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Alfaifi J, Buisset C, Postillon A, Orry X, Chanty H, Germain A, Ayav A. Unusual massive venous hemorrhage after pancreatoduodenectomy treated by endovascular approach. J Surg Case Rep 2024; 2024:rjae256. [PMID: 38752152 PMCID: PMC11095255 DOI: 10.1093/jscr/rjae256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 04/02/2024] [Indexed: 05/18/2024] Open
Abstract
Most post-pancreaticoduodenectomy hemorrhages (PPH) are of arterial origin, and some studies have suggested that an interventional radiology approach is most effective in reducing mortality. Venous PPH is rare, and identifying its source can be challenging. We report a case of late venous PPH in the context of a pancreatic fistula following pancreaticoduodenectomy. During surgical exploration, the area of potential bleeding was inaccessible due to major inflammatory adhesions aggravated by the presence of pancreatic fistula and the delay of relaparotomy. No intra-abdominal bleeding was detected on imaging studies or during abdominal exploration; only a massive bleeding through the drain orifice, which required packing, was observed. Percutaneous transhepatic portography was performed to localize and treat the origin of the bleeding. The hemorrhage was successfully treated by endovascular approach. We found no reports in the literature on the use of interventional radiology with venous stenting to treat venous PPH, except in cases of gastrointestinal variceal hemorrhage due to portal occlusion.
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Affiliation(s)
- Jaber Alfaifi
- Department of Digestive, Endocrine and Metabolic Surgery, Hôpital Robert Schuman – UNEOS Groupe Hospitalier Associatif, rue du Champ Montoy, Metz 57070, France
| | - Cyrille Buisset
- Department of Digestive, Endocrine and Metabolic Surgery, Hôpital Robert Schuman – UNEOS Groupe Hospitalier Associatif, rue du Champ Montoy, Metz 57070, France
| | - Agathe Postillon
- Department of Digestive Surgery, Hôpital Bel-Air – CHR Metz-Thionville, rue du Friscaty, Thionville 57100, France
| | - Xavier Orry
- Department of Radiology, University Hospital of Nancy, rue du Moran, Vandoeuvre-les, 54500 Nancy, France
| | - Hervé Chanty
- Department of Hepatobiliary, Colorectal and Oncologic Surgery, University Hospital of Nancy, rue du Moran, Vandoeuvre-les-Nancy 54500 Nancy, France
| | - Adeline Germain
- Department of Hepatobiliary, Colorectal and Oncologic Surgery, University Hospital of Nancy, rue du Moran, Vandoeuvre-les-Nancy 54500 Nancy, France
| | - Ahmet Ayav
- Department of Hepatobiliary, Colorectal and Oncologic Surgery, University Hospital of Nancy, rue du Moran, Vandoeuvre-les-Nancy 54500 Nancy, France
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Interventional Radiological Management and Prevention of Complications after Pancreatic Surgery: Drainage, Embolization and Islet Auto-Transplantation. J Clin Med 2022; 11:jcm11206005. [PMID: 36294326 PMCID: PMC9605367 DOI: 10.3390/jcm11206005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/26/2022] [Accepted: 10/05/2022] [Indexed: 11/29/2022] Open
Abstract
Pancreatic surgery still remains burdened by high levels of morbidity and mortality with a relevant incidence of complications, even in high volume centers. This review highlights the interventional radiological management of complications after pancreatic surgery. The current literature regarding the percutaneous drainage of fluid collections due to pancreatic fistulas, percutaneous transhepatic biliary drainage due to biliary leaks and transcatheter embolization (or stent–graft) due to arterial bleeding is analyzed. Moreover, also, percutaneous intra-portal islet auto-transplantation for the prevention of pancreatogenic diabetes in case of extended pancreatic resection is also examined. Moreover, a topic not usually treated in other similar reviewsas percutaneous intra-portal islet auto-transplantation for the prevention of pancreatogenic diabetes in case of extended pancreatic resection is also one of our areas of focus. In islet auto-transplantation, the patient is simultaneously donor and recipient. Differently from islet allo-transplantation, it does not require immunosuppression, has no risk of rejection and is usually efficient with a small number of transplanted islets.
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Fu N, Qin K, Li J, Jin J, Jiang Y, Deng X, Shen B. Who could complete and benefit from the adjuvant chemotherapy regarding pancreatic ductal adenocarcinoma? A multivariate-adjusted analysis at the pre-adjuvant chemotherapy timing. Cancer Med 2022; 11:3397-3406. [PMID: 35434972 PMCID: PMC9487870 DOI: 10.1002/cam4.4698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 01/24/2022] [Accepted: 03/11/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND The pre-adjuvant chemotherapy (PAC) status of postoperative pancreatic ductal adenocarcinoma (PDAC) patients has not been studied and elaborated well previously. METHOD The association of PAC variables and prognoses was explored using a multivariable Cox model, restricted cubic spline analysis, and correlation analysis. The main outcomes were overall survival (OS) and progression-free survival (PFS). The secondary outcome was chemotherapy completeness (CHC). RESULTS A total of 401 eligible patients were enrolled in sequential surgery and chemotherapy. The chemotherapy regimen, PAC fasting blood glucose (FBG), and elevated fasting blood glucose (eFBG) status were associated with CHC (regimen types: p = 0.005, continuous FBG: p = 0.014, eFBG status: p = 0.012). Early administration of adjuvant chemotherapy (<34 days) was a risk factor for the limited OS and PFS (OS: aHR: 1.61 [1.09-2.38], p = 0.016; PFS: aHR: 1.91 [1.29-2.82], p = 0.001). Patients with higher PAC body mass index (BMI), receiving Gemcap regimen, and with lower PAC tumor marker value were observed with better survival prognoses (PAC BMI: OS: 0.927 [0.875-0.983], p = 0.011; Gemcap: OS: 0.533 [0.312-0.913], p = 0.022; Gemcap: PFS: 0.560 [0.341-0.922], p = 0.023; PAC CA125: OS: 1.004 [1.002-1.006], p < 0.001; PAC CA125: PFS: 1.003 [1.000-1.005], p = 0.031; PAC CEA: OS: 1.050 [1.026-1.074], p < 0.001). The BMI decrease was mainly concentrated in the first 3 months of chemotherapy courses (first 3 months: p < 0.001; latter 3 months: p = 0.097). And CEA, compared to CA125 and CA199, was a better prognostic indicator (CEA: first 3 months: PFS p = 0.011, OS p < 0.001; latter 3 months: PFS p = 0.024, OS p = 0.041). CONCLUSION PDAC patients should be treated with adjuvant chemotherapy over 34 postoperative days. PAC sarcopenia was a risk factor for OS, but not PFS and limited CHC. Those with higher PAC FBG levels were more likely to finish chemotherapy. CEA, compared to CA125 and CA199, was a better prognostic indicator.
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Affiliation(s)
- Ningzhen Fu
- Pancreatic Disease Center, Department of General SurgeryRuijin Hospital, Shanghai Jiaotong University School of MedicineShanghaiChina
- Research Institute of Pancreatic DiseaseShanghai Jiaotong University School of MedicineShanghaiChina
- State Key Laboratory of Oncogenes and Related GenesShanghaiChina
- Institute of Translational MedicineShanghai Jiaotong UniversityShanghaiChina
| | - Kai Qin
- Pancreatic Disease Center, Department of General SurgeryRuijin Hospital, Shanghai Jiaotong University School of MedicineShanghaiChina
- Research Institute of Pancreatic DiseaseShanghai Jiaotong University School of MedicineShanghaiChina
- State Key Laboratory of Oncogenes and Related GenesShanghaiChina
- Institute of Translational MedicineShanghai Jiaotong UniversityShanghaiChina
| | - Jingfeng Li
- Pancreatic Disease Center, Department of General SurgeryRuijin Hospital, Shanghai Jiaotong University School of MedicineShanghaiChina
- Research Institute of Pancreatic DiseaseShanghai Jiaotong University School of MedicineShanghaiChina
- State Key Laboratory of Oncogenes and Related GenesShanghaiChina
- Institute of Translational MedicineShanghai Jiaotong UniversityShanghaiChina
| | - Jiabin Jin
- Pancreatic Disease Center, Department of General SurgeryRuijin Hospital, Shanghai Jiaotong University School of MedicineShanghaiChina
- Research Institute of Pancreatic DiseaseShanghai Jiaotong University School of MedicineShanghaiChina
- State Key Laboratory of Oncogenes and Related GenesShanghaiChina
- Institute of Translational MedicineShanghai Jiaotong UniversityShanghaiChina
| | - Yu Jiang
- Pancreatic Disease Center, Department of General SurgeryRuijin Hospital, Shanghai Jiaotong University School of MedicineShanghaiChina
- Research Institute of Pancreatic DiseaseShanghai Jiaotong University School of MedicineShanghaiChina
- State Key Laboratory of Oncogenes and Related GenesShanghaiChina
- Institute of Translational MedicineShanghai Jiaotong UniversityShanghaiChina
| | - Xiaxing Deng
- Pancreatic Disease Center, Department of General SurgeryRuijin Hospital, Shanghai Jiaotong University School of MedicineShanghaiChina
- Research Institute of Pancreatic DiseaseShanghai Jiaotong University School of MedicineShanghaiChina
- State Key Laboratory of Oncogenes and Related GenesShanghaiChina
- Institute of Translational MedicineShanghai Jiaotong UniversityShanghaiChina
| | - Baiyong Shen
- Pancreatic Disease Center, Department of General SurgeryRuijin Hospital, Shanghai Jiaotong University School of MedicineShanghaiChina
- Research Institute of Pancreatic DiseaseShanghai Jiaotong University School of MedicineShanghaiChina
- State Key Laboratory of Oncogenes and Related GenesShanghaiChina
- Institute of Translational MedicineShanghai Jiaotong UniversityShanghaiChina
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Maccabe TA, Robertson HF, Skipworth J, Rees J, Roberts K, Pathak S. A systematic review of post-pancreatectomy haemorrhage management stratified according to ISGPS grading. HPB (Oxford) 2022; 24:1110-1118. [PMID: 35101359 DOI: 10.1016/j.hpb.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 11/15/2021] [Accepted: 12/08/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Morbidity and mortality from post-pancreatectomy haemorrhage (PPH) remains high. The International Study Group of Pancreatic Surgery (ISGPS) published guidelines to standardise definitions of PPH severity, management and reporting. This study aimed to i) identify the number of studies reporting PPH using ISGPS guidelines (Grade A, B or C) and ii) describe treatment modality success by grade. METHODS A systematic literature review was performed, identifying studies reporting PPH by ISGPS Grade and their subsequent management. RESULTS Of 62 studies reporting on PPH management, 17 (27.4%) stratified by ISGPS guidelines and included 608 incidences of PPH: 48 Grade A, 274 Grade B (62 early, 166 late, 46 unspecified) and 286 Grade C. 96% of Grade A PPH were treated conservatively. Of 62 early Grade B, 54.8% were managed conservatively and 37.1% surgically. Late Grade B were managed non-operatively in 25.3% (42/166), with successful endoscopy in 90.9% (10/11) and angiography in 90.3% (28/31). In Grade C, endoscopic treatment was successful in 64.4% (29/45) and angiography in 90.8% (108/119). Surgical intervention was required in 43.5% early Grade B, 7.8% late Grade B and 33.2% Grade C. CONCLUSION PPH grading is underreported and despite guidelines, inconsistencies remain when using definitions and reporting of outcomes.
