old woman who appeared with abdominal pain, nausea, vomiting, and oral intake intolerance. Symptoms were present for 1 week; she was admitted to the nearest clinic, and surgical management was offered. The patient went to an open pancreatic necrosectomy; however, she presented purulent exudate from the surgical wound and drains. Was referred to our center; on abdominal contrasted computed tomography, a transmesenteric defect and cutaneous-pancreatic fistula were found.

Interobserver Variability in the International Study Group for Pancreatic Surgery (ISGPS)-Defined Complications After Pancreatoduodenectomy: An International Cross-Sectional Multicenter Study

OBJECTIVE

To determine the interobserver variability for complications of pancreatoduodenectomy as defined by the International Study Group for Pancreatic Surgery (ISGPS) and others.

BACKGROUND

Good interobserver variability for the definitions of surgical complications is of major importance in comparing surgical outcomes between and within centers. However, data on interobserver variability for pancreatoduodenectomy-specific complications are lacking.

METHODS

International cross-sectional multicenter study including 52 raters from 13 high-volume pancreatic centers in 8 countries on 3 continents. Per center, 4 experienced raters scored 30 randomly selected patients after pancreatoduodenectomy. In addition, all raters scored 6 standardized case vignettes. This variability and the "within centers" variability were calculated for 2-fold scoring (no complication/grade A vs grade B/C) and 3-fold scoring (no complication/grade A vs grade B vs grade C) of postoperative pancreatic fistula, postpancreatoduodenectomy hemorrhage, chyle leak, bile leak, and delayed gastric emptying. Interobserver variability is presented with Gwet AC-1 measure for agreement.

RESULTS

Overall, 390 patients after pancreatoduodenectomy were included. The overall agreement rate for the standardized cases vignettes for 2-fold scoring was 68% (95% CI: 55%-81%, AC1 score: moderate agreement), and for 3-fold scoring 55% (49%-62%, AC1 score: fair agreement). The mean "within centers" agreement for 2-fold scoring was 84% (80%-87%, AC1 score; substantial agreement).

CONCLUSIONS

The interobserver variability for the ISGPS-defined complications of pancreatoduodenectomy was too high even though the "within centers" agreement was acceptable. Since these findings will decrease the quality and validity of clinical studies, ISGPS has started efforts aimed at reducing the interobserver variability.

Impact of Straight Stomach Reconstruction on Delayed Gastric Emptying and Nutritional Recovery After Pancreaticoduodenectomy

BACKGROUND

The aim of this study was to evaluate the effectiveness of a modified reconstruction technique-anchored straight stomach reconstruction-in reducing the incidence of delayed gastric emptying (DGE) after pancreaticoduodenectomy (PD) and its impact on postoperative nutritional recovery.

METHODS

A case series analysis of 125 consecutive PD patients was conducted: 104 of them had undergone anchored straight stomach reconstruction (SSR group) and the remaining 21 without (Non-SSR group). The incidence of DGE and the change in postoperative nutritional status (body weight and serum albumin level during 12 months post-surgery) were compared.

RESULTS

The incidence of DGE in the SSR group (13%) was significantly lower than that in the Non-SSR group (33%) (P = .018); further the significant DGE (grade B or C) was only 5%. Comparison of nutritional status showed that SSR facilitated a prompt recovery of body weight and serum albumin level at 6 months after PD. At 12 months after surgery, body weight gain was significantly better in the SSR group than in the Non-SSR group (P = .006), and albumin level tended to be higher in the SSR group (P = .071).

CONCLUSION

Straight stomach reconstruction is able to reduce DGE in patients after PD and also improves their postoperative nutritional recovery.

Extracellular volume fraction derived from dual-energy CT: a potential predictor for acute pancreatitis after pancreatoduodenectomy

OBJECTIVES

To investigate the value of extracellular volume (ECV) fraction and fat fraction (FF) derived from dual- energy CT (DECT) for predicting postpancreatectomy acute pancreatitis (PPAP) after pancreatoduodenectomy (PD).

METHODS

This retrospective study included patients who underwent DECT and PD between April 2022 and September 2022. PPAP was determined according to the International Study Group for Pancreatic Surgery (ISGPS) definition. Iodine concentration (IC) and FF of the pancreatic parenchyma were measured on preoperative DECT. The ECV fraction was calculated from iodine map images of the equilibrium phase. The independent predictors for PPAP were assessed by univariate and multivariable logistic regression analysis and receiver operating characteristic (ROC) curve analysis.

RESULTS

Sixty-nine patients were retrospectively enrolled (median age, 60 years; interquartile range, 55-70 years; 47 men). Of these, nine patients (13.0%) developed PPAP. These patients had lower portal venous phase IC, equilibrium phase IC, FF, and ECV fraction, and higher pancreatic parenchymal-to-portal venous phase IC ratio and pancreatic parenchymal-to-equilibrium phase IC ratio, compared with patients without PPAP. After multivariable analysis, ECV fraction was independently associated with PPAP (odd ratio [OR], 0.87; 95% confidence interval [CI]: 0.79, 0.96; p < 0.001), with an area under the curve (AUC) of 0.839 (sensitivity 100.0%, specificity 58.3%).

