Use of omentum or falciform ligament does not decrease complications after pancreaticoduodenectomy: nationwide survey of the Japanese Society of Pancreatic Surgery. Surgery. 2012;151:183-191. [PMID: 21982073 DOI: 10.1016/j.surg.2011.07.023]

A ligamentum teres hepatis and falciform ligament 'belt and braces' approach in laparoscopic pancreaticoduodenectomy using a modified Blumgart anastomosis to minimize severe pancreatic fistula and post-operative complications

BACKGROUND

To determine whether ligamentum teres hepatis and falciform ligament, wrapped around the gastroduodenal artery (GDA) and reinforced the posterior wall in pancreatojejunostomy (PJ), protects the GDA stump and other skeletal blood vessels from erosive hemorrhage and reduces the incidence of clinically relevant post-operative pancreatic fistula (CR-POPF) and post-operative complications after laparoscopic pancreaticoduodenectomy (LPD).

METHODS

We reviewed patients undergone LPD between January 2019 and June 2023. Patients were divided into two groups according to whether the ligamentous flap had been used to wrap the GDA stump (Group A) or to reinforce the posterior wall in PJ, together with the GDA wrapping procedure (Group B). Peri-operative data were reviewed to determine the effectiveness of this approach in preventing CR-POPF, post-pancreatectomy hemorrhage (PPH), and other complications.

RESULTS

We enrolled 272 patients (Group A, 154 patients; Group B, 118 patients). Group B patients had significantly fewer ≥ Grade II Clavien-Dindo classification morbidities and CR-POPFs (P < 0.05), and lower length of hospital stay (LOS) and abdominal drainage tube insertion times. Risk factor analysis indicated that main pancreatic duct dilation, the PJ reinforcement procedure, and soft pancreatic tissue were associated with ≥Grade II Clavien-Dindo morbidities and CR-POPF complications.

CONCLUSIONS

The ligamentous flap application in LPD provided shelter to GDA stump and other skeletal blood vessels under PJ from erosive digestive juices, reinforced the posterior wall in PJ, reduced the incidence of CR-POPF and ≥Grade II Clavien-Dindo classification morbidities. This simple procedure is effective for improving surgical safety of LPD.

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.

Prevention of postpancreatectomy hemorrhage after laparoscopic pancreaticoduodenectomy by wrapping ligamentum teres hepatis surrounding hepatic portal artery

Postpancreatectomy hemorrhage (PPH) is an important risk factor for postoperative complications after laparoscopic pancreaticoduodenectomy (LPD). Recent studies have reported that the use of ligamentum teres hepatis (LTH) in LPD may reduce the risk of PPH. Therefore, this study aims to investigate whether wrapping the hepatic hilar artery with the LTH can reduce PPH after LPD. We reviewed the data of 131 patients who underwent LPD in our team from April 2018 to December 2023. The patients were divided into Groups A (60 patients) and B (71 patients) according to whether the hepatic portal artery was wrapped or not. The perioperative data of the two groups were compared to evaluate the effect of LTH wrapping the hepatic hilar artery on LPD. The platelet count of Group A was (225.25 ± 87.61) × 10^9/L, and that of Group B was (289.38 ± 127.35) × 10^9/L, with a statistically significant difference (p < 0.001). The operation time of group A [300.00 (270.00, 364.00)] minutes was shorter than that of group B [330.00 (300.00, 360.00)] minutes, p = 0.037. In addition, A set of postoperative hospital stay [12.00 (10.00, 15.00)] days shorter than group B [15.00 (12.00, 19.50)] days, p < 0.001. No PPH occurred in Group A, while 8 patients in Group B had PPH (7 cases of gastroduodenal artery hemorrhage and 1 case of proper hepatic artery hemorrhage), p = 0.019. The new technique of wrapping the hepatic hilar artery through the LTH can effectively reduce the occurrence of PPH after LPD.

Retromesenteric omental flap as arterial coverage in pancreaticoduodenectomy: A novel technique to prevent postpancreatectomy hemorrhage

BACKGROUND

Clinically relevant postpancreatectomy hemorrhage occurs in 10% to 15% of patients after pancreaticoduodenectomy, mainly in association with clinically relevant postoperative pancreatic fistula. Prevention of postpancreatectomy hemorrhage by arterial coverage with a round ligament plasty or an omental flap is controversial. This study assessed the impact of arterial coverage with an original retromesenteric omental flap on postpancreatectomy hemorrhage after pancreaticoduodenectomy.

METHODS

This single-center retrospective study included 812 open pancreaticoduodenectomies (2012-2021) and compared 146 procedures with arterial coverage using retromesenteric omental flap to 666 pancreaticoduodenectomies without arterial coverage. The Fistula Risk Score was calculated. The primary endpoint was a 90-day clinically relevant postpancreatectomy hemorrhage rate according to the International Study Group of Pancreatic Surgery classification.

RESULTS

There were more patients with a Fistula Risk Score ≥7 in the arterial coverage-retromesenteric omental flap group: 18 (12%) versus 48 (7%) (P < .01). Clinically relevant postpancreatectomy hemorrhage was less frequent in the arterial coverage- retromesenteric omental flap group than in the no arterial coverage group: 5 (3%) versus 66 (10%), respectively (P = .01). Clinically relevant postoperative pancreatic fistula occurred in 28 (19%) patients in the arterial coverage- retromesenteric omental flap group compared with 165 (25%) in the no arterial coverage group (P = .001). There were fewer reoperations for postpancreatectomy hemorrhage or postoperative pancreatic fistula in the arterial coverage- retromesenteric omental flap group: 1 (0.7%) versus 32 (5%) in the no arterial coverage group (P = .023). In multivariate analysis, arterial coverage with retromesenteric omental flap was an independent protective factor of clinically relevant postpancreatectomy hemorrhage (odds ratio 0.33; 95% confidence interval [0.12-0.92], P = .034) whereas postoperative pancreatic fistula of any grade (odds ratio = 10.1; 95% confidence interval: 5.1-20.3, P < .001) was predictive of this complication.

CONCLUSION

Arterial coverage with retromesenteric omental flap can reduce rates of clinically relevant postpancreatectomy hemorrhage after pancreaticoduodenectomy. This easy and costless technique should be prospectively evaluated to confirm these results.

Efficacy of the two-parts wrapping technique in reducing postoperative complications in laparoscopic pancreaticoduodenectomy

BACKGROUND

The advancement of laparoscopic technology has broadened the application of laparoscopic pancreaticoduodenectomy (LPD) for treating pancreatic head and ampullary tumors. Despite its benefits, postoperative pancreatic fistula (POPF) and postpancreatectomy hemorrhage (PPH) remain significant complications. Ligamentum teres hepatis wrapping around the gastroduodenal artery (GDA) stump show limitations in reducing POPF and PPH.

METHODS

This study retrospectively analyzed patients undergoing LPD from January 2016 to October 2023, We compared the effectiveness of the two-parts wrapping (the ligamentum teres hepatis wrapping of the gastroduodenal artery stump and the omentum flap wrapping of the pancreatojejunal anastomosis) and ligamentum teres hepatis wrapping around the gastroduodenal artery (GDA) in reducing postoperative pancreatic fistula (POPF) and postpancreatectomy hemorrhage (PPH), using propensity score matching for the analysis.

RESULTS

A total of 172 patients were analyzed, showing that the two-parts wrapping group significantly reduced the rates of overall and severe complications, POPF, and PPH compared to ligamentum teres hepatis wrapping around the GDA group. Specifically, the study found lower rates of grade B/C POPF and no instances of PPH in the two-parts wrapping group, alongside shorter postoperative hospital stays and drainage removal times. These benefits were particularly notable in patients with soft pancreatic textures and pancreatic duct diameters of < 3 mm.

CONCLUSION

The two-parts wrapping technique significantly reduce the risks of POPF and PPH in LPD, offering a promising approach for patients with soft pancreas and pancreatic duct diameter of < 3 mm.

The effect of omentoplasty in various surgical operations: systematic review and meta-analysis

BACKGROUND

Omentoplasty is commonly used in various surgeries. However, its effectiveness is unsure due to lack of convincing data and research. To clarify the impact of omentoplasty on postoperative complications of various procedures, this systematic review and meta-analysis was performed.

