Prevention, prediction, and mitigation of postoperative pancreatic fistula

The Value of Textbook Outcome in Benchmarking Pancreatoduodenectomy for Nonfunctioning Pancreatic Neuroendocrine Tumors

BACKGROUND

Textbook outcome (TO) is a composite variable that can define the quality of pancreatic surgery. The aim of this study is to evaluate TO after pancreatoduodenectomy (PD) for nonfunctioning pancreatic neuroendocrine tumors (NF-PanNETs).

PATIENTS AND METHODS

All patients who underwent PD for NF-PanNETs (2007-2016) in different centers were included in this retrospective study. TO was defined as the absence of severe postoperative complications and mortality, length of hospital stay ≤ 19 days, R0 resection, and at least 12 lymph nodes harvested.

RESULTS

Overall, 477 patients were included. The TO rate was 32%. Tumor size [odds ratio (OR) 1.696; p = 0.013], a minimally invasive approach (OR 12.896; p = 0.001), and surgical volume (OR 2.062; p = 0.023) were independent predictors of TO. The annual frequency of PDs increased over time as well as the overall rate of TO. At a median follow-up of 44 months, patients who achieved TO had similar disease-free (p = 0.487) and overall survival (p = 0.433) rates compared with patients who did not achieve TO. TO rate in patients with NF-PanNET > 2 cm was 35% versus 27% in patients with NF-PanNET ≤ 2 cm (p = 0.044). Considering only NF-PanNETs > 2 cm, patients with TO and those without TO had comparable 5-year overall survival rates (p = 0.766) CONCLUSIONS: TO is achieved in one-third of patients after PD for NF-PanNETs and is not associated with a benefit in terms of long-term survival.

Continuous drain irrigation as a risk mitigation strategy for postoperative pancreatic fistula: a meta-analysis

BACKGROUND

Postoperative pancreatic fistula serves as the principle cause for the morbidity and mortality observed after pancreatectomy. Continuous drain irrigation as a treatment strategy for infected pancreatic necrosis has previously been described; however, its role adter pancreatectomy has yet to be determined. The aim of this study was to determine whether continuous drain irrigation reduces postoperative pancreatic fistula.

METHODS

A meta-analysis of the pre-existing literature was performed. The primary end point was whether continuous drain irrigation reduced postoperative pancreatic fistula after pancreatectomy. The secondary end point evaluated its impact on postoperative morbidity, mortality, and length of stay.

RESULTS

Nine articles involving 782 patients were included. Continuous drain irrigation use was associated with a statistically significant reduction in postoperative pancreatic fistula rates (odds ratio [95% confidence interval] 0.40 [0.19-0.82], P = .01). Upon subgroup analysis, a significant reduction in clinically relevant postoperative pancreatic fistula was also noted (odds ratio 0.37 [0.20-0.66], P = .0008). A reduction in postoperative complications was also observed-delayed gastric emptying (0.45 [0.24-0.84], P = .01) and the need for re-operation (0.33 [0.11-0.96], P = .04). This reduction in postoperative complications translated into a reduced length of stay (mean difference -2.62 [-4.97 to -0.26], P = .03).

CONCLUSION

Continuous drain irrigation after pancreatectomy is a novel treatment strategy with a limited body of published evidence. After acknowledging the limitations of the data, initial analysis would suggest that it may serve as an effective risk mitigation strategy against postoperative pancreatic fistula. Further research in a prospective context utilizing patient risk stratification for fistula development is, however, required to define its role within clinical practice.

Sixteen cases of laparoscopic central pancreatectomy for benign or low-grade malignant tumours in the pancreatic neck and proximal body

BACKGROUND

The purpose of this study is to examine and analyse the outcomes and patient experiences associated with laparoscopic central pancreatectomy.

METHODS

The perioperative data of 16 patients who underwent laparoscopic central pancreatectomy were retrospectively analysed at Ningbo Medical Center Lihuili Hospital (Xingning Branch and Eastern Branch) from September 2017 to July 2023.