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Affiliation(s)
- Thomas A Maccabe
- Department of Hepatopancreatobiliary Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol UK.
| | - Harry F Robertson
- Department of Hepatopancreatobiliary Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol UK
| | - James Skipworth
- Department of Hepatopancreatobiliary Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol UK
| | - Jonathan Rees
- Department of Hepatopancreatobiliary Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol UK
| | - Keith Roberts
- Department of Hepatopancreatobiliary Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol UK; Department of Pancreatic Surgery, University Hospitals Birmingham, UK
| | - Samir Pathak
- Department of Hepatopancreatobiliary Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol UK
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Evaluation of factors predicting loss of benefit provided by laparoscopic distal pancreatectomy compared to open approach. Updates Surg 2021; 74:213-221. [PMID: 34687429 DOI: 10.1007/s13304-021-01194-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/12/2021] [Indexed: 10/20/2022]
Abstract
Several studies showed safety and feasibility of laparoscopic distal pancreatectomy (LDP) as compared to open distal pancreatectomy (ODP). Patients who underwent LDP or ODP (2015-2019) were included. A 1:1 propensity score matching (PSM) was used to reduce the effect of treatment selection bias. Aim of this study was to identify those factors influencing the loss of benefit (defined as a significantly better outcome compared to ODP) after LDP. Overall, 387 patients underwent DP (n = 250 LDP, n = 137 ODP). After PSM, 274 patients (n = 137 LDP, n = 137 ODP) were selected. LDP was associated with reduced intraoperative blood loss (median: 200 mL vs. 250 mL, p < 0.001), decreased wound infection rate (1% vs. 9%, p = 0.044) and shorter time to functional recovery (TFR) (median: 4 days vs. 5 days, p = 0.002). Consequently, TFR > 5 days and blood loss > 250 mL were defined as loss of benefit after LDP. In the LDP group, age > 70 years [Odds Ratio (OR) 2.744, p = 0.022] and duration of surgery > 208 min (OR 2.957, p = 0.019) were predictors of TFR > 5 days and intraoperative blood loss > 250 mL, respectively. No differences in terms of TFR were found between ODP and LDP groups in patients > 70 years (p = 0.102). Intraoperative blood loss was significantly higher in the ODP group, also when the analysis was limited to surgical procedures with operative time > 208 min (p = 0.003). In conclusion, LDP seems comparable to ODP in terms of TFR in patients aged > 70 years. This finding could be helpful in the choice of the best surgical approach in elderly patients undergoing potentially challenging DPs.
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Alekyan BG, Lusnikov VP, Varava AB, Kriger AG. [Endovascular treatment of arterial bleeding after pancreatic surgery]. Khirurgiia (Mosk) 2021:76-83. [PMID: 34363449 DOI: 10.17116/hirurgia202108176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pancreatic surgery is complex and associated with a risk of complications including bleeding. Bleeding after pancreatic surgery is rare, but characterized by high mortality. This review is devoted to classification, diagnosis and treatment strategies for bleeding after pancreatic surgery. Methods and results of endovascular surgery are of special attention.
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Affiliation(s)
- B G Alekyan
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - V P Lusnikov
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - A B Varava
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - A G Kriger
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
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Shinde RS, Pandrowala S, Navalgund S, Pai E, Bhandare MS, Chaudhari VA, Sullivan R, Shrikhande SV. Centralisation of Pancreatoduodenectomy in India: Where Do We Stand? World J Surg 2021; 44:2367-2376. [PMID: 32161986 DOI: 10.1007/s00268-020-05466-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The volume-outcome relationship dictates that high-volume centres lead to improved patient outcomes after pancreatoduodenectomy (PD). We conducted a retrospective review to fathom the situation in India for PD and whether referral to high-volume centres would make a positive impact. METHOD A systematic literature search in MEDLINE was performed, and all articles published from Indian centres from 01.03.2008 to 30.11.2019 were scrutinised. Any series with less than 20 patients, case reports, abstracts, unpublished data and personal communications were excluded. RESULTS A total of 36 unique series including 6226 patients from 24 institutes across India were identified. Amongst the 24 institutes, 2 institutes reported less than 10 cases/year, 11 reported 10-25 cases/year and 11 reported ≥26 cases/year. Overall perioperative morbidity was 42.4%, 43.4% and 41% for centres doing <10, 10-25 and ≥26 cases/year, respectively. Operative mortality also improved with increasing number of cases/year (5.1% vs. 6.6% vs. 3.2%, respectively). CONCLUSION With increasing volume of cases per year, trend towards improved PD outcomes is observed. To optimise the use of healthcare facilities, it would be pragmatic to consider building an organised referral system for complex surgeries to deliver unsurpassed patient care with maximum utilisation of the available healthcare infrastructure.
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Affiliation(s)
- Rajesh S Shinde
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Saneya Pandrowala
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Sunil Navalgund
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Esha Pai
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Manish S Bhandare
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Vikram A Chaudhari
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Richard Sullivan
- Institute of Cancer Policy, King's College London, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Shailesh V Shrikhande
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India.
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Partelli S, Ricci C, Rancoita PMV, Montorsi R, Andreasi V, Ingaldi C, Arru G, Pecorelli N, Crippa S, Alberici L, Di Serio C, Casadei R, Falconi M. Preoperative predictive factors of laparoscopic distal pancreatectomy difficulty. HPB (Oxford) 2020; 22:1766-1774. [PMID: 32340858 DOI: 10.1016/j.hpb.2020.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 03/29/2020] [Accepted: 04/02/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Laparoscopic distal pancreatectomy (LDP) is a challenging operation due to technical complexity and tumor-related factors. Aim of this study was to identify preoperative risk factors affecting LDP difficulty. METHODS Consecutive patients who underwent LDP between 2015 and 2018 at San Raffaele Hospital and Policlinico S.Orsola-Malpighi Hospital were enrolled retrospectively. Three variables were used to define surgical difficulty: conversion to open, duration of surgery >3rd quartile and intraoperative blood loss >3rd quartile. The presence of ≥1 of these 3 variables was considered as another measure of difficulty. RESULTS Overall, 191 patients were included. Conversion to open was required in 25 patients (13%). At multiple regression analysis, tumor proximity to major vessels was the only independent predictor of conversion from laparoscopic to open (p < 0.001). No variables independently predicted an excessive duration of surgery. Male gender (p = 0.033) and increasing parenchymal thickness at resection line (p = 0.018) were independent predictors of excessive blood loss. Increasing parenchymal thickness at resection line (p = 0.014) and tumor proximity to major vessels (p = 0.002) were significant risk factors for the presence of ≥1 outcome of surgical difficulty. CONCLUSION Male gender, increasing parenchymal thickness at resection line and tumor proximity to major vessels represent preoperative risk factors of LDP difficulty.
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Affiliation(s)
- Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; "Vita-Salute San Raffaele" University, Milan, Italy
| | - Claudio Ricci
- Department of Internal Medicine and Surgery, Alma Mater Studiorum, University of Bologna, S. Orsola-Malpighi, Bologna, Italy
| | - Paola M V Rancoita
- University Centre of Statistics in the Biomedical Sciences, "Vita-Salute San Raffaele" University, Milan, Italy
| | - Roberto Montorsi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; "Vita-Salute San Raffaele" University, Milan, Italy
| | - Valentina Andreasi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; "Vita-Salute San Raffaele" University, Milan, Italy
| | - Carlo Ingaldi
- Department of Internal Medicine and Surgery, Alma Mater Studiorum, University of Bologna, S. Orsola-Malpighi, Bologna, Italy
| | - Giaime Arru
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; "Vita-Salute San Raffaele" University, Milan, Italy
| | - Nicolò Pecorelli
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; "Vita-Salute San Raffaele" University, Milan, Italy
| | - Laura Alberici
- Department of Internal Medicine and Surgery, Alma Mater Studiorum, University of Bologna, S. Orsola-Malpighi, Bologna, Italy
| | - Clelia Di Serio
- University Centre of Statistics in the Biomedical Sciences, "Vita-Salute San Raffaele" University, Milan, Italy
| | - Riccardo Casadei
- Department of Internal Medicine and Surgery, Alma Mater Studiorum, University of Bologna, S. Orsola-Malpighi, Bologna, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy; "Vita-Salute San Raffaele" University, Milan, Italy.