METHODS

A systematic review of published literatures from four databases: PubMed, Web of Science, Cochrane Library, and Embase before 14 July 2022. The authors primarily included publications on five major surgical operations performed in conjunction with omentoplasty: thoracic surgery, esophageal surgery, gastrointestinal surgery, pelvi-perineal surgery, and liver surgery. The protocol was registered in PROSPERO.

RESULTS

This review included 25 273 patients from 91 studies ( n =9670 underwent omentoplasty). Omentoplasty was associated with a lower risk of overall complications particularly in gastrointestinal [relative risk (RR) 0.53; 95% CI: 0.39-0.72] and liver surgery (RR 0.54; 95% CI: 0.39-0.74). Omentoplasty reduced the risk of postoperative infection in thoracic (RR 0.38; 95% CI: 0.18-0.78) and liver surgery (RR 0.39; 95% CI: 0.29-0.52). In patients undergoing esophageal (RR 0.89; 95% CI: 0.80-0.99) and gastrointestinal (RR 0.28; 95% CI: 0.23-0.34) surgery with a BMI greater than 25, omentoplasty is significantly associated with a reduced risk of overall complications compared to patients with normal BMI. No significant differences were found in pelvi-perineal surgery, except infection in patients whose BMI ranged from 25 kg/m 2 to 29.9 kg/m 2 (RR 1.25; 95% CI: 1.04-1.50) and anastomotic leakage in patients aged over 60 (RR 0.59; 95% CI: 0.39-0.91).

CONCLUSION

Omentoplasty can effectively prevent postoperative infection. It is associated with a lower incidence of multiple postoperative complications in gastrointestinal and liver surgery.

Pedicled ligament flaps during pancreatoduodenectomy are associated with reduced hemorrhage from hepatic artery and gastroduodenal artery stump during pancreatoduodenectomy: a systematic review, meta-analysis and trial sequential analysis

BACKGROUND

The aim of this study was to investigate whether pedicled ligament flaps (PLF) covering around the hepatic and gastroduodenal artery stump can provide better clinical outcomes in pancreatoduodenectomy (PD).

METHODS

We conducted a comprehensive search of databases (inception to January 2023) to identify studies comparing PD with or without PLF covering the skeletonized arteries. The perioperative and postoperative outcomes were compared. Pooled odds ratios (ORs) with 95 % confidence intervals (CIs) were calculated using fixed-effects models.

RESULTS

Ten studies were included in the qualitative synthesis. Six studies with 3538 patients met the inclusion criteria for the meta-analysis. Patients in the PLF group had a significantly lower rate of PPH from the hepatic artery or gastroduodenal artery stump (H/G PPH) (OR: 0.41; 95 % CI, 0.22-0.75; P < 0.01) and overall PPH (OR: 0.65; 95 % CI, 0.46-0.93; P = 0.02). There were no significant differences between the two groups in terms of morbidity, grade B/C postoperative pancreatic fistula (B/C POPF), delayed gastric emptying (DGE), reoperation, or mortality.

CONCLUSION

Prophylactic pedicled ligament flaps covering around the skeletonized arteries significantly reduced overall PPH and H/G PPH, and it seemed to have no obvious influence on other complications.

Wrapping gastroduodenal artery stump with the teres hepatis ligament to prevent postpancreatectomy hemorrhage after pancreaticoduodenectomy

BACKGROUND

Gastroduodenal artery (GDA) stump erosion hemorrhage is a fatal complication after pancreaticoduodenectomy. This study aimed to determine whether GDA stump wrapping with the teres hepatis ligament during pancreaticoduodenectomy decreased the incidence of postpancreatectomy hemorrhage (PPH).

METHODS

We reviewed 307 patients who had undergone pancreaticoduodenectomy between March 2019 and June 2022. The patients were divided into two groups according to application of GDA stump wrapping with the teres hepatis ligament: GDA wrapping group (165 patients) and no-wrapping group (142 patients). The perioperative data were compared between the groups.

RESULTS

The clinical characteristics were balanced between the two groups. Grades B and C PPH and GDA-stump-related hemorrhage were significantly reduced in the GDA wrapping group compared with the no-wrapping group (PPH B/C, 13.4% vs 6.1%, P = 0.029; GDA hemorrhage, 5.6% vs 0.6%, P = 0.014). No difference was observed in the incidence of clinically relevant postoperative pancreatic fistula, biliary leak, intra-abdominal abscess, delayed gastric emptying, 90-day mortality, and postoperative hospital stay between the two groups.

CONCLUSION

Wrapping GDA stump with the teres hepatis ligament reduced the incidence of GDA-stump-related PPH. Therefore, the wrapping technique is a simple and effective strategy to prevent PPH. Prospective studies are needed to confirm the benefit of this procedure.

Wrapping pancreaticojejunostomy using the ligamentum teres hepatis during laparoscopic pancreaticoduodenectomy: a propensity score matching analysis

BACKGROUND AND OBJECTIVE

It is controversial whether wrapping around the pancreaticojejunostomy (PJ) could reduce the rate of postoperative pancreatic fistula (POPF), especially in laparoscopic pancreaticoduodenectomy (LPD). This study aims to summarize our single-center initial experience in wrapping around PJ using the ligamentum teres hepatis (LTH) and demonstrate the feasibility and safety of this method.

METHODS

Patients who underwent LPD applying the procedure of wrapping around the PJ were identified. The cohort was compared to the cohort with standard non-wrapping PJ. A 1:1 propensity score matching (PSM) was performed to compare the early postoperative outcomes of the two cohorts. Risk factors for POPF were determined by using univariate and multivariate logistic regression analysis.

RESULTS

Overall, 143 patients were analyzed (LPD without wrapping (n = 91) and LPD with wrapping (n = 52)). After 1:1 PSM, 48 patients in each cohort were selected for further analysis. Bile leakage, DGE, intra-abdominal infection, postoperative hospital stays, harvested lymph nodes, and R0 resection were comparable between the two cohorts. However, the wrapping cohort was associated with significantly less POPF B (1 vs 18, P = 0.003), POPF C (0 vs 8, P = 0.043), and Clavien-Dindo classification level III-V (5 vs 26, P = 0.010). No patients died due to the clinically relevant POPF in the two cohorts. No patients who underwent the LTH wrapping procedure developed complications directly related to the wrapping procedure. After PSM, whether wrapping was an independent risk factor for POPF (OR = 0.202; 95%CI:0.080-0.513; P = 0.001).

CONCLUSIONS

Wrapping the LTH around the PJ technique for LPD was safe, efficient, and reproducible with favorable perioperative outcomes in selected patients. However, further validations using high-quality RCTs are still required to confirm the findings of this study.

Ligamentum teres hepatis wrapping of the gastroduodenal artery stump for protection in total laparoscopic pancreaticoduodenectomy: a single-center experience

OBJECTIVE

Hemorrhage from the stump of the gastroduodenal artery (GDA) is a significant postoperative risk with pancreaticoduodenectomy (PD). Studies have shown that wrapping the GDA stump using the omentum or the falciform ligament can help prevent bleeding. We aimed to determine whether wrapping the GDA stump with the ligamentum teres hepatis (LTH) would reduce postoperative PD hemorrhage.

METHODS

We retrospectively reviewed data for 148 patients who underwent laparoscopic pancreatoduodenectomy (LPD) at our hospital from November 2015 to September 2021. We compared perioperative data from 63 LPD patients without wrapping of the GDA (unwrapped group) and 85 whose GDA stumps were wrapped (wrapped group).

RESULTS

There were no significant differences in the groups' baseline characteristics. The postoperative GDA stump bleeding incidence was significantly lower in the wrapped group than that in the unwrapped group (7.9% vs. 0, respectively). There was also no significant difference in the incidence of other complications (intra-abdominal infection, postoperative pancreatic fistula (POPF), biliary fistula, and gastrointestinal bleeding).

CONCLUSION

Using the LTH to wrap the GDA stump during LPD can reduce bleeding from the GDA stump but not the incidence of other complications.