CONCLUSIONS

A lower ECV fraction is independently associated with the occurrence of PPAP after PD. ECV fraction may serve as a potential predictor for PPAP after PD.

CLINICAL RELEVANCE STATEMENT

DECT-derived ECV fraction of pancreatic parenchyma is a promising biomarker for surgeons to preoperatively identify patients with higher risk for postpancreatectomy acute pancreatitis after PD and offer selective perioperative management.

KEY POINTS

PPAP is a complication of pancreatic surgery, early identification of higher-risk patients allows for risk mitigation. Lower DECT-derived ECV fraction was independently associated with the occurrence of PPAP after PD. DECT aids in preoperative PAPP risk stratification, allowing for appropriate treatment to minimize complications.

Enhanced Recovery After Surgery (ERAS) in Pancreatic Surgery: The Surgeon's Point of View

Pancreatic surgery is complex and associated with higher rates of morbidity and mortality compared to other abdominal surgeries. Over the past decade, the introduction of new technologies, such as minimally invasive approaches, improvements in multimodal treatments, advancements in anesthesia and perioperative care, and better management of complications, have collectively improved patient outcomes after pancreatic surgery. In particular, the adoption of Enhanced Recovery After Surgery (ERAS) recommendations has reduced hospital stays and improved recovery times, as well as post-operative outcomes. The aim of this narrative review is to highlight the surgeon's perspective on the ERAS program for pancreatic surgery, with a focus on its potential advantages for perioperative functional recovery outcomes.

Prognostic Impact of Para-Aortic Lymph Node Metastasis in Resected Non-Pancreatic Periampullary Cancers

BACKGROUND

Surgery remains debatable in para-aortic lymph node (PALN, station 16b1) metastasis in non-pancreatic periampullary cancer (NPPAC). This study examined the impact of PALN metastasis on outcomes following pancreaticoduodenectomy (PD) in NPPAC.

METHODS

A retrospective analysis of patients with NPPAC who were explored for PD with PALN dissection was performed. Based on the extent of nodal involvement on final histopathology, they were stratified as node-negative (N0), regional node involved (N+) and metastatic PALN (N16+) and their outcomes were compared.

RESULTS

Between 2011 and 2022, 153/887 PD patients underwent a PALN dissection, revealing N16+ in 42 patients (27.4%), of whom 32 patients underwent resection. The 3-years overall survival (OS) for patients with N16+ was 28% (95% confidence interval [CI] 13-60%), notably lower than the 67% (95% CI 53-83.5%; p = 0.007) for those without PALN metastasis. Stratified by nodal involvement, the median OS for N+ and N16+ patients was similar (28.4 months and 26.2 months, respectively). The N0 subgroup had a significantly longer 3-years OS of 87.5% (95% CI 79-96.7%; p = 0.0051). Interestingly, 10 patients not offered resection following N16+ identified on frozen section had a median survival of only 9 months. The perioperative morbidity and mortality in patients undergoing PD with PALN dissection were similar to standard resections.

CONCLUSION

In a select group of patients with NPPAC, PD in isolated PALN metastasis was associated with improved OS. The survival in this group of patients was comparable with regional node-positive patients and significantly better than palliative treatment alone.

Modified reconstruction approach after pancreaticoduodenectomy optimizes postoperative outcomes: Results from a multivariate cohort analysis

Despite technical advances in recent decades and a decrease in hospital mortality (<5%), pancreaticoduodenectomy (PD) is still associated with major postoperative complications, even in high-volume centers. The present study aimed to assess the effect of a modified reconstruction technique on postoperative morbidity and mortality. A cohort study of all patients (n=218) undergoing PD between January 2010 and December 2019 was performed at Attikon University Hospital (Athens, Greece). Several variables were studied, including demographic data, past medical history, perioperative parameters, tumor markers and pathology, duration of hospitalization, postoperative complications, 30-day-survival, postoperative mortality and overall survival using multivariate logistic regression and survival analysis techniques. In this cohort, 123 patients [modified PD (mPD) group] underwent a modified reconstruction after a pylorus-preserving pancreaticoduodenectomy, which consisted of gastrojejunostomy and pancreaticojejunostomy on the same loop and an isolated hepaticojejunostomy on another loop. In the standard PD (StPD) group, 95 patients underwent standard reconstruction. The median age was 67 years, ranging from 25 to 89 years. Compared with in the StPD group, the mPD group had significantly lower rates of grade B and C pancreatic fistula (4.9% vs. 28.4%), delayed gastric emptying (7.3% vs. 42.1%), postoperative hemorrhage (3.3% vs. 20%), intensive care unit admission (8.1% vs. 18.9%), overall morbidity (Clavien-Dindo grade III-V: 14.7% vs. 42.0%), perioperative mortality (4.1% vs. 14.7%), and shorter hospitalization stay (11 days vs. 20 days). However, no difference was noted regarding median survival (35 months vs. 30 months). In this single-center series, a modified reconstruction after PD appears to be associated with improved postoperative outcomes. However, further evaluation in larger multi-center trials is required.