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Das S, Ray S, Mangla V, Mehrotra S, Lalwani S, Mehta NN, Yadav A, Nundy S. Post pancreaticoduodenectomy hemorrhage: A retrospective analysis of incidence, risk factors and outcome. Saudi J Gastroenterol 2020; 26:292421. [PMID: 32811797 PMCID: PMC8019141 DOI: 10.4103/sjg.sjg_145_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/24/2020] [Accepted: 07/04/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The operative mortality after pancreaticoduodenectomy (PD) has declined but morbidity still remains considerable. Post pancreaticoduodenectomy hemorrhage (PPH) occurs in 3-13% of patients following PD. We studied the incidence and outcomes of patients with PPH after PD to determine the associated risk factors and effect on hospital stay. METHODS We retrospectively analyzed from a prospectively collected data of patients developing PPH following PD between January 2007 and May 2018. ISGPS definition and grading system were used. By using univariate and multivariate analyses, independent predictors of PPH were identified. RESULTS Of the 340 patients undergoing PD, PPH occurred in 39 patients (11.5%), of whom 5 (12.8%) had Grade A, 22 (56.4%) had Grade B and 12 (30.8%) had Grade C PPH. Six (15.4%) of the 39 patients with PPH died against an overall mortality in the study population of 16 out of 340 patients (4.7%), reflecting higher mortality (P = 0.019) in patients with PPH . The independent risk factors for PPH were a high pre-operative bilirubin (mean 4.7 vs. 7.4 mg/dl, P = 0.01) and INR (mean 1.2 vs. 1.72, P = 0.024), whereas it was closely followed by but, but not significantly associated with pre-operative biliary stent placement (P = 0.09). Pancreatico-jejunostomy (PJ) leak was seen in 20.7% in non-hemorrhage group vs. 41% in hemorrhage group (P = 0.008) and was an independent risk factor for PPH. CONCLUSION PPH occurred in 11.5% of patients and resulted in a mortality four times greater than those without a PPH. It occurred more frequently in patents with a high pre-operative serum bilirubin, INR, biliary stenting or those with a PJ leak.
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Affiliation(s)
- Subhashish Das
- Department of Surgical Gastroenterology, Sir Gangaram Hospital, New Delhi, India
| | - Samrat Ray
- Department of Surgical Gastroenterology, Sir Gangaram Hospital, New Delhi, India
| | - Vivek Mangla
- Department of Surgical Gastroenterology, Sir Gangaram Hospital, New Delhi, India
| | - Siddharth Mehrotra
- Department of Surgical Gastroenterology, Sir Gangaram Hospital, New Delhi, India
| | - Shailendra Lalwani
- Department of Surgical Gastroenterology, Sir Gangaram Hospital, New Delhi, India
| | - Naimish N. Mehta
- Department of Surgical Gastroenterology, Sir Gangaram Hospital, New Delhi, India
| | - Amitabh Yadav
- Department of Surgical Gastroenterology, Sir Gangaram Hospital, New Delhi, India
| | - Samiran Nundy
- Department of Surgical Gastroenterology, Sir Gangaram Hospital, New Delhi, India
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Lediju Bell MA. Photoacoustic imaging for surgical guidance: Principles, applications, and outlook. JOURNAL OF APPLIED PHYSICS 2020; 128:060904. [PMID: 32817994 PMCID: PMC7428347 DOI: 10.1063/5.0018190] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 07/30/2020] [Indexed: 05/08/2023]
Abstract
Minimally invasive surgeries often require complicated maneuvers and delicate hand-eye coordination and ideally would incorporate "x-ray vision" to see beyond tool tips and underneath tissues prior to making incisions. Photoacoustic imaging has the potential to offer this feature but not with ionizing x-rays. Instead, optical fibers and acoustic receivers enable photoacoustic sensing of major structures-such as blood vessels and nerves-that are otherwise hidden from view. This imaging process is initiated by transmitting laser pulses that illuminate regions of interest, causing thermal expansion and the generation of sound waves that are detectable with conventional ultrasound transducers. The recorded signals are then converted to images through the beamforming process. Photoacoustic imaging may be implemented to both target and avoid blood-rich surgical contents (and in some cases simultaneously or independently visualize optical fiber tips or metallic surgical tool tips) in order to prevent accidental injury and assist device operators during minimally invasive surgeries and interventional procedures. Novel light delivery systems, counterintuitive findings, and robotic integration methods introduced by the Photoacoustic & Ultrasonic Systems Engineering Lab are summarized in this invited Perspective, setting the foundation and rationale for the subsequent discussion of the author's views on possible future directions for this exciting frontier known as photoacoustic-guided surgery.
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Affiliation(s)
- Muyinatu A. Lediju Bell
- Department of Electrical and Computer Engineering, Johns Hopkins University, Baltimore, Maryland 21218, USA
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11
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Muglia R, Lanza E, Poretti D, D'Antuono F, Gennaro N, Gavazzi F, Zerbi A, Chiti A, Pedicini V. Emergency endovascular treatments for delayed hemorrhage after pancreaticobiliary surgery: indications, outcomes, and follow-up of a retrospective cohort. Abdom Radiol (NY) 2020; 45:2593-2602. [PMID: 32172410 DOI: 10.1007/s00261-020-02480-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate the outcomes of emergency endovascular treatments for delayed bleeding after pancreaticobiliary surgery. METHODS We retrospectively evaluated 21 patients (M:F = 13:8, median age = 64 years) undergoing 23 endovascular treatments, performed from 2010 to 2017 in a single center. Data collected were patient characteristics; surgery; pathology; incidence of postoperative pancreatic fistulas (POPF); bleeding signs on CT and angiography; damaged artery; endovascular tools used; technical and clinical success; intervals between surgery, endovascular treatment, and discharge; survival rates. RESULTS Sixteen patients had pancreatoduodenectomy, three hepaticojejunostomy, two distal pancreatectomy. Indications for surgery were mainly biliary (33%), pancreatic (19%), or duodenal (10%) malignancies. Seventeen patients had "grade C" POPF, three suffered a biliary leak, one had no POPF. Active bleeding was present in 17/23 CTs and in 22/23 angiographies, mostly from hepatic (43%), gastroduodenal (22%), and splenic (13%) arteries. The endovascular treatments were performed with coils (26%), glue (22%), stent-graft (22%), and their combinations (30%). Sixteen patients had a single endovascular treatment, one underwent a second embolization, three had subsequent surgery, one had repeat embolization followed by surgery. Relaparotomy rate was 19%. Median hospital stay was 37 days (range 12-75); median intervals among pancreaticobiliary surgery, endovascular treatment, and discharge were 21 (2-36) and 12 (8-47) days, respectively. We observed 4/21 intrahospital deaths (median: 31 days from endovascular treatment, 4-53); 1-year survival rate of discharged patients was 71%. CONCLUSIONS Endovascular treatment using embolization and/or stent-graft placement is a useful first-line intervention to halt postoperative hemorrhage after pancreaticobiliary surgery and decreases the need for urgent relaparotomy.
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Affiliation(s)
- Riccardo Muglia
- Training School in Radiology, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milano, Italy.
| | - Ezio Lanza
- Department of Diagnostic and Interventional Radiology, Humanitas Research Hospital, Via A. Manzoni 56, 20089, Rozzano, Milano, Italy
| | - Dario Poretti
- Department of Diagnostic and Interventional Radiology, Humanitas Research Hospital, Via A. Manzoni 56, 20089, Rozzano, Milano, Italy
| | - Felice D'Antuono
- Department of Diagnostic and Interventional Radiology, Humanitas Research Hospital, Via A. Manzoni 56, 20089, Rozzano, Milano, Italy
| | - Nicolò Gennaro
- Training School in Radiology, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milano, Italy
| | - Francesca Gavazzi
- Department of General Surgery, Humanitas Research Hospital, Via A. Manzoni 56, 20089, Rozzano, Milano, Italy
| | - Alessandro Zerbi
- Department of General Surgery, Humanitas Research Hospital, Via A. Manzoni 56, 20089, Rozzano, Milano, Italy
| | - Arturo Chiti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, Milano, Italy
| | - Vittorio Pedicini
- Department of Diagnostic and Interventional Radiology, Humanitas Research Hospital, Via A. Manzoni 56, 20089, Rozzano, Milano, Italy
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12
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Brodie B, Kocher HM. Systematic review of the incidence, presentation and management of gastroduodenal artery pseudoaneurysm after pancreatic resection. BJS Open 2019; 3:735-742. [PMID: 31832579 PMCID: PMC6887902 DOI: 10.1002/bjs5.50210] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 06/10/2019] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- B Brodie
- Barts and the London School of Medicine and Dentistry London UK
| | - H M Kocher
- Centre for Tumour Biology, Barts Cancer Institute Queen Mary University of London London UK.,Barts and the London Hepato-Pancreato-Biliary Centre The Royal London Hospital, Barts Health NHS Trust, Whitechapel London UK
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13
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Analysis of risk factors for hemorrhage and related outcome after pancreatoduodenectomy in an intermediate-volume center. Updates Surg 2019; 71:659-667. [DOI: 10.1007/s13304-019-00673-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 07/27/2019] [Indexed: 02/06/2023]
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14
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Partelli S, Mazza M, Andreasi V, Muffatti F, Crippa S, Tamburrino D, Falconi M. Management of small asymptomatic nonfunctioning pancreatic neuroendocrine tumors: Limitations to apply guidelines into real life. Surgery 2019; 166:157-163. [DOI: 10.1016/j.surg.2019.04.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 03/20/2019] [Accepted: 04/07/2019] [Indexed: 12/20/2022]
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15
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Kempski KM, Wiacek A, Graham M, González E, Goodson B, Allman D, Palmer J, Hou H, Beck S, He J, Bell MAL. In vivo photoacoustic imaging of major blood vessels in the pancreas and liver during surgery. JOURNAL OF BIOMEDICAL OPTICS 2019; 24:1-12. [PMID: 31411010 PMCID: PMC7006046 DOI: 10.1117/1.jbo.24.12.121905] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 07/22/2019] [Indexed: 05/07/2023]
Abstract
Abdominal surgeries carry considerable risk of gastrointestinal and intra-abdominal hemorrhage, which could possibly cause patient death. Photoacoustic imaging is one solution to overcome this challenge by providing visualization of major blood vessels during surgery. We investigate the feasibility of in vivo blood vessel visualization for photoacoustic-guided liver and pancreas surgeries. In vivo photoacoustic imaging of major blood vessels in these two abdominal organs was successfully achieved after a laparotomy was performed on two swine. Three-dimensional photoacoustic imaging with a robot-controlled ultrasound (US) probe and color Doppler imaging were used to confirm vessel locations. Blood vessels in the in vivo liver were visualized with energies of 20 to 40 mJ, resulting in 10 to 15 dB vessel contrast. Similarly, an energy of 36 mJ was sufficient to visualize vessels in the pancreas with up to 17.3 dB contrast. We observed that photoacoustic signals were more focused when the light source encountered a major vessel in the liver. This observation can be used to distinguish major blood vessels in the image plane from the more diffuse signals associated with smaller blood vessels in the surrounding tissue. A postsurgery histopathological analysis was performed on resected pancreatic and liver tissues to explore possible laser-related damage. Results are generally promising for photoacoustic-guided abdominal surgery when the US probe is fixed and the light source is used to interrogate the surgical workspace. These findings are additionally applicable to other procedures that may benefit from photoacoustic-guided interventional imaging of the liver and pancreas (e.g., biopsy and guidance of radiofrequency ablation lesions in the liver).