Laparoscopic pancreaticoduodenectomy and laparoscopic pancreaticoduodenectomy with robotic reconstruction: single-surgeon experience and technical notes

Purpose

Despite the increasing number of robotic pancreaticoduodenectomies, laparoscopic pancreaticoduodenectomy (LPD) and LPD with robotic reconstruction (LPD-RR) are still valuable surgical options for minimally invasive pancreaticoduodenectomy (MIPD). This study introduces the surgical techniques, tips, and outcomes of our experience with LPD and LPD-RR.

Methods

Between March 2014 and July 2021, 122 and 48 patients underwent LPD and LPD-RR respectively, at CHA Bundang Medical Center in Korea. The operative settings, procedures, and trocar placements were identical in both approaches; however, different trocars were used. We introduced our techniques of retraction methods for Kocherization and uncinate process dissection, pancreatic reconstruction, pancreatic division, and protection using the round ligament. The perioperative surgical outcomes of LPD and LPD-RR were compared.

Results

Baseline demographics of patients in the LPD and LPD-RR groups were comparable, but the LPD group had older age (65.5 ± 11.6 years vs. 60.0 ± 14.1 years, p = 0.009) and lesser preoperative chemotherapy (15.6% vs. 35.4%, p = 0.008). The proportion of malignant disease was similar (LPD group, 86.1% vs. LPD-RR group, 83.3%; p = 0.759). Perioperative outcomes were also comparable, including operative time, estimated blood loss, clinically relevant postoperative pancreatic fistula (LPD group, 9.0% vs. LPD-RR group, 10.4%; p = 0.684), and major postoperative complication rates (LPD group, 14.8% vs. LPD-RR group, 6.2%; p = 0.082).

Conclusion

Both LPD and LPR-RR can be safely performed by experienced surgeons with acceptable surgical outcomes. Further investigations are required to evaluate the objective benefits of robotic surgical systems in MIPD and establish widely acceptable standardized MIPD techniques.

Utility of Falciform Ligament in Abdominal Surgery: A Systematic Review

OBJECTIVE

The aim of the present systematic review was to assess current trends in use of falciform ligament in abdominal surgery.

BACKGROUND

The falciform ligament has been proposed in surgical literature as a suitable pedicle or flap with acceptable surgical outcomes; however, it is underutilized in abdominal surgery.

METHODS

We performed a literature search and meta-analysis. All English studies describing use of a falciform ligament were eligible for inclusion.

RESULTS

Of the 547 articles mentioning use of falciform ligament, 32 full text articles were included in this review. The majority were case reports (n = 14). The mremaining papers included retrospective analysis (n = 10), randomized control trials (n = 2), reviews (n = 3), and technique descriptions (n = 6).

CONCLUSION

The falciform ligament appears to be a safe and easily accessible natural tissue with a variety of surgical applications. It is most useful as a pedicle flap and could have benefit in foregut surgery including hepatic, pancreatic, biliary, gastric, and esophageal operations.

The falciform/round ligament "flooring," an effective method to reduce life-threatening post-pancreatectomy hemorrhage occurrence

PURPOSE

Late post-pancreatectomy hemorrhage (PPH) represents the most severe complication after pancreatic surgery. We have measured the efficacy of major vessels "flooring" with falciform/round ligament to prevent life-threatening grade C late PPH after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP).

METHODS

All consecutive patients who underwent PD and DP between 2013 and 2021 were retrospectively reviewed on a prospectively maintained database. The cohort was divided in two groups: "flooring" vs. "no flooring" method group. The "no flooring" group had omental flap interposition. Patient characteristics and operative and postoperative data including clinically relevant postoperative pancreatic fistula (CR-POPF), late PPH (grade B and C), and 90-day mortality were compared between the two groups.

RESULTS

Two hundred and forty patients underwent pancreatic resections, including 143 PD and 97 DP. The "flooring" method was performed in 61 patients (39 PD and 22 DP). No difference was found between the two groups concerning severe morbidity, CR-POPF, delayed PPH, and mortality rate. The rate of patients requiring postoperative intensive care unit was lower in the "flooring" than in the "no flooring" method group (11.5% vs. 25.1%, p = 0.030). Among patients with grade B/C late PPH (n = 30), the rate of life-threatening grade C late PPH was lower in the "flooring" than in the "no flooring" method group (28.6% (n = 2/7) vs. 82.6% (n = 19/24), p = 0.014). Risk factor analysis showed that the "flooring" method was the only protective factor against grade C late PPH occurrence (p = 0.013).

CONCLUSION

The "flooring" method using the falciform/round ligament should be considered during pancreatectomies to reduce the occurrence of life-threatening grade C late PPH.

A Simple Classification of Pancreatic Duct Size and Texture Predicts Postoperative Pancreatic Fistula: A classification of the International Study Group of Pancreatic Surgery

OBJECTIVE

The aim of this study was to develop a classification system for pancreas-associated risk factors in pancreatoduodenectomy (PD).

SUMMARY BACKGROUND DATA

Postoperative pancreatic fistula (POPF) is the most relevant PD-associated complication. A simple standardized surgical reporting system based on pancreas-associated risk factors is lacking.

METHODS

A systematic literature search was conducted to identify studies investigating clinically relevant (CR) POPF (CR-POPF) and pancreas-associated risk factors after PD. A meta-analysis of CR-POPF rate for texture of the pancreas (soft vs not-soft) and main pancreatic duct (MPD) diameter was performed using the Mantel-Haenszel method. Based on the results, the International Study Group of Pancreatic Surgery (ISGPS) proposes the following classification: A, not-soft (hard) texture and MPD >3 mm; B, not-soft (hard) texture and MPD ≤3 mm; C, soft texture and MPD >3 mm; D, soft texture and MPD ≤3 mm. The classification was evaluated in a multi-institutional, international cohort.

RESULTS

Of the 2917 articles identified, 108 studies were included in the analyses. Soft pancreatic texture was significantly associated with the development of CR-POPF [odds ratio (OR) 4.24, 95% confidence interval (CI) 3.67-4.89, P < 0.01) following PD. Similarly, MPD diameter ≤3 mm significantly increased CR-POPF risk compared with >3 mm diameter MPDs (OR 3.66, 95% CI 2.62-5.12, P < 0.01). The proposed 4-stage system was confirmed in an independent cohort of 5533 patients with CR-POPF rates of 3.5%, 6.2%, 16.6%, and 23.2% for type A-D, respectively ( P < 0.001).

CONCLUSION

For future pancreatic surgical outcomes studies, the ISGPS recommends reporting these risk factors according to the proposed classification system for better comparability of results.

Regional vessels wrapping following pancreaticoduodenectomy reduces the risk of post-operative extra-luminal bleeding. A systematic review

Background

Post-pancreatectomy bleeding is a potentially fatal complication which results from the erosion of the regional visceral arteries, mainly the hepatic artery and stump of the gastro-duodenal artery, caused by a leak or fistula from the pancreatic anastomosis. The objective of this article is to assess whether wrapping of regional vessels with omentum or falciform/teres ligament following pancreaticoduodenectomy reduces the risk of extra-luminal bleeding.

Materials and method

Standard medical electronic databases were searched with the help of a local librarian and relevant published randomised controlled trials (RCT) and any type of comparative trial were shortlisted according to the inclusion criteria. The summated outcome of post-operative extra-luminal bleeding in patients undergoing pancreaticoduodenectomy was evaluated using the principles of meta-analysis on RevMan 5 statistical software.

Result

Two RCTs and 5 retrospective studies on 4100 patients undergoing pancreaticoduodenectomy were found suitable for this meta-analysis. There were 1404 patients in the wrapping-group (WG) and 2696 patients in the no-wrapping group (NWG). In the random effects model analysis, the incidence of extra-luminal haemorrhage was statistically lower in WG [odds ratio 0.51, 95%, CI (0.31, 0.85), Z = 2.59, P = 0.01]. There was moderate heterogeneity between the studies; however it was not statistically significant.

Conclusion

The wrapping of regional vessels (using omentum, falciform ligament or ligamentum teres) following pancreaticoduodenectomy seems to reduce the risk of post-operative extra-luminal bleeding. However, more RCTs of robust quality recruiting a greater number of patients are required to validate these findings as this study presents the combined data of two RCTs and 5 retrospective studies.