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Affiliation(s)
- Kelley M. Kempski
- University of Delaware, Department of Biomedical Engineering, Newark, Delaware, United States
| | - Alycen Wiacek
- Johns Hopkins University, Department of Electrical and Computer Engineering, Baltimore, Maryland, United States
| | - Michelle Graham
- Johns Hopkins University, Department of Electrical and Computer Engineering, Baltimore, Maryland, United States
| | - Eduardo González
- Johns Hopkins University, Department of Biomedical Engineering, Baltimore, Maryland, United States
| | - Bria Goodson
- Delta State University, Department of Biology, Cleveland, Mississippi, United States
| | - Derek Allman
- Johns Hopkins University, Department of Electrical and Computer Engineering, Baltimore, Maryland, United States
| | - Jasmin Palmer
- Massachusetts Institute of Technology, Department of Mechanical Engineering, Cambridge, Massachusetts, United States
| | - Huayu Hou
- Johns Hopkins University, Department of Electrical and Computer Engineering, Baltimore, Maryland, United States
| | - Sarah Beck
- Johns Hopkins Medicine, Department of Molecular and Comparative Pathobiology, Baltimore, Maryland, United States
| | - Jin He
- Johns Hopkins Medicine, Department of Surgery, Baltimore, Maryland, United States
- Johns Hopkins Medicine, Department of Oncology, Baltimore, Maryland, United States
| | - Muyinatu A. Lediju Bell
- Johns Hopkins University, Department of Electrical and Computer Engineering, Baltimore, Maryland, United States
- Johns Hopkins University, Department of Biomedical Engineering, Baltimore, Maryland, United States
- Johns Hopkins University, Department of Computer Science, Baltimore, Maryland, United States
- Address all correspondence to Muyinatu A. Lediju Bell, E-mail:
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16
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Biondetti P, Fumarola EM, Ierardi AM, Carrafiello G. Bleeding complications after pancreatic surgery: interventional radiology management. Gland Surg 2019; 8:150-163. [PMID: 31183325 DOI: 10.21037/gs.2019.01.06] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Surgical intervention in the pancreas region is complex and carries the risk of complications, also of vascular nature. Bleeding after pancreatic surgery is rare but characterized by high mortality. This review reports epidemiology, classification, diagnosis and treatment strategies of hemorrhage occurring after pancreatic surgery, focusing on the techniques, roles and outcomes of interventional radiology (IR) in this setting. We then describe the roles and techniques of IR in the treatment of other less common types of vascular complications after pancreatic surgery, such as portal vein (PV) stenosis, portal hypertension and bleeding of varices.
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Affiliation(s)
- Pierpaolo Biondetti
- Diagnostic and Interventional Radiology Department, ASST Santi Paolo and Carlo, University of Milan, Milan, Italy
| | - Enrico Maria Fumarola
- Diagnostic and Interventional Radiology Department, ASST Santi Paolo and Carlo, University of Milan, Milan, Italy
| | - Anna Maria Ierardi
- Diagnostic and Interventional Radiology Department, ASST Santi Paolo and Carlo, University of Milan, Milan, Italy
| | - Gianpaolo Carrafiello
- Diagnostic and Interventional Radiology Department, ASST Santi Paolo and Carlo, University of Milan, Milan, Italy
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17
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Duodeno-jejunal or gastro-enteric leakage after pancreatic resection: a case–control study. Updates Surg 2019; 71:295-303. [DOI: 10.1007/s13304-019-00637-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/22/2019] [Indexed: 12/13/2022]
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18
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Sánchez Acedo P, Zazpe Ripa C, Eguaras Córdoba I, Herrera Cabezón J, Tarifa Castilla A, Camarero Triana B. The effect of a preoperative biliary prosthesis on the infectious complications of the pancreaticoduodenectomy. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 111:817-822. [DOI: 10.17235/reed.2019.6228/2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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19
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Duarte Garcés AA, Andrianello S, Marchegiani G, Piccolo R, Secchettin E, Paiella S, Malleo G, Salvia R, Bassi C. Reappraisal of post-pancreatectomy hemorrhage (PPH) classifications: do we need to redefine grades A and B? HPB (Oxford) 2018; 20:702-707. [PMID: 29459002 DOI: 10.1016/j.hpb.2018.01.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 12/15/2017] [Accepted: 01/03/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-pancreatectomy hemorrhage (PPH) remains a major complication. The aim of this study was to reappraise the International Study Group of Pancreatic Surgery (ISGPS) classification. METHODS The clinical utility of the ISGPS classification was tested on consecutive pancreatic resections performed at the Pancreas Institute of the University of Verona Hospital. RESULTS PPH occurred in 65 of the 2429 patients (6.8%) undergoing pancreatic resection. Outcome of patients without PPH and with grade A PPH were comparable in terms of mortality, length of stay, ICU stay and readmission. Patients with grade B late and mild and grade B early and severe PPH had similar hospital stay and mortality rates, but differed in relaparotomy rate (10.1 vs. 81.2%, p < 0.01). Replacing "time of PPH onset" criterion with post-operative pancreatic fistula (POPF), severe PPH alone, mild PPH/POPF and severe PPH/POPF differed significantly for hospital stay (14 vs. 23 vs. 35 days, p < 0.01) and mortality rate (0 vs. 4 vs. 25%, p = 0.05). CONCLUSION Grade A PPH shared the same outcome of patients without PPH. Grade B PPH included two categories of patients with different treatment modalities. The use of "concomitant POPF" instead of "time of onset" segregated three discrete categories that differed significantly in terms of clinical outcomes and management.
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Affiliation(s)
- Alvaro A Duarte Garcés
- Departamento Cirugía Hepato Biliar y Pancreatica, Hospital Pablo Tobon Uribe, Medellìn, Colombia; General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Stefano Andrianello
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberta Piccolo
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Erica Secchettin
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
| | - Claudio Bassi
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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20
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Marley L, Navadgi S, Banting S, Fox A, Hii M, Knowles B. Safety, efficacy and compliance of extended thromboprophylaxis in hepatobiliary and upper gastrointestinal surgery. ANZ J Surg 2018; 89:357-361. [DOI: 10.1111/ans.14287] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 10/04/2017] [Accepted: 10/05/2017] [Indexed: 02/04/2023]
Affiliation(s)
- Leah Marley
- Department of Surgery, St Vincent's Hospital Melbourne Victoria Australia
| | - Suresh Navadgi
- Department of Surgery, St Vincent's Hospital Melbourne Victoria Australia
| | - Simon Banting
- Department of Surgery, St Vincent's Hospital Melbourne Victoria Australia
- Department of Surgery, The University of Melbourne Melbourne, Victoria Australia
| | - Adrian Fox
- Department of Surgery, St Vincent's Hospital Melbourne Victoria Australia
- Department of Surgery, The University of Melbourne Melbourne, Victoria Australia
| | - Michael Hii
- Department of Surgery, St Vincent's Hospital Melbourne Victoria Australia
- Department of Surgery, The University of Melbourne Melbourne, Victoria Australia
| | - Brett Knowles
- Department of Surgery, St Vincent's Hospital Melbourne Victoria Australia
- Department of Surgery, The University of Melbourne Melbourne, Victoria Australia
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21
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Courtin-Tanguy L, Turrini O, Bergeat D, Truant S, Darnis B, Delpero JR, Mabrut JY, Regenet N, Sulpice L. Multicentre study of the impact of factors that may affect long-term survival following pancreaticoduodenectomy for distal cholangiocarcinoma. HPB (Oxford) 2018; 20:405-410. [PMID: 29208352 DOI: 10.1016/j.hpb.2017.10.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 10/20/2017] [Accepted: 10/27/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although the peri-operative mortality following pancreaticoduodenectomy (PD) for distal cholangiocarcinoma (DCC) has decreased, the post-operative morbidity remains high. The aim of this study was to evaluate the impact of factors that may affect the long term survival for patients with DCC following PD. METHODS All patients who underwent PD for DCC between January 2000 and December 2015 in 5 tertiary referral centers underwent retrospective medical record review. Factors likely to influence overall (OS) and disease-free (DFS) survivals were assessed by univariate and multivariate analysis. RESULTS A total of 201 on 217 patients who underwent PD for DCC were included for further analysis. The median OS was 39 months, with actuarial survival rates at 1, 3, and 5 years of 85%, 53% and 39%. Recurrence occurred in 123 (61%) patients. The median DFS was 16 months, with actuarial survival rates at 1, 3 and 5 years of 60%, 37% and 28%. Following multivariate analysis, peri-operative blood transfusions (PBT) were associated to worse OS (HR = 2.25 [1.31-3.85], P = 0.003) and DFS (HR = 2.08 [1.24-3.5], P = 0.005). CONCLUSION This study confirms the negative impact of PBT on the oncologic result following PD for DCC.
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Affiliation(s)
- Laëtitia Courtin-Tanguy
- CHU Rennes, Service de Chirurgie Hépatobiliaire et Digestive, Rennes, France; Université Rennes1, Faculté de Médecine, Rennes, France; INSERM U991, Foie Métabolismes et Cancer, Rennes, France
| | - Olivier Turrini
- Institut Paoli-Calmettes, Marseille, France; INSERM U1068, Centre de Recherche en Cancérologie, Marseille, France; CNRS U7258, Université Aix-Marseille et Institut Paoli-Calmettes, Parc Scientifique et Technologique de Luminy, Marseille, France
| | - Damien Bergeat
- CHU Rennes, Service de Chirurgie Hépatobiliaire et Digestive, Rennes, France; Université Rennes1, Faculté de Médecine, Rennes, France; INRA UR1341 ADNC, St Gilles, France
| | - Stéphanie Truant
- CHU Lille, Service de Chirurgie Digestive et Transplantation, Lille, France; INSERM U1172, Centre de Recherche Jean-Pierre Aubert, Lille, France
| | - Benjamin Darnis
- CHU Lyon, Département de Chirurgie Digestive et de Transplantation Hépatique, Lyon, France
| | | | - Jean Y Mabrut
- CHU Lyon, Département de Chirurgie Digestive et de Transplantation Hépatique, Lyon, France
| | - Nicolas Regenet
- CHU Nantes, Clinique de Chirurgie Digestive et Endocrinienne, Nantes, France
| | - Laurent Sulpice
- CHU Rennes, Service de Chirurgie Hépatobiliaire et Digestive, Rennes, France; Université Rennes1, Faculté de Médecine, Rennes, France; INSERM U991, Foie Métabolismes et Cancer, Rennes, France; INSERM U1414, Centre D'investigation Clinique, Rennes, France.
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22
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Hashimoto D, Nakagawa S, Umezaki N, Yamao T, Kitano Y, Yamamura K, Kaida T, Arima K, Imai K, Yamashita YI, Chikamoto A, Baba H. Efficacy and safety of postoperative anticoagulation prophylaxis with enoxaparin in patients undergoing pancreatic surgery: A prospective trial and literature review. Pancreatology 2017; 17:464-470. [PMID: 28366422 DOI: 10.1016/j.pan.2017.03.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 03/26/2017] [Accepted: 03/28/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND /Objectives: Enoxaparin is low-molecular-weight heparin that is used for postoperative thromboprophylaxis. The purpose of this study was to evaluate the efficacy and safety of enoxaparin after pancreatic resection. We additionally carried out a literature review regarding venous thromboembolism (VTE) and postoperative bleeding mainly after hepatobiliary-pancreatic surgery. METHODS This was a prospective, single-arm study. Patients aged 20-79 years who planned to undergo pancreatic resection followed by postoperative anticoagulation therapy with enoxaparin were enrolled from 2013 to 2016. The exclusion criteria were low renal function, active bleeding, clinical signs of VTE at screening, or evidence of thromboembolic disease before surgery. The primary endpoint was the incidence of postoperative VTE. The secondary endpoint was the incidence of postoperative complications. For the literature review, PubMed was searched for relevant articles and the PRISMA guidelines were used. RESULTS In total, 103 patients were analyzed. Two patients (1.9%) developed asymptomatic VTE, and no patients developed symptomatic VTE. No in-hospital mortality occurred. Morbidities (Clavien-Dindo grade ≥ IIIa) occurred in 29 patients (28.1%). Three patients (2.9%) developed intra-abdominal hemorrhage due to pseudoaneurysm formation after pancreaticoduodenectomy or distal pancreatectomy. The literature review included nine articles, and all indicated that the results of this study were feasible. CONCLUSION This is the first prospective trial to focus on pharmacologic prophylaxis with enoxaparin after pancreatic surgery. Postoperative anticoagulant therapy with enoxaparin was used in patients who underwent pancreatic surgery with a low incidence of VTE and no increase in postoperative bleeding events compared with existing evidence.
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Affiliation(s)
- Daisuke Hashimoto
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Shigeki Nakagawa
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Naoki Umezaki
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Takanobu Yamao
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Yuki Kitano
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Kensuke Yamamura
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Takayoshi Kaida
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Kota Arima
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Katsunori Imai
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Yo-Ichi Yamashita
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Akira Chikamoto
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan.
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Ansari D, Tingstedt B, Lindell G, Keussen I, Ansari D, Andersson R. Hemorrhage after Major Pancreatic Resection: Incidence, Risk Factors, Management, and Outcome. Scand J Surg 2017; 106:47-53. [PMID: 26929287 DOI: 10.1177/1457496916631854] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
BACKGROUND AND AIMS Hemorrhage is a rare but dreaded complication after pancreatic surgery. The aim of this study was to examine the incidence, risk factors, management, and outcome of postpancreatectomy hemorrhage in a tertiary care center. MATERIALS AND METHODS A retrospective observational study was conducted on 500 consecutive patients undergoing major pancreatic resections at our institution. Postpancreatectomy hemorrhage was defined according to the International Study Group of Pancreatic Surgery criteria. RESULTS A total of 68 patients (13.6%) developed postpancreatectomy hemorrhage. Thirty-four patients (6.8%) had a type A, 15 patients (3.0%) had a type B, and the remaining 19 patients (3.8%) had a type C bleed. Postoperative pancreatic fistula Grades B and C and bile leakage were significantly associated with severe postpancreatectomy hemorrhage on multivariable logistic regression. For patients with postpancreatectomy hemorrhage Grade C, the onset of bleeding was in median 13 days after the index operation, ranging from 1 to 85 days. Twelve patients (63.2%) had sentinel bleeds. Surgery lead to definitive hemostatic control in six of eight patients (75.0%). Angiography was able to localize the bleeding source in 8/10 (80.0%) cases. The success rate of angiographic hemostasis was 8/8. (100.0%). The mortality rate among patients with postpancreatectomy hemorrhage Grade C was 2/19 (10.5%), and both fatalities occurred late as a consequence of eroded vessels in association with pancreaticogastrostomy. CONCLUSION Delayed hemorrhage is a serious complication after major pancreatic surgery.Sentinel bleed is an early warning sign. Postoperative pancreatic fistula and bile leakage are important risk factors for severe postpancreatectomy hemorrhage.
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Affiliation(s)
- D Ansari
- 1 Department of Surgery, Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
| | - B Tingstedt
- 1 Department of Surgery, Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
| | - G Lindell
- 1 Department of Surgery, Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
| | - I Keussen
- 2 Department of Radiology, Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
| | - D Ansari
- 3 Department of Cardiothoracic Surgery, Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
| | - R Andersson
- 1 Department of Surgery, Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
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25
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Hemorrhage after pancreaticoduodenectomy: does timing matter? HPB (Oxford) 2016; 18:861-869. [PMID: 27524733 PMCID: PMC5061014 DOI: 10.1016/j.hpb.2016.07.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 05/23/2016] [Accepted: 07/05/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hemorrhage after pancreaticoduodenectomy is a potentially fatal complication. We retrospectively reviewed state-wide data to evaluate incidence, type of hemorrhage, treatment modalities, and outcomes. METHODS Healthcare Cost and Utilization Project's Florida State Inpatient Database was queried 2007-2011 for patients undergoing pancreaticoduodenectomy. Characteristics and outcomes were compared by χ2. Multivariate logistic regression model was generated for risk of hemorrhage during index visit. RESULTS Of 2548 patients, 217 (8.5%) developed post-operative hemorrhage during their index visit with 139 (64.0%) requiring angiographic, endoscopic, or operative intervention. Overall mortality during index visit was 5.7% (146) - significantly higher in those patients who had post-operative hemorrhage (24.9%) vs not (4.0%) (p < 0.0001). Mortality was significantly higher when post-operative hemorrhage occurred during the second (POD 8-14) vs first (POD 0-7) week at 15/28 vs 16/74, respectively (p = 0.007). On multivariate analysis, male sex (OR 1.56, p = 0.003), vascular resection (OR 1.88, p = 0.017), very low hospital volume (≤7 PD/year; OR 1.62, p = 0.016), and post-operative intra-abdominal/wound infection (OR 2.31, p < 0.0001) were independent predictors for risk of hemorrhage during index visit. CONCLUSIONS Hemorrhage following pancreaticoduodenectomy remains common, resulting in significantly increased mortality. Hemorrhage during the second post-operative week carries approximately double the mortality of early bleeding, suggesting different etiologies requiring differing treatment approaches.
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Advances in the Surgical Management of Resectable and Borderline Resectable Pancreas Cancer. Surg Oncol Clin N Am 2016; 25:287-310. [PMID: 27013365 PMCID: PMC10181830 DOI: 10.1016/j.soc.2015.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Successful surgical resection offers the only chance for cure in patients with pancreatic cancer. However, pancreatic resection is feasible in less than 20% of the patients. In this review, the current state of surgical management of pancreatic cancer is discussed. The definition of resectability based on cross-sectional imaging and the technical aspects of surgery, including vascular resection and/or reconstruction, management of aberrant vascular anatomy and extent of lymphadenectomy, are appraised. Furthermore, common pancreatic resection-specific postoperative complications and their management are reviewed.