•

Post pancreaticoduodenectomy haemorrhage can be mortality and morbidity increasing complication.

•

The aim is to assess the effectiveness of regional vessels wrapping in decreasing post operative bleeding.

•

Two RCTs and five retrospective studies were used to obtain the submitted data.

•

Regional vessels wrapping was associated with reduced bleeding post pancreaticoduodenectomy.

Prospective randomized controlled trial of omental roll-up technique on pancreatojejunostomy anastomosis for reducing perioperative complication in patients undergoing pancreatoduodenectomy

BACKGROUND

Wrapping pancreatojejunal anastomosis with omentum to prevent postoperative pancreatic fistula (POPF) has only been reported in non-randomized, controlled trials. Therefore, this study aimed to conduct a randomized, controlled trial to compare outcomes between omental roll-up and non-omental roll-up in pancreatojejunal anastomosis.

METHODS

This single-center, randomized, two-arm trail (Clinical Trials Register: NCT03083938) was conducted between February 2017 and February 2019. We studied 34 patients in the omental roll-up group and 34 patients in the non-omental roll-up group. The primary endpoint was the incidence of clinically relevant POPF. Thirty-day mortality and morbidity were recorded.

RESULTS

Patients' demographic data were not significantly different between the two groups, except for histological diagnosis, with a significantly higher incidence of pancreatic cancer in the omental roll-up group (n = 15, 44.1%) than in the non-omental roll-up group (n = 9, 26.4%) (P = 0.042). There was one death in the non-omental roll-up group due to myocardial infarction. The incidence of POPF was not different between the omental roll-up group (n = 5, 14.7%) and non-omental roll-up group (n = 7, 20.6%) (P = 0.525). No differences were found in postoperative hemorrhage after pancreatectomy, delayed gastric emptying, and chyle leakage between the groups.

CONCLUSION

This study shows that omental roll-up does not decrease the incidence of POPF after pancreatoduodenectomy.

Wrapping the stump of the gastroduodenal artery using the ligamentum teres hepatis during laparoscopic pancreaticoduodenectomy: a center's preliminary experience

BACKGROUND

The present study aims to assess the preliminary outcomes of the effectiveness of wrapping the ligamentum teres hepatis (LTH) around the gastroduodenal artery stump for the prevention of erosion hemorrhage after laparoscopic pancreaticoduodenectomy (LPD).

METHODS

We reviewed 247 patients who had undergone LPD between January 2016 and April 2019. The patients were divided into two groups according to whether LTH wrapped the stump of the gastroduodenal artery: group A (119 patients) who underwent the LTH wrapping procedure, and group B (128 patients) who did not undergo the procedure. The perioperative data from the two groups were reviewed to assess the effectiveness of the LTH procedure for the prevention of postpancreatectomy hemorrhage (PPH) and other complications.

RESULTS

No differences were observed in the clinical characteristics between the two groups. The data from 247 patients were acceptable for analysis: 119 patients underwent wrapping, and 128 patients did not. The incidence of clinically relevant pancreatic fistula (8.4% vs 3.9%), biliary fistula (2.5% vs 1.6%), intra-abdominal infection (10.1% vs 3.9%) and delayed gastric emptying (13.4% vs 16.4%) showed no significant difference between group A and group B. The 90-day mortality and 90-day reoperation rates (0.8% vs 0.8% and 5.0% vs 3.1%) were also similar between group A and group B. Furthermore, postpancreatectomy hemorrhage of Grade B and C occurred in 0 patients (0.0%) in the wrapping group, which was significantly less frequent than the occurrence in the nonwrapping group (7 patients; 5.5%, P = 0.02).

CONCLUSIONS

Wrapping the LTH around the gastroduodenal artery stump after LPD does not reduce the incidence of clinically relevant pancreatic fistula, biliary fistula or delayed gastric emptying. However, this procedure has a trend of reducing the rate of PPH of Grade B and C after LPD and is simple to perform.

Applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery-a review of their utility and efficacy

BACKGROUND AND PURPOSE

Despite their ubiquitous presence, easy availability and diverse possibilities, falciform ligament and hepatic round ligament have been used less frequently than their potential dictates. This article aims to comprehensively review the applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery and assess their utility and efficacy.

METHODS

Medical literature/indexing databases were searched, using internet search engines, for pertinent articles and analysed.

RESULTS

The studied flap and graft have found utility predominantly in the management of diaphragmatic hernias, gastro-oesophageal reflux disease, peptic perforations, biliary reconstruction, venous reconstruction, post-operative pancreatic fistula, post-pancreatectomy haemorrhage, hepatic cyst cavity obliteration, liver bleed, sternal dehiscence, splenectomy, reinforcement of aortic stump, feeding access, diagnostic/therapeutic access into portal system, composite tissue allo-transplant and ventriculo-peritoneal shunting where they have exhibited the desired efficacy.

CONCLUSIONS

Hepatic round ligament/falciform ligament flap and graft are versatile and have multifarious applications in abdominal surgery with some novel and unique uses in hepatopancreaticobiliary surgery including liver transplantation. Their evident efficacy needs wider adoption to realise their true potential.

Superior perianastomotic fluid collection in the early postoperative period affects pseudoaneurysm occurrence after pancreaticoduodenectomy

PURPOSE

Pseudoaneurysm (PA) after pancreaticoduodenectomy (PD) is a harmful complication due to postoperative pancreatic fistula. However, the preventive method for PA is unclear. This study aimed to assess the risk factors for PA after PD and to evaluate the clinical features of patients with PA.

METHODS

Medical records of 54 patients who underwent PD and developed clinically relevant postoperative pancreatic fistula (POPF) were retrospectively reviewed. We evaluated postoperative computed tomography (CT) findings, including the perianastomotic fluid collection (PFC) location on postoperative day 4. Perioperative findings and postoperative CT findings were compared between patients with and without PA after PD.

RESULTS

The PA group included nine patients (17%). The median postoperative day of diagnosis of PA was 17 (range, 7-33). The PA locations were the gastroduodenal artery stump (n = 3), dorsal pancreatic artery (DPA) stump from the common hepatic artery (n = 4), DPA stump from the replaced right hepatic artery (n = 1), and inferior pancreaticoduodenal artery stump (n = 1). The prevalence of falciform ligament wrap to the hepatic artery was lower (33% vs. 78%, p = 0.014) and superior PFC prevalence was higher (100% vs. 58%, p = 0.019) in the PA group than in the non-PA group. Superior PFC reached the dorsal part of the caudate lobe of the liver in all patients with PA. Furthermore, all PAs occurred at the arteries that could not be wrapped by the falciform ligament.

CONCLUSION

Prevention of superior PFC and falciform ligament wrapping may reduce PA occurrence after PD with clinically relevant POPF.

[Pancreatodigestive anastomosis: from history to modernity]

This review is devoted to history of pancreatodigestive anastomoses (PDA), technique of the most popular PDA, causes of pancreatic fistula and its prevention. Contradictory data were obtained in randomized trials and meta-analyses devoted to pancreatic anastomoses. There is no optimal anastomosis excluding clinically significant postoperative pancreatic fistula. Therefore, further studies should be aimed at new approaches reducing the incidence of clinically significant postoperative pancreatic fistula.

[Predictors of external pancreatic fistulae after pancreatic resection]

Despite a significant decrease in postoperative mortality after pancreatic resections in recent years (5.2-15% after pancreatoduodenectomy and about 5% after distal pancreatectomy), incidence of postoperative complications remains high (30-50% and 22-50%, respectively). Postoperative pancreatic fistula is one of the most common and formidable complications. Currently, most authors use the classification proposed by the International Study Group for Pancreatic Fistula (biochemical failure, fistula type B and C). Prediction of the risk of postoperative fistula is still a complex and unresolved problem of modern surgical pancreatology. According to the literature, the main risk factors of postoperative pancreatic fistulae are obesity and high body mass index, concomitant cardiovascular diseases, no neoadjuvant chemo- and radiotherapy, soft pancreatic texture, narrow pancreatic duct, no fibrotic changes in parenchyma, adipose infiltration of the pancreas, advanced intraoperative blood loss, as well as center experience. Most often, magnetic resonance imaging, computed tomography, ultrasound elastography and various multivariate risk assessment systems are used to estimate the risk of pancreatic fistulae. However, a generally accepted technique does not exist. This manuscript is devoted to analysis of risk factors of postoperative pancreatic fistulae and diagnostic methods for assessment of this risk.