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Endovascular management of delayed post-pancreatectomy haemorrhage. Eur Radiol 2016; 26:3456-65. [PMID: 26815369 DOI: 10.1007/s00330-016-4213-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 11/03/2015] [Accepted: 01/13/2016] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To assess the patient outcome after endovascular treatment of delayed post-pancreatectomy haemorrhage (PPH) as first-line treatment. METHODS Between January 2005 and November 2013, all consecutive patients referred for endovascular treatment of PPH were included. Active bleeding, pseudoaneurysms, collections and the involved artery were recorded on pretreatment CT. Endovascular procedures were classified as technical success (source of bleeding identified on angiogram and treated), technical failure (source of bleeding identified but incompletely treated) and abstention (no abnormality identified, no treatment performed). Factors associated with rebleeding were analysed. RESULTS Sixty-nine patients (53 men) were included (mean 59 years old (32-75)). Pretreatment CT showed 27 (39 %) active bleeding. In 22 (32 %) cases, no involved artery was identified. Technical success, failure and abstention were observed in 48 (70 %), 9 (13 %) and 12 patients (17 %), respectively. Thirty patients (43 %) experienced rebleeding. Rebleeding rates were 29 %, 58 % and 100 % in case of success, abstention and failure (p < 0.001). Treatment failure/abstention was the only factor associated with rebleeding. Overall, 74 % of the patients were successfully treated by endovascular procedure(s) alone. CONCLUSION After a first endovascular procedure for PPH, the rebleeding rate is high and depends upon the success of the procedure. Most patients are successfully treated by endovascular approach(es) alone. KEY POINTS • After a first endovascular procedure for PPH the rebleeding rate is high • The rebleeding rate is significantly associated with initial technical success • Three-quarters of the patients are successfully treated by endovascular procedure(s) alone.
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Hashimoto S, Ito K, Koshida S, Kanno Y, Ogawa T, Masu K, Iwashita Y, Horaguchi J, Kobayashi G, Noda Y. Risk Factors for Post-Endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis and Stent Dysfunction after Preoperative Biliary Drainage in Patients with Malignant Biliary Stricture. Intern Med 2016; 55:2529-36. [PMID: 27629944 DOI: 10.2169/internalmedicine.55.6832] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Objective To retrospectively evaluate the risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and stent dysfunction after performing preoperative biliary drainage (BD) in patients with malignant biliary stricture. Methods Between January 2003 and February 2013, 105 consecutive patients who had undergone transpapillary BD before surgery were enrolled in this study. Procedure-related complications, stent dysfunction rates, and their respective risk factors were investigated. PEP was defined according to the consensus guidelines. Results Fifty-five patients had bile duct cancer, 31 had pancreatic cancer, 16 had ampullary cancer, and 3 had gallbladder cancer. Endoscopic biliary stenting (EBS) and nasobiliary drainage (NBD) were performed in 84 patients and 21 patients, respectively. PEP occurred in 10% of the patients, with a significantly higher frequency in those with hilar/upper bile duct stricture (p=0.026) and a normal bilirubin level at admission (p=0.016). Of the 84 patients who underwent initial EBS, stent dysfunction occurred in 13%. The mean number of days from EBS to stent dysfunction was 14±12 days. A multivariate analysis revealed a male gender (p=0.048), a stent diameter ≤8 Fr (p=0.036), and an ERCP procedure time ≥45 minutes (p=0.021) to be risk factors for stent dysfunction. No NBD tube dysfunction was observed. Conclusion Patients with upper/hilar bile duct stricture or a normal bilirubin level are at high risk of developing PEP after preoperative BD. NBD or EBS with a large-bore stent is therefore recommended as preoperative BD.
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Abstract
Delayed arterial hemorrhage is a rare complication of pancreaticoduodenectomy that is associated with a high mortality and has no standard management. Between 2000 and 2011, 204 pancreaticoduodenectomies were performed, and there were 3 cases of delayed arterial hemorrhage. We reviewed the role of endoscopy, laparotomy, and interventional radiology the management of delayed hemorrhage. One patient presented with intraluminal bleeding and upper gastrointestinal endoscopy failed to identify the bleeding site. Two patients presented with bleeding from the drain tube. Laparotomy was performed in the patient with intraluminal bleeding and interventional radiology was employed for the other 2 patients. There was no hemorrhage-related mortality or rebleeding, but the patient who underwent laparotomy developed sepsis. Endoscopy may have no role in the initial management of delayed arterial hemorrhage after pancreaticoduodenectomy. Interventional radiology is less invasive compared with laparotomy, and may be considered as the first-line treatment for delayed arterial hemorrhage in pancreaticoduodenectomy patients.
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Jilesen APJ, Tol JAMG, Busch ORC, van Delden OM, van Gulik TM, Nieveen van Dijkum EJM, Gouma DJ. Emergency management in patients with late hemorrhage after pancreatoduodenectomy for a periampullary tumor. World J Surg 2015; 38:2438-47. [PMID: 24791669 DOI: 10.1007/s00268-014-2593-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The mortality rate due to late hemorrhage after surgery for periampullary tumors is high, especially in patients with anastomotic leakage. Patients usually require emergency intervention for late hemorrhage. In this study patients with late hemorrhage and their outcomes were analyzed. Furthermore, independent predictors for late hemorrhage, the need for emergency intervention, and type of intervention are reported. METHODS From a prospective database that includes 1,035 patients who underwent pancreatoduodenectomy for periampullary tumors between 1992 and 2012, patients with late hemorrhage (>24 h after index operation) were identified. Patient, disease-specific, and operation characteristics, type of intervention, and outcomes were analyzed. Emergency intervention was defined as surgical or radiological intervention in hemodynamically unstable patients. RESULTS Of the 47 patients (4.5 %) with late hemorrhage, pancreatic fistula was an independent predictor for developing late hemorrhage (OR 10.2). The mortality rate in patients with late hemorrhage was 13 % compared with 1.5 % in all patients without late hemorrhage. Twenty patients required emergency intervention; 80 % underwent primary radiological intervention and 20 % primary surgical intervention. Extraluminal location of the bleeding (OR 5.6) and occurrence of a sentinel bleed (OR 6.6) are indications for emergency intervention. CONCLUSION The type of emergency intervention needed for late hemorrhage is unpredictable. Radiological intervention is preferred, but if it fails, immediate change to surgical treatment is mandatory. This can be difficult to manage but possible when both radiological and surgical interventions are in close proximity such as in a hybrid operating room and should be considered in the emergency management of patients with late hemorrhage.
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Affiliation(s)
- Anneke P J Jilesen
- Department of Surgery, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands,
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Chen JF, Xu SF, Zhao W, Tian YH, Gong L, Yuan WS, Dong JH. Diagnostic and Therapeutic Strategies to Manage Post-Pancreaticoduodenectomy Hemorrhage. World J Surg 2014; 39:509-15. [DOI: 10.1007/s00268-014-2809-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Meng G, Xing Q, Yuan Q, Du Z, Wang Y, Meng H. Internal compared with external drainage of pancreatic duct during pancreaticoduodenectomy: a retrospective study. Chin J Cancer Res 2014; 26:277-84. [PMID: 25035654 DOI: 10.3978/j.issn.1000-9604.2014.06.05] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 05/06/2014] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To compare internal with external drainage of the pancreatic duct during pancreaticoduodenectomy with regard to the incidence of postoperative pancreatic fistula (POPF) and other complications. METHODS We retrospectively analyzed 316 patients who underwent pancreaticoduodenectomy with a placed drainage tube (external, n=128; internal, n=188) in the pancreatic duct from 1 January 1999 to 31 December 2011 in Tianjin Third Central Hospital of China. The incidence of POPF and some other complications were compared. RESULTS There was no difference in the incidence rates of POPF between those given an internal or external drainage tube (P=0.788), but POPF was more severe in the former (P=0.014). Intraperitoneal bleeding rate was also higher in the patients with internal drainage (P=0.040), but operative time and postoperative hospitalization were longer in those with external drainage (P=0.002 and P=0.007, respectively). There was no difference between the groups with regard to the incidence rates of gastrointestinal bleeding, delayed gastric emptying, pulmonary infection, or incision infection and in-hospital mortality. CONCLUSIONS External drainage of the pancreatic duct during pancreaticoduodenectomy can decrease the severity of POPF, but operative time and postoperative hospitalization will be extended.
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Affiliation(s)
- Guangxing Meng
- 1 Department of Hepatobiliary Surgery, Tianjin Third Central Hospital, Tianjin Hepatobiliary Research Institute, Tianjin 300170, China ; 2 Department of Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Qianzhe Xing
- 1 Department of Hepatobiliary Surgery, Tianjin Third Central Hospital, Tianjin Hepatobiliary Research Institute, Tianjin 300170, China ; 2 Department of Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Qiang Yuan
- 1 Department of Hepatobiliary Surgery, Tianjin Third Central Hospital, Tianjin Hepatobiliary Research Institute, Tianjin 300170, China ; 2 Department of Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Zhi Du
- 1 Department of Hepatobiliary Surgery, Tianjin Third Central Hospital, Tianjin Hepatobiliary Research Institute, Tianjin 300170, China ; 2 Department of Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Yijun Wang
- 1 Department of Hepatobiliary Surgery, Tianjin Third Central Hospital, Tianjin Hepatobiliary Research Institute, Tianjin 300170, China ; 2 Department of Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Hua Meng
- 1 Department of Hepatobiliary Surgery, Tianjin Third Central Hospital, Tianjin Hepatobiliary Research Institute, Tianjin 300170, China ; 2 Department of Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
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Hemorrhage from the pancreatic cut end into the jejunum after binding pancreaticojejunostomy: report of a case. Surg Today 2013; 44:1754-6. [DOI: 10.1007/s00595-013-0618-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 03/04/2013] [Indexed: 01/08/2023]
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Darnis B, Lebeau R, Chopin-Laly X, Adham M. Postpancreatectomy hemorrhage (PPH): predictors and management from a prospective database. Langenbecks Arch Surg 2013; 398:441-8. [PMID: 23435636 DOI: 10.1007/s00423-013-1047-8] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Accepted: 01/07/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND Postpancreatectomy hemorrhage (PPH) is a dreaded complication in pancreatic surgery. Today, there is a definition and grading of PPH without therapeutic consensus. We reviewed our prospective database to identify predictors and assess therapeutic strategy. METHOD We included all patients who underwent pancreatectomy between 2005 and 2010. Data were collected prospectively. We used the International Study Group Of Pancreatic Surgery (ISGPS) definition for PPH to include patients in the PPH group. RESULTS Forty-six of 285 patients showed a PPH (16.1 %). The ISGPS classification was graded A = 3, B = 26, and C = 17. The average time to the onset of PPH was 7 days. CT-scan identified the origin of PPH in 43.5 % of the cases. PPH was responsible for a longer duration of hospital stay (p = 0.004), a higher hospital mortality (21.7 vs 2.5 %, p < 0.0001) and a lower survival (40 vs 70 % (p = 0.05) at 36 months). The first-intention treatment of PPH was conservative in 32 % and interventional in 68 %: endoscopy (6.4 %), transcatheter arterial embolization (TAE, 30.4 %), and surgical (30.4 %). In multivariate analysis, predictors of PPH were: pancreatic fistula (24 vs 8 % p = 0.028), pancreatoduodenectomy (70 vs 43 % p = 0.029), age (61.6 vs 58.8 %, p = 0.03), and nutritional risk index (NRI) (p = 0.048). CONCLUSION In our series, risk factors for PPH were age, pancreatic fistula, pancreatoduodenectomy, and NRI. Its occurrence is associated with significantly higher hospital mortality and a lower survival rate. Our first-line treatment was radiological TAE. Surgical treatment is offered in case of failure of interventional radiology or in case of uncontrolled hemodynamic.
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Affiliation(s)
- B Darnis
- Department of HBP Surgery, Edouard Herriot hospital, HCL, Lyon Faculty of Medicine, UCBL1, 5 Place d'Arsonval, 69437 Lyon, Cedex 03, France
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Shrikhande SV, Barreto SG, Somashekar BA, Suradkar K, Shetty GS, Talole S, Sirohi B, Goel M, Shukla PJ. Evolution of pancreatoduodenectomy in a tertiary cancer center in India: improved results from service reconfiguration. Pancreatology 2012; 13:63-71. [PMID: 23395572 DOI: 10.1016/j.pan.2012.11.302] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Revised: 09/05/2012] [Accepted: 11/03/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pancreatic cancer incidence in India is low. Over the years, refinements in technique of pancreatoduodenectomy (PD) may have improved outcomes. No data is available from India, South-Central, or South West Asia to assess the impact of these refinements. PURPOSE To assess the impact of service reconfiguration and standardized protocols on outcomes of PD in a tertiary cancer center in India. METHODS Three specific time periods marking major shifts in practice and performance of PD were identified, viz. periods A (1992-2001; pancreaticogastrostomy predominantly performed), B (2003-July 2009; standardization of pancreaticojejunal anastomosis), and C (August 2009-December 2011; introduction of neoadjuvant chemo-radiotherapy and increased surgical volume). RESULTS 500 PDs were performed with a morbidity and mortality rate of 33% and 5.4%, respectively. Over the three periods, volume of cases/year significantly increased from 16 to 60 (p < 0.0001). Overall incidence of post-operative pancreatic anastomotic leak/fistula (POPF), hemorrhage, delayed gastric emptying (DGE), and bile leak was 11%, 6%, 3.4%, and 3.2%, respectively. The overall morbidity rates, as well as, the above individual complications significantly reduced from period A to B (p < 0.01) with no statistical difference between periods B and C. CONCLUSION Evolution of practice and perioperative management of PD for pancreatic cancer at our center improved perioperative outcomes and helped sustain the improvements despite increasing surgical volume. By adopting standardized practices and gradually improving experience, countries with low incidence of pancreatic cancer and resource constraints can achieve outcomes comparable to high-incidence, developed nations. SYNOPSIS The manuscript represents the largest series on perioperative outcomes for pancreatoduodenectomy from South West and South-Central Asia - a region with a low incidence of pancreatic cancer and a disproportionate distribution of resources highlighting the impact of high volumes, standardization and service reconfiguration.
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Affiliation(s)
- Shailesh V Shrikhande
- Department of Gastrointestinal and Hepato-Pancreato-Biliary Surgical Oncology, Tata Memorial Hospital, Parel, Mumbai, India.
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Correa-Gallego C, Brennan MF, D'Angelica MI, DeMatteo RP, Fong Y, Kingham TP, Jarnagin WR, Allen PJ. Contemporary experience with postpancreatectomy hemorrhage: results of 1,122 patients resected between 2006 and 2011. J Am Coll Surg 2012; 215:616-21. [PMID: 22921325 DOI: 10.1016/j.jamcollsurg.2012.07.010] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Revised: 07/16/2012] [Accepted: 07/16/2012] [Indexed: 12/28/2022]
Abstract
BACKGROUND Postpancreatectomy hemorrhage (PPH) is a life-threatening complication of pancreatic resection. Most published series span decades and do not reflect contemporary practice. This study analyzes the rate, management, and outcomes of PPH during a recent 5-year period. STUDY DESIGN Patients in whom PPH developed between 2006 and 2011 were identified from a prospective database. Postpancreatectomy hemorrhage was defined as evidence of bleeding associated with a drop in hemoglobin (≥ 3 g/dL) and/or clinical signs of hemodynamic compromise, and categorized as early or late (<24 hours or >24 hours from operation). Demographics and operative and perioperative outcomes were analyzed using standard descriptive statistics. RESULTS Overall incidence of PPH was 3% (33 of 1,122 pancreatectomies) and was similar for pancreaticoduodenectomy (25 of 739 [3%]), distal (6 of 350 [2%]), and central pancreatectomy (2 of 31 [6%]) (p = 0.26). Early hemorrhage was seen in 21% (7 of 33) and was always extraluminal; these patients underwent reoperation and recovered fully. Late hemorrhage (26 of 33 [79%]) was predominantly intraluminal (18 of 26 [69%]), occurring at a median of 12 days postoperatively (4 to 23 days), and was treated endoscopically (13 of 26 [50%]), angiographically (10 of 26 [38%]), or surgically (3 of 26 [10%]). Postpancreatectomy hemorrhage was associated with longer hospitalization (10 [range 8 to 17] days vs 7 [range 6 to 9] days; p < 0.01); mortality, however, was not increased (1 of 33 [3%] vs 17 of 1,089 [2%]; p = 0.95). Hemorrhage began after discharge in 39% of patients (13 of 33), with the only death occurring in a patient from this group. CONCLUSIONS Postpancreatectomy hemorrhage can be managed successfully with low mortality (3%). Early hemorrhage requires urgent reoperation, and management of delayed hemorrhage should be guided by location (intra- vs extraluminal). Greater pressure to reduce length of hospital stay appears to have increased the likelihood of PPH occurring after discharge; patients and physicians should be aware of this possibility.
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Affiliation(s)
- Camilo Correa-Gallego
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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Post-pancreaticoduodenectomy hemorrhage. Incidence, diagnosis, and treatment. World J Surg 2012; 35:2543-8. [PMID: 21882027 DOI: 10.1007/s00268-011-1222-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Although mortality post-pancreaticoduodenectomy (PD) has decreased, morbidity rates continue to be high, ranging from 30% to 50%. Among complications, hemorrhage stands out; it is associated with high mortality and there is no standard management. The aim of the present study was to analyze the incidence, diagnosis, and treatment of hemorrhage post-cephalic PD at our center. METHODS From January 2005 to December 2008, 107 PDs were performed. A retrospective review of characteristics of patients with postoperative hemorrhage was made from our prospective database. Demographic data, diagnosis, treatment (medical, laparotomy, interventional radiology), association with fistula (pancreatic or biliary), intra- or extraluminal hemorrhage, bleeding time (early or late), severity (moderate/severe), and mortality were analyzed. RESULTS Eighteen patients (18/107; 16.82%) hemorrhaged after PD. Hemorrhage appeared early (< 24 h) in 4 of these 18 patients (22.2%), and it was severe in 13/18 (72%). Hemorrhage-related mortality was 11% (2/18) and hospital mortality was 22.2% (4/18). Arteriography was performed in 8/18 patients (44.4%) and was effective in 6/8 (75%); laparotomy was performed in 8/18 (44.4%). Re-bleeding occurred in 5 of these 18 patients after the first treatment (27.8%). An association between hemorrhage and fistula was observed. CONCLUSIONS Hemorrhage after pancreatic resection must be considered a complication with relatively high mortality. Diagnosis should be established and treatment applied rapidly. Pancreatic and/or biliary fistulae were significantly associated with a higher risk of postoperative hemorrhage. Interventional radiology is a good therapeutic option.
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Eckardt AJ, Klein F, Adler A, Veltzke-Schlieker W, Warnick P, Bahra M, Wiedenmann B, Neuhaus P, Neumann K, Glanemann M. Management and outcomes of haemorrhage after pancreatogastrostomy versus pancreatojejunostomy. Br J Surg 2011; 98:1599-607. [DOI: 10.1002/bjs.7623] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2011] [Indexed: 12/11/2022]
Abstract
Abstract
Background
Postpancreatectomy haemorrhage (PPH) is a major cause of morbidity and mortality after pancreaticoduodenectomy (PD). It remains unclear whether performance of a pancreatogastrostomy (PG) instead of a pancreatojejunostomy (PJ) improves outcomes owing to better endoscopic accessibility.