A systematic review and meta-analysis on the role of omental or falciform ligament wrapping during pancreaticoduodenectomy

BACKGROUND

The role of wrapping in the setting of pancreaticoduodenectomy (PD) is controversial. This study aimed to assess whether the use of omental or falciform ligament wrapping of pancreatic anastomosis and/or vessels could reduce the rate of POPF and postpancreatectomy hemorrhage (PPH) after PD.

METHODS

Studies comparing PD with (PD-W) and without wrapping (PD-nW) were included. Primary outcomes were POPF and extraluminal PPH. Dichotomous variables were analyzed for risk ratios (RR) with 95% Confidence Intervals.

RESULTS

Nine studies involving 4384 patients were considered. The risk of POPF and clinically relevant POPF (CR-POPF) was similar between patients with and without omental wrapping of pancreatic anastomosis when considered as overall. A significant benefit from wrapping in terms of CR-POPF (RR 0.14, P = 0.002) was reported for patients who underwent PD with pancreaticojejunostomy (PJ). The risk of extraluminal PPH was slightly lower in patients who underwent vessels wrapping compared to those who did not (RR 0.58, P = 0.020). Similar extraluminal PPH rates were reported for patients with and without wrapping of pancreatic anastomosis (P = 0.620).

DISCUSSION

Data from low-evidence studies suggest that omental wrapping of PJ may reduce the incidence of CR-POPF, whereas vessels wrapping may have a slight effect for preventing extraluminal PPH.

Flooring the Major Vessels with Falciform Ligament to Prevent Post-Pancreatectomy Hemorrhage

BACKGROUND

One of the most severe pancreatic surgery complications is post-pancreatectomy hemorrhage (PPH). This study's aim was to evaluate the efficacy of flooring the major vessels with falciform ligament in preventing PPH after pancreatoduodenectomy (PD).

METHODS

This study was a retrospective review of 500 consecutive patients who underwent PD between Jan 2010 and Dec 2019 at Hiroshima University. Morbidities, including postoperative pancreatic fistula (POPF) or PPH and 90-day mortality, were analyzed. The study cohort was divided into two groups based on the time of surgery (2010-2016 and 2017-2019), i.e., before and after implementation of falciform ligament flooring method. The patient characteristics, operative parameters, clinicopathological factors, morbidity, and mortality were compared between the two periods.

RESULTS

Morbidity and mortality rates in the entire cohort were 21% and 1.4%, respectively. The incidence of Grade B/C POPF and PPH was 9.0% and 3.8%, respectively. There was no significant difference between the two periods with respect to Grade B/C POPF, morbidity rate, and mortality rate; however, the rate of Grade B/C PPH significantly decreased from 5.2 to 1.6% p = .027. On multivariate analysis, the absence of the falciform ligament flooring method was an independent PPH risk factor p = .003.

CONCLUSIONS

Falciform ligament flooring method may help decrease the incidence of PPH after PD.

Pancreatic Fat and Body Composition Measurements by Computed Tomography are Associated with Pancreatic Fistula After Pancreatectomy

OBJECTIVES

Postoperative pancreatic fistula (POPF) is the most threatening complication after pancreatectomy. This study aimed to directly assess pancreatic fatty infiltration with preoperative computed tomography (CT) imaging and to investigate whether a preoperative analysis of patient variables, including CT characteristics and clinical factors, can predict POPF.

METHODS

We enrolled 150 consecutive patients who underwent curative pancreatectomy. Radiographic factors, including pancreatic fat volume, were measured using preoperative CT imaging and the predictive factors were explored using univariate and multivariate analyses.

RESULTS

POPF developed in 30 patients (20.0%). The ratio of pancreatic fat (RPF) ≥ 4.83% was associated with a risk of POPF, high body mass index (BMI), and obese body habitus. Patients with POPF were significantly more likely to have high BMI (≥ 25 kg/m²), obese body habitus, and an RPF ≥ 4.83% than patients without POPF. In the multivariate analysis, visceral fat area/skeletal muscle index (VFA/SMI) ≥ 1.94 (odds ratio [OR] 4.28, 95% confidence interval [CI] 1.43-12.9, p = 0.0095) was the sole independent predictive factor for POPF. For patients with a soft pancreas, VFA/SMI ≥ 1.94 (OR 5.67, 95% CI 2.05-15.7, p = 0.0008) was again the sole independent predictive factor for POPF.

CONCLUSION

Preoperative CT images can examine pancreatic fatty infiltration, and patients who had POPF were significantly associated with a high RPF. Among several parameters, VFA/SMI was the only independent predictive factor for clinically relevant POPF. Preoperative evaluation of these body composition variables and the pancreatic configuration could be useful for predicting POPF.

Embedment of the gastroduodenal artery stump into the jejunal serosa: A new technique aiming to prevent post-pancreatectomy hemorrhage

Post-pancreaticoduodenectomy hemorrhage has an estimated incidence of 5% and a mortality rate of 11-38%. Vascular erosion resulting from pancreatic leak and skeletonization of the arterial wall during pancreatic mobilization may be the two possible mechanisms responsible for this complication, which most commonly affects the gastroduodenal artery stump. A novel technique of wrapping up the gastroduodenal artery stump into the jejunal serosa to decrease postoperative hemorrhage is presented.

Drain Amylase or Lipase for the Detection of POPF-Adding Evidence to an Ongoing Discussion

Objectives: A postoperative pancreatic fistula (POPF) is defined as a threefold increase in the amylase concentration in abdominal drains on or after the third postoperative day (POD). However, additional lipase fluid analysis is widely used despite lacking evidence. In this study, drain amylase and lipase levels were compared regarding their value in detecting POPF. Methods: We conducted a retrospective study including all patients who underwent pancreatic resections at our center between 2005 and 2016. Drain fluid analysis was performed from day 2 to 5. Results: 990 patients were included in the analysis. Overall, 333 (34%) patients developed a POPF. The median amylase and lipase concentrations at POD 3 in cases with POPF were 11.55 µmol/(s·L) (≈13 ×-fold increase) and 39 µmol/(s·L) (≈39 ×-fold increase), respectively. Seven patients with subsequent POPF (2%) were missed with amylase analysis on POD 3, but detected using 3-fold lipase analysis. The false-positive rate of lipase was 51/424 = 12%. A cutoff lipase value at POD 3 of > 4.88 yielded a specificity of 94% and a sensitivity of 89% for development of a POPF. Increased body mass index turned out as risk factor for the development of POPF in a multivariable model. Conclusions: Threefold-elevated lipase concentration may be used as an indicator of a POPF. However, the additional detection of POPF using simultaneous lipase analysis is marginal. Therefore, assessment of lipase concentration does not provide added clinical value and only results in extra costs.

Systematic review of the incidence, presentation and management of gastroduodenal artery pseudoaneurysm after pancreatic resection

Background

Gastroduodenal artery (GDA) pseudoaneurysm is a serious complication following pancreatic resection, associated with high morbidity and mortality rates. This review aimed to report the incidence of GDA pseudoaneurysm after pancreatic surgery, and describe clinical presentation and management.

Methods

MEDLINE and Embase were searched systematically for clinical studies evaluating postoperative GDA pseudoaneurysm. Incidence was calculated by dividing total number of GDA pseudoaneurysms by the total number of pancreatic operations. Additional qualitative data related to GDA pseudoaneurysm presentation and management following pancreatic resection were extracted and reviewed from individual reports.

Results

Nine studies were selected for systematic review involving 4227 pancreatic operations with 55 GDA pseudoaneurysms, with a reported incidence of 1·3 (range 0·2–8·3) per cent. Additional data were extracted from 39 individual examples of GDA pseudoaneurysm from 14 studies. The median time for haemorrhage after surgery was at 15 (range 4–210) days. A preceding complication in the postoperative period was documented in four of 21 patients (67 per cent), and sentinel bleeding was observed in 14 of 20 patients (70 per cent). Postoperative complications after pseudoaneurysm management occurred in two‐thirds of the patients (14 of 21). The overall survival rate was 85 per cent (33 of 39).