Methods
A large retrospective analysis was undertaken to compare outcomes of PPH, depending on whether a PG or PJ was performed. The primary outcome was the rate of successful endoscopy. A secondary outcome was the therapeutic success after adding surgery.
Results
Of 944 patients who had a PD, 8·4 per cent developed PPH. Endoscopy was the primary intervention in 21 (81 per cent) of 26 patients with a PG and 34 (64 per cent) of 53 with a PJ; it identified the bleeding site in 35 and 25 per cent respectively (P = 0·347). Successful endoscopic treatment was more common in the PG group (31 versus 9 per cent; P = 0·026). Surgery was performed for PPH in 15 patients (58 per cent) with a PG and 35 (66 per cent) with a PJ (P = 0·470). The majority of haemorrhages that required surgery were non-anastomotic intra-abdominal haemorrhages (12 of 15 versus 21 of 35; P = 0·171). Endoscopic or conservative treatment for PPH was successful in 42 per cent of patients with a PG and 32 per cent with a PJ (P = 0·520). The success rate increased to 85 and 91 per cent respectively when surgery was included in the algorithm (P = 0·467).
Conclusion
The type of pancreatic anastomosis and its inherent effect on endoscopic accessibility had very little impact on the outcome of PPH. This was because haemorrhage frequently occurred from intra-abdominal or non-anastomotic intraluminal lesions.
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Affiliation(s)
- A J Eckardt
- Department of Gastroenterology and Hepatology, Deutsche Klinik für Diagnostik, Wiesbaden, Germany
| | - F Klein
- Department of Gastroenterology and Hepatology, Central Interdisciplinary Endoscopy, Campus Virchow, Germany
| | - A Adler
- Department of General, Visceral and Transplantation Surgery, Charité, Campus Virchow, Germany
| | - W Veltzke-Schlieker
- Department of General, Visceral and Transplantation Surgery, Charité, Campus Virchow, Germany
| | - P Warnick
- Department of Gastroenterology and Hepatology, Deutsche Klinik für Diagnostik, Wiesbaden, Germany
| | - M Bahra
- Department of Gastroenterology and Hepatology, Deutsche Klinik für Diagnostik, Wiesbaden, Germany
| | - B Wiedenmann
- Department of General, Visceral and Transplantation Surgery, Charité, Campus Virchow, Germany
| | - P Neuhaus
- Department of Gastroenterology and Hepatology, Central Interdisciplinary Endoscopy, Campus Virchow, Germany
| | - K Neumann
- Department of Biomathematics, Statistics, Charité, Campus Mitte, Berlin, Germany
| | - M Glanemann
- Department of Gastroenterology and Hepatology, Central Interdisciplinary Endoscopy, Campus Virchow, Germany
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Welsch T, Eisele H, Zschäbitz S, Hinz U, Büchler MW, Wente MN. Critical appraisal of the International Study Group of Pancreatic Surgery (ISGPS) consensus definition of postoperative hemorrhage after pancreatoduodenectomy. Langenbecks Arch Surg 2011; 396:783-91. [PMID: 21611815 DOI: 10.1007/s00423-011-0811-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Accepted: 05/10/2011] [Indexed: 12/11/2022]
Abstract
PURPOSE Postpancreatectomy hemorrhage (PPH) is one of the most serious complications after pancreatoduodenectomy (PD). This study analyzed and validated the International Study Group of Pancreatic Surgery (ISGPS) definition of PPH and aimed to identify risk factors for early (<24 h) and late PPH. METHODS Patients who underwent PD for pancreatic head tumors between 2001 and 2008 were included and complications were prospectively recorded. Factors associated with PPH were assessed by uni- and multivariate analysis. RESULTS Complete datasets were available for 796 patients. Classic and pylorus-preserving PD was performed in 13.8% and 86.2% of the patients, respectively. According to the ISGPS definition, PPH occurred in 29.1% of the cases (232 of 796 patients): 4.8% grade A, 15.2% grade B, and 9.2% grade C. The definition is based largely on surrogate markers (e.g., transfusion requirement) that are affected by other critical illnesses and more than 97% of patients with mild PPH had no clinical signs of bleeding. The need for postoperative intensive care as well as the incidence of pancreatic fistula, relaparotomy, and mortality rates significantly increased from grades A to C. Thirty-seven patients (4.6%) required interventional (endoscopy or angiography) and/or relaparotomy for PPH. Relaparotomy for PPH was performed in 3.1% of all patients. Independent risk factors for early PPH were preoperative anemia (hemoglobin, <11 mg/dl) and multivisceral resection while advanced age, chronic renal insufficiency, increased blood loss, and long operation time were associated with late PPH. CONCLUSIONS The ISGPS definition of PPH is feasible and applicable but produces a high rate of false positive mild PPH cases. The different grades still significantly correlate with relevant outcome variables, thus the definition discriminates postoperative courses, but a minor modification of the definition of mild PPH is suggested. The new results further demonstrate the need to optimize preoperative anemia and chronic renal insufficiency.
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Affiliation(s)
- Thilo Welsch
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
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Impact of methicillin-resistant Staphylococcus Aureus (MRSA) infection on patient outcome after pancreatoduodenectomy (PD)--a cause for concern? Pancreas 2010; 39:1211-4. [PMID: 20944489 DOI: 10.1097/mpa.0b013e3181e00cad] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES This study evaluated the impact of methicillin-resistant Staphylococcus aureus (MRSA) hospital-acquired infection on postoperative complications and patient outcome after pancreatoduodenectomy (PD). METHODS Seventy-nine patients who underwent PD were monitored for hospital-acquired MRSA. The patients were grouped as (1) no MRSA infection, (2) skin colonization with MRSA, and (3) systemic MRSA infection. RESULTS Forty (51%) of the 79 patients were MRSA positive during hospital admission. Fourteen of the 40 patients swabbed for MRSA were found positive (skin colonization), and 26 patients (33%) developed systemic MRSA infection after PD. The sites of MRSA infection included (1) abdominal drain fluid (16/26; 42%), (2) sputum (4/26; 15%), (3) blood cultures (2/26; 8%), and (4) combination of sites (9/26; 35%). The patients with systemic MRSA infection had a longer postoperative stay (31 vs 22 days; P = 0.005) and increased incidence of chest infections compared with MRSA-negative patients (14 vs 4; P = 0.02). Four of the 16 patients with MRSA-positive drain fluid had a postpancreatectomy hemorrhage compared with 3 of the 63 patients with no MRSA infection in drain fluid (P = 0.02). CONCLUSION Of the 79 patients admitted for PD, 51% became colonized with MRSA infection. Systemic hospital-acquired MRSA infection in 33% was associated with prolonged postoperative stay, increased wound and chest infections, and increased risk of postoperative hemorrhage.
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Liver abscess after common hepatic artery embolization for delayed hemorrhage following pancreaticoduodenectomy: a case report. Case Rep Med 2010; 2010:280430. [PMID: 20589213 PMCID: PMC2892662 DOI: 10.1155/2010/280430] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Revised: 04/23/2010] [Accepted: 04/26/2010] [Indexed: 12/19/2022] Open
Abstract
A 55-year-old man underwent pancreaticoduodenectomy for bile duct carcinoma in March 2009. The patient developed anastomotic leakage and had a short episode of hemorrhage from the drainage tubes with spontaneous disappearance. CT and upper endoscopy did not reveal the source of bleeding. A massive life-threatening hemorrhage occurred on the 18th postsurgical day. Emergency angiography showed a 2.7-cm pseudoaneurysm of the gastroduodenal artery stump, and hepatic artery embolization was performed. After embolization, an abscess appeared in segments 2/3 of the liver without involving the right lobe. We treated conservatively by drainage and antibiotics. During the course of therapy after embolization, the patient experienced several episodes of high fever but did not develop hepatic failure. On the 68th day after embolization, the abscess had penetrated to the lesser sac, which was immediately treated by percutaneous drainage. Anastomotic leakage was treated by continuous irrigation from the drain, for which complete resolution was achieved by the 34th day after embolization. The patient was discharged 101 days after embolization. Imaging and the clinical course demonstrate a unique mechanism of abscess formation after embolization.
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Tani M, Kawai M, Hirono S, Ina S, Miyazawa M, Shimizu A, Yamaue H. A prospective randomized controlled trial of internal versus external drainage with pancreaticojejunostomy for pancreaticoduodenectomy. Am J Surg 2010; 199:759-64. [PMID: 20074698 DOI: 10.1016/j.amjsurg.2009.04.017] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Revised: 04/15/2009] [Accepted: 04/15/2009] [Indexed: 12/19/2022]
Abstract
BACKGROUND A stent often is placed across the pancreaticojejunostomy. However, there is no report compared between internal drainage and external drainage. METHODS We conducted a prospective randomized trial (NCT00628186 registered at http://ClinicalTrials.gov) with 100 patients who underwent pancreaticoduodenectomy and we compared the effects on postoperative course. RESULTS The incidence of pancreatic fistula according to the International Study Group on Pancreatic Fistula criteria was not different (external, 20%; vs internal, 26%), and the incidence of the other complications was similar between stent types. The median postoperative hospital stay was 21 days (range, 8-163 d) in the internal drainage group, which was shorter than the median stay of 24 days (range, 21-88 d) in the external drainage group (P = .016). CONCLUSIONS Both internal drainage and external drainage were safety devices for pancreaticojejunostomy. Internal drainage simplifies postoperative managements and it might shorten postoperative stay for pancreaticoduodenectomy.
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Affiliation(s)
- Masaji Tani
- Second Department of Surgery, Wakayama Medical University, School of Medicine, 811-1 Kimiidera, Wakayama 641-8510, Japan
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