Conclusion

GDA pseudoaneurysm is a rare yet serious cause of haemorrhage after pancreatic surgery, with high mortality. The majority of the patients had a preceding complication. Sentinel bleeding was an important clinical indicator.

Surgical techniques and postoperative management to prevent postoperative pancreatic fistula after pancreatic surgery

Postoperative pancreatic fistula (POPF) is one of the most severe complications after pancreatic surgeries. POPF develops as a consequence of pancreatic juice leakage from a surgically exfoliated surface and/or anastomotic stump, which sometimes cause intraperitoneal abscesses and subsequent lethal hemorrhage. In recent years, various surgical and perioperative attempts have been examined to reduce the incidence of POPF. We reviewed several well-designed studies addressing POPF-related factors, such as reconstruction methods, anastomotic techniques, stent usage, prophylactic intra-abdominal drainage, and somatostatin analogs, after pancreaticoduodenectomy and distal pancreatectomy, and we assessed the current status of POPF. In addition, we also discussed the current status of POPF in minimally invasive surgeries, laparoscopic surgeries, and robotic surgeries.

Postoperative hemorrhage complications following the Whipple procedure

OBJECTIVES

Although the Whipple operation is an essential surgical technique, its high morbidity (30% to 60%) and mortality (5%) are problems to be addressed. The incidence of postoperative hemorrhage has been reported between 5% and 16% in the literature. In this study, the data and results regarding postoperative hemorrhage complications from our clinic were evaluated.

MATERIAL AND METHODS

The files of 185 patients who had undergone Whipple operation in our hospital in the last five years were evaluated retrospectively, and the causes of hemorrhage were attempted to be determined.

RESULTS

It was found that 6 out of the 13 (7%) patients who had hemorrhage died. In six of there 13 cases, hemorrhage occurred due to fistulas from the portal vein, gastroduodenal artery, and pancreatic arteries at variable periods. Two cases were found to have developed disseminated intravascular coagulation as a result of sepsis. Early intervention was performed in two cases who bled from the meso veins and in one case who bled from the portal vein. Laparotomy and hemostasis were performed in a patient who bled from the gastric anastomosis line. In a patient who had been taking low molecular weight heparin, bleeding from the drains and nasogastric tube stopped following the cessation of the drug.

CONCLUSION

Preventive procedures such as connection of the vascular structures, use of vascular sealants, omental patching during surgery, and reducing the risk of complications by using somatostatin analogs were performed to prevent hemorrhages after Whipple operations. In addition to standard methods, angiography and embolization have emerged as effective methods in the diagnosis and treatment of hemorrhages. Furthermore, determination and elimination of independent risk factors, such as jaundice, affecting fistula formation and bleeding in the perioperative period, is important for prevention.

Use of Neoveil or TachoSil to prevent pancreatic fistula following pancreaticoduodenectomy: A retrospective study

The aim of this study was to evaluate the effectiveness of using Neoveil and TachoSil sponges at the pancreaticojejunostomy anastomosis site in reducing the rate and severity of postoperative pancreatic fistula (POPF).In this study, we retrospectively evaluated data that were prospectively collected on pancreaticoduodenectomy (PD) procedures. Patients were divided into 3 groups: no patch application, Neoveil patch application, and TachoSil patch application. Demographic and surgical data were analyzed.Around 165 patients with PD were enrolled in this study and were divided into 3 groups. In the standard group (n = 43), no patch was applied, while in the Neoveil and TachoSil groups (n = 84 and n = 38, respectively), the pancreaticojejunostomy anastomosis site was covered with Neoveil and TachoSil patches, respectively. POPF grade B or above occurred in 37.2% (16/43), 14.3% (12/84), and 18.8% (6/38) of patients in the standard, Neoveil and TachoSil groups, respectively, with a significant difference between patients with and without patch application (P = .004). On multivariate logistic analysis of predictive factors for POPF, male sex, patch application, and hospital day were found to be the significant independent predictors of POPF grade B or above.Significant independent predictors of POPF were male sex and patch application. This study demonstrated that the use of Neoveil or TachoSil patches may reduce the incidence of POPF after PD.

Discharge destination following pancreaticoduodenectomy: A NSQIP analysis of predictive factors and post-discharge outcomes

INTRODUCTION

Pancreaticoduodenectomy is a complex surgical procedure. The purpose of this study was to identify factors associated non-home discharge destination and to characterize outcomes after non-home discharge.

METHODS

10,719 pancreaticoduodenectomy cases contained in the National Surgical Quality Improvement Program (NSQIP) Targeted Pancreatectomy dataset (years 2014-2016) were examined with univariate and multivariate logistic regression.

RESULTS

1336 patients (12.5%) were discharged to rehabilitation, skilled care, or acute care facilities. Preoperative factors significantly associated with non-home discharge on multivariate analysis were female gender, older age, elevated BMI, poor functional status or dyspnea, smoking, low albumin, COPD, and ascites. Intraoperative factors significantly associated with non-home discharge destination on multivariate analysis were longer operative time, open surgery, softer pancreatic texture, drain placement, and jejunostomy tube placement. A nomogram was generated for estimating probability of non-home discharge immediately after surgery.

CONCLUSION

Preoperative and intraoperative factors can be used to predict probability of non-home discharge immediately after completion of pancreaticoduodenectomy.

Pancreatic duct size and gland texture are associated with pancreatic fistula after pancreaticoduodenectomy but not after distal pancreatectomy

BACKGROUND

Pancreatic fistula remains a morbid complication after pancreatectomy. Since the proposed mechanism of pancreatic fistula is different between pancreaticoduodenectomy and distal pancreatectomy, we hypothesized that pancreatic gland texture and duct size are not associated with pancreatic fistula after distal pancreatectomy.

METHODS

All patients ≥18 years in the 2014-15 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) targeted pancreatectomy dataset were linked with the ACS NSQIP Public Use File (PUF). Pancreatic duct size (<3 mm, 3-6 mm, >6 mm) and pancreatic gland texture (hard, intermediate, soft) were categorized. Separate multivariable analyses were performed to evaluate associations between pancreatic duct size and gland texture after pancreaticoduodenectomy and distal pancreatectomy.

RESULTS

A total of 9366 patients underwent pancreaticoduodenectomy or distal pancreatectomy during the study period. Proportion of pancreatic fistula was similar after distal pancreatectomy (606 of 3132, 19.4%) and pancreaticoduodenectomy (1163 of 6335, 18.4%, p = 0.245). Both pancreatic gland texture and duct size were significantly associated with pancreatic fistula after pancreaticoduodenectomy (p<0.001). However, there was no association between pancreatic fistula and gland texture or duct size (all p≥0.169) after distal pancreatectomy. Operative approach (minimally invasive versus open) was not associated with pancreatic fistula after distal pancreatectomy (p = 0.626). Patients with pancreatic fistula after distal pancreatectomy had increased rate of postoperative complications including longer length of stay, higher rates of readmission and reoperation compared to patients who did not have a pancreatic fistula (all p<0.001).

CONCLUSIONS

Unlike among patients who had pancreaticoduodenectomy, pancreatic gland texture and duct size are not associated with development of pancreatic fistula following distal pancreatectomy. Other clinical factors should be considered in this patient population.

Pancreatoduodenectomy with or without prophylactic falciform ligament wrap around the gastroduodenal artery stump for prevention of pancreatectomy hemorrhage

Background

The purpose of this study is to evaluate whether wrapping of the pedicled falciform ligamentum flap around the gastroduodenal artery (GDA) stump/hepatic artery can significantly decrease the incidence of erosion hemorrhage after pancreatoduodenectomy (PD).

Methods/design

This is a randomized controlled multicenter trial involving 400 patients undergoing PD. Patients will be randomized into two groups. The intervention group consists of 200 patients with a prophylactic wrapping of the GDA stump using the pedicled falciform ligament. The control group consists of 200 patients without the wrap. The primary endpoint is the rate of postoperative erosion hemorrhage of the GDA stump or hepatic artery within 3 months. The secondary endpoints are postpancreatectomy hemorrhage stratified according to the texture of the pancreas, postoperative pancreatic fistula (POPF), postoperative rate of therapeutic interventions, morbidity, and mortality.

Discussion

Only few retrospective studies investigated the effectiveness of a falciform ligament wrap around the GDA for prevention of erosion hemorrhage. Erosion hemorrhage occurs in up to 6–9% of cases after PD and is most frequently evoked by a POPF. Erosion hemorrhage is associated with a remarkable mortality of over 30%. The rate of hemorrhage after performing the wrap is reported to be low. However, there exist no prospectively controlled data to support its general use. Therefore, the presented randomized controlled trial will provide clinically relevant evidence of the effectiveness of the wrap with statistical significance.

Trial registration

clinicaltrials.gov, NCT02588066; Registered on 27 October 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2580-0) contains supplementary material, which is available to authorized users.

Preoperative imaging evaluation of pancreatic pathologies for the objective prediction of pancreatic fistula after pancreaticoduodenectomy

In performing pancreaticoduodenectomy (PD) or when conducting clinical trials involving PD procedure, a universal platform for predicting the risk of postoperative pancreatic fistula (POPF) is indispensable. In this article, the most significant imaging studies that focused on the objective preoperative assessment of pancreatic pathologies in association with the occurrence of POPF after PD were reviewed. Several recently developed imaging modalities can objectively predict the occurrence of POPF after PD by assessing the elasticity, fibrosis, and fatty infiltration of the pancreas. These valuable imaging modalities include: (1) acoustic radiation force impulse ultrasound (US) electrography which provides information about the elastic properties of the pancreas; (2) contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) with/without contrast-enhancement which reflect the histological degree of pancreatic fibrosis; and (3) multi-detector row CT and/or MRI which reflects the microscopic fatty infiltration of the pancreas. The precise and objective preoperative risk assessment of POPF enables surgeons to customize appropriate management strategies for individual patients undergoing PD. This would be also beneficial for stratifying patients for enrolment in relevant studies that involve pancreatic head resection, as objective criteria could be set for the definitive evaluation of collected data related to surgical outcomes across different institutions and surgeons.

Prevention of pancreatic fistula using polyethylene glycolic acid mesh reinforcement around pancreatojejunostomy: the propensity score-matched analysis

BACKGROUND

Several small-scale studies have shown that wrapping polyethylene glycolic acid (PGA) mesh around the anastomotic site reinforced pancreaticojejunostomy following pancreatoduodenectomy (PD) with favorable outcomes. This study investigated the efficacy of PGA mesh for reducing postoperative pancreatic fistula (POPF) and evaluated other risk factors for POPF.

METHODS

This study enrolled 464 consecutive patients who underwent PD performed by one surgeon between 2006 and 2015, including a PGA group of 281 patients (60.6%) and a control group of 183 patients (39.4%). All pancreatico-enteric anastomoses were performed using double-layered, duct-to-mucosa, end-to-side pancreaticojejunostomy.

RESULTS

Mean patient age was 63.1 years. The rates of overall (27.0% vs. 37.2%, P = 0.024) and clinically relevant (Grades B, C; 13.9% vs. 24.0%, P = 0.006) POPF were significantly lower in the PGA than in the control group. Following propensity score matching, the rates of clinically relevant POPF (12.6% vs. 22.4%, P = 0.024) and complications (40.2% vs. 63.8%, P < 0.001) remained significantly lower in the PGA group. Multivariate analysis showed that non-pancreatic disease, greater blood loss, higher body mass index, and non-application of PGA mesh were significantly associated with the development of clinically relevant POPF.

CONCLUSIONS

PGA mesh reinforcement of pancreaticojejunostomy may prevent POPF as well as reducing overall abdominal complications after PD.

In Patients with a Soft Pancreas, a Thick Parenchyma, a Small Duct, and Fatty Infiltration Are Significant Risks for Pancreatic Fistula After Pancreaticoduodenectomy

BACKGROUND

This study sought to characterize soft and hard pancreatic textures radiologically and histologically, and to identify specific risks in a soft pancreas associated with postoperative pancreatic fistula (POPF) formation after pancreaticoduodenectomy (PD).

METHODS

Consecutive 145 patients who underwent PD at a single institution between January 2010 and May 2013 were studied. Pancreatic consistency was intraoperatively judged as soft or hard. Pancreatic configuration was assessed using preoperative CT. Histologic components of the pancreatic stump were evaluated using a morphometric analysis. Clinicopathologic parameters were then analyzed for the risk of clinically relevant POPF.

RESULTS

Compared with patients with a hard pancreas (n = 66), those with a soft pancreas (n = 79) had a smaller main pancreatic duct (MPD) diameter and a larger parenchymal thickness on CT, had a smaller fibrosis ratio and a larger lobular ratio histologically, and developed clinically relevant POPF more frequently (P < 0.001 for all). In patients with a soft pancreas, an MPD diameter <2 mm, a parenchymal thickness ≥10 mm, a lobular ratio <75%, and a fat ratio ≥20% were independently associated with clinically relevant POPF (P < 0.010 for all).

CONCLUSION

In patients with a soft pancreas, a thick parenchyma, a small MPD, and fatty infiltration were strongly associated with clinically relevant POPF after PD.

Falciform ligament wrap for prevention of gastroduodenal artery bleed after pancreatoduodenectomy

BACKGROUND

The present study aims to assess the effectiveness and current evidence of a pedicled falciform ligament wrap around the gastroduodenal artery stump for prevention of erosion hemorrhage after pancreatoduodenectomy (PD).

METHODS

Retrospective data were pooled for meta-analysis. At the own center, patients who underwent PD between 2012 and 2015 were retrospectively analyzed based on the intraoperative performance of the wrap. A systematic literature review and meta-analysis was performed that combined the published and the obtained original data. The following databases were searched: Medline, Embase, Web of Science, and the Cochrane Library.

RESULTS

At the own center, a falciform ligament wrap was performed in 39 of 196 PDs (20%). The wrap group contained more ampullary neoplasms, but the pancreatic fistula rate was not significantly different from the nonwrap group (28% versus 32%). In median, erosion hemorrhage occurred after 21.5 d, and it was lethal in 39% of the patients. Its incidence was not significantly lower in the wrap group (incidence: 7.7% versus 9.6% in the nonwrap group). The systematic literature search yielded four retrospective studies with a high risk of bias; only one study was controlled. When the five data sets of published and own cases with a falciform ligament wrap were pooled, the incidence of erosion hemorrhage was 5 of 533 cases (0.9%) compared with 24 of 297 cases (8.1%) without the wrap.

CONCLUSIONS

The reported incidence of erosion hemorrhage after the falciform ligament wrap is low, but there are still insufficient controlled data to support its general use.

Postoperative infectious complications after pancreatic resection

BACKGROUND

Although mortality associated with pancreatic surgery has decreased dramatically, high morbidity rates are still of major concern. This study aimed to identify the prevalence of, and risk factors for, infectious complications after pancreatic surgery.

METHODS

The Japanese Society of Pancreatic Surgery conducted a multi-institutional analysis of complications in patients who underwent pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) between January 2010 and December 2012. Risk factors that were significantly associated with infectious complications in univariable models were included in a multivariable logistic regression model, and a nomogram was created to predict the risk of infectious complications after pancreatectomy.

RESULTS

Infectious complications occurred in 1459 (35.2 per cent) of 4147 patients in the PD group and 426 (25.2 per cent) of 1692 patients in the DP group (P < 0.001). Nine risk factors for infectious complications after PD were identified: male sex, age 70 years or more, body mass index at least 25 kg/m(2), other previous malignancy, liver disease, bile contamination, duration of surgery 7 h or longer, intraoperative blood transfusion and soft pancreas. Five risk factors for infectious complications after DP were identified: chronic steroid use, smoking, duration of surgery 5 h or more, intraoperative blood transfusion and non-laparoscopic surgery. Occurrence of a postoperative infectious complication was significantly associated with mortality and reoperation after PD (odds ratio (OR) 4.33, 95 per cent c.i. 2.01 to 9.92 and OR 3.26, 1.86 to 5.82, respectively) and DP (OR 6.32, 1.99 to 22.55; OR 3.74, 1.61 to 9.04).

CONCLUSION

Prolonged operating time, intraoperative blood transfusion, bile contamination (PD) and non-laparoscopic surgery (DP) are risk factors for postoperative infectious complications that could be targeted to improve outcome after pancreatectomy.

Postoperative drain amylase predicts pancreatic fistula in pancreatic surgery: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

This study to evaluate the utility of drain fluid amylase as a predictor of PF in patients undergoing pancreatic surgery based on the International Study Group of Pancreatic Fistula definitions of pancreatic fistula.

METHODS

A comprehensive search was carried out using Pubmed (Medline), Embase, Web of science and Cochrane database for clinical trials, which studied DFA as a diagnostic marker for pancreatic fistula after pancreatic surgery. Sensitivity, specificity and the diagnostic odds ratios with 95% confidence interval were calculated for each study. Summary receiver-operating curves were conducted and the area under the curve was evaluated.

RESULTS

A total of 10 studies were included. The pooled sensitivity and specificity of drain fluid amylase Day 1 for the diagnosis of postoperative pancreatic fistula were 81% and 87%, respectively (area under the curve was 0.897, diagnostic odds ratios was 16.83 and 95%CI was 12.66-22.36), the pooled sensitivity and specificity of drain fluid amylase Day 3 for the diagnosis of postoperative pancreatic fistula were 56% and 79%, respectively (area under the curve was 0.668, diagnostic odds ratios was 3.26 and 95%CI was 1.83-5.82) CONCLUSIONS: The drain fluid amylase Day 1, instead of drain fluid amylase Day 3, may be a useful criterion for the early identification of postoperative pancreatic fistula, and a value of drain fluid amylase Day 1 over than 1300 U/L was a risk factor of pancreatic fistula. And the diagnostic accuracy and the proposed cut-off levels of drain fluid amylase Day 1 in predicting the postoperative pancreatic fistula will have to be validated by multicenter prospective studies.

Pancreatoduodenectomy - preventing complications

Increased awareness of periampullary & pancreatic head cancers, and the accompanying improved outcomes following pancreatoduodenectomy (PD), has possibly led to an increase in patients seeking treatment for the same. While there has definitely been a reduction in morbidity rates following PD in the last few decades, this decline has not mirrored the drastic fall in mortality. Amongst the foremost in the factors responsible for this reduction in mortality is the standardization of surgical technique and development of dedicated teams to manage all aspects of this demanding procedure. This review intends to provide the reader with an overview of major complications following this major surgery and measures to prevent them based on the authors' experience.

Application of air insufflation to prevent clinical pancreatic fistula after pancreaticoduodenectomy

AIM: To introduce an air insufflation procedure and to investigate the effectiveness of air insufflation in preventing pancreatic fistula (PF).

METHODS: From March 2010 to August 2013, a total of 185 patients underwent pancreaticoduodenectomy (PD) at our institution, and 74 patients were not involved in this study for various reasons. The clinical outcomes of 111 patients were retrospectively analyzed. The air insufflation test was performed in 46 patients to investigate the efficacy of the pancreaticojejunal anastomosis during surgery, and 65 patients who did not receive the air insufflation test served as controls. Preoperative assessments and intraoperative outcomes were compared between the 2 groups. Univariate and multivariate analyses were performed to identify the risk factors for PF.

RESULTS: The two patient groups had similar baseline demographics, preoperative assessments, operative factors, pancreatic factors and pathological results. The overall mortality, morbidity, and PF rates were 1.8%, 48.6%, and 26.1%, respectively. No significant differences were observed in either morbidity or mortality between the two groups. The rate of clinical PF (grade B and grade C PF) was significantly lower in the air insufflation test group, compared with the non-air insufflation test group (6.5% vs 23.1%, P = 0.02). Univariate analysis identified the following parameters as risk factors related to clinical PF: estimated blood loss; pancreatic duct diameter ≤ 3 mm; invagination anastomosis technique; and not undergoing air insufflation test. By further analyzing these variables with multivariate logistic regression, estimated blood loss, pancreatic duct diameter ≤ 3 mm and not undergoing air insufflation test were demonstrated to be independent risk factors.

CONCLUSION: Performing an air insufflation test could significantly reduce the occurrence of clinical PF after PD. Not performing an air insufflation test was an independent risk factor for clinical PF.

Wrapping in pancreatic surgery: a systematic review

BACKGROUND

Wrapping in pancreatic surgery involves the use of the omentum or falciform ligament (FL) to wrap the local retroperitoneal vessels, the pancreatojejunal anastomosis or the pancreatic section of distal pancreatectomy. However, there is no clear evidence that wrapping in fact provides benefits. We have performed a systematic review of the literature about this topic.

METHODS

We conducted a literature search in the PubMed/MEDLINE database (1966-2012) for any language using various combinations of the following terms: wrapping, omental, omentum, pancreas, pancreatoduodenectomy and falciform ligament.

RESULTS

We selected 12 articles. Among five series that included a control group, only one obtained a statistically significant reduction in pancreatic fistula (PF) in the wrapping group and other series showed a lower percentage of post-operative haemorrhage in the wrapping group. In the seven series without control groups, a slight decrease in the rate of post-operative bleeding and PF was observed.

CONCLUSIONS

On the basis of the literature available at present, we cannot recommend the use of wrapping with omentum and/or FL in pancreatic surgery. Prospective randomized studies applying a systematic wrapping technique are needed in order to establish whether its use should be generalized.

A new approach for Roux-en-Y reconstruction after pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula remains the most common complication of pancreaticoduodenectomy (PD) and is potentially lethal. It contributes significantly to prolonged hospitalization and mortality. In this study, we introduced a new technical approach, a modified Roux-en-Y reconstruction and evaluated its safety and feasibility.

METHODS

We retrospectively reviewed the patients who had undergone PD with the modified Roux-en-Y reconstructive technique for periampullary malignancies from January 2011 to June 2012. The data on complications, hospital stay and outcomes after the modified Roux-en-Y reconstruction were analyzed.

RESULTS

The reconstruction was performed in 171 patients, of whom 92 received pancreaticogastrostomy and 79 received pancreaticojejunostomy. The median duration of surgery was 4.0 hours (range 3.1-6.9) in all patients, and the median blood loss was 530 mL (range 200-2000). Sixty-nine patients were subjected to transfusions, with a median transfusion volume of 430 mL (range 200-1400). The median hospital stay of the patients was 14 days (range 11-38). Their operative mortality was zero and overall morbidity was 18.1% (31 patients). Only four patients (2.3%) developed pancreatic fistulas (grade A fistulas in two patients and grade B in two patients); no patients developed grade C fistula. None of the patients developed bile reflux gastritis.

CONCLUSIONS

The modified Roux-en-Y reconstruction, which isolates biliary anastomosis from pancreatic, gastric or jejunal anastomosis, is a safe, reliable, and favorable technique. But it needs further investigation in randomized controlled trials.

Portal annular pancreas: a systematic review of a clinical challenge

Portal annular pancreas (PAP) is an asymptomatic congenital pancreas anomaly, in which portal and/or mesenteric veins are encased by pancreas tissue. The aim of the study was to determine the role of PAP in pancreatic surgery as well as its management and potential complication, specifically, postoperative pancreatic fistula (POPF).On the basis of a case report, the MEDLINE and ISI Web of Science databases were systematically reviewed up to September 2012. All articles describing a case of PAP were considered.In summary, 21 studies with 59 cases were included. The overall prevalence of PAP was 2.4% and the patients' mean (SD) age was 55.9 (16.2) years. The POPF rate in patients with PAP (12 pancreaticoduodenectomies and 3 distal pancreatectomies) was 46.7% (in accordance with the definition of the International Study Group of Pancreatic Surgery).Portal annular pancreas is a quite unattended pancreatic variant with high prevalence and therefore still remains a clinical challenge to avoid postoperative complications. To decrease the risk for POPF, attentive preoperative diagnostics should also focus on PAP. In pancreaticoduodenectomy, a shift of the resection plane to the pancreas tail should be considered; in extensive pancreatectomy, coverage of the pancreatic remnant by the falciform ligament could be a treatment option.