RESULTS

All surgical procedures were completed without the need for intraoperative conversion to open surgery. In two cases, intraoperative cholangiography was performed, while in four cases, intraoperative fluoroscopic laparoscopic assistance was utilized. The duration of the operations varied from 160 to 360 min, with an average of 281.75 min. The estimated volume of intraoperative bleeding ranged from 50 to 300 mL, with an average of 113.75 mL. The postoperative pathology results revealed that there were two cases of intraductal papillary mucinous neoplasm, six cases of serous cystic neoplasms, one case of mucinous cystic neoplasm, five cases of solid pseudopapillary neoplasms, and two cases of neuroendocrine tumours. The maximum diameter of the tumours ranged from 3.0 to 5.0 cm, with an average of 3.67 cm. There were no instances of postoperative common bile duct stenosis or biliary leakage. Among the cases, five did not exhibit pancreatic fistula, six experienced biochemical leakage, three had grade B pancreatic fistula, and two had grade C pancreatic fistula.

CONCLUSION

Laparoscopic central pancreatectomy, as a method to preserve pancreatic function, entails specific surgical risks and a notable likelihood of postoperative pancreatic fistula, necessitating the expertise of seasoned surgeons for its execution.

Dual-crosslinking immunostimulatory hydrogel synchronously suppresses pancreatic fistula and pancreatic cancer relapse post-resection

In pancreatic cancer (PC), surgical resection remains the sole curative option, albeit patients undergoing resection are susceptible to postoperative pancreatic fistula (PF) formation and tumor recurrence. An unmet need exists for a unified strategy capable of concomitantly averting PF and tumor relapse to mitigate morbidity in PC patients after surgery. Herein, an original dual crosslinked biological sealant hydrogel (methacrylate-hyaluronic acid-dopamine (MA-HA-DA) and sulfhydryl-hyaluronic acid-dopamine (SH-HA-DA)) was engineered as a drug depot and loaded with polydopamine-cloaked cytokine interleukin-15 and platelets conjugated with anti-TIGIT. In vitro analyses validated favorable tissue adhesion, cytocompatibility, and stability of the hydrogels. In a PF rodent model, the hydrogel effectively adhered to the pancreatic stump, sealing the severed pancreatic end and impeding post-operative elevations in amylase and lipase. In PC murine models, hydrogels potently stimulated CD8+ T and NK cells to deter residual tumor re-growth and distant metastasis. This innovative hydrogel strategy establishes a new framework for concomitant prevention of PF and PC recurrence.

Clinical usefulness of routinely performed drain fluid cultures after pancreaticoduodenectomy. A new ally to predict patients' outcomes?

BACKGROUND

Previous studies showed that bacterial contamination of surgical drains was associated with higher morbidity and mortality following pancreaticoduodenectomy (PD). However, there is still no agreement on the routine use of fluid drainage cultures in the management of patients underwent PD. Therefore, we aimed to clarify the role of surgical drain bacterial contamination in predicting patients' postoperative course.

METHOD

Single-centre study including patients underwent PD at Humanitas Research Hospital (2010-2021). Preoperative, intraoperative and postoperative data were collected. Routinely performed fluid drain cultures on postoperative day (POD) 5 were analyzed and compared among patients throughout the cohort.

RESULTS

A total of 825 patients were analyzed. Bacterial contamination of surgical drains was observed in 420 (50.9 %) patients and it was found to be associated with a higher rate of B/C grade pancreatic fistula (POPF) (P < 0.001), Clavien-Dindo≥3 (P < 0.001), 30-day mortality (P = 0.011), wound infection (P < 0.001), relaparotomies (P = 0.003) and greater length of hospital stay (LOS) (P < 0.001). Also, E. coli surgical drain contamination was demonstrated to double the risk of B/C grade POPF development (OR = 1.628, 95 % IC = 1.009-2.625, P = 0.046). Finally, preoperative biliary drainage (OR = 2.474, 95 % IC = 1.855-3.298, P < 0.001), age ≥75 years old (OR = 1.492, 95 % IC = 1.077-2.067, P = 0.016) and isolated Roux-en-Y pancreaticojejunostomy (OR = 1.639, 95 % IC = 1.229-2.188, P < 0.001) were identified as risk factors for surgical drains bacterial contamination.

CONCLUSION

Bacterial contamination of surgical drains predicts the development of B/C grade POPF and other major complications after PD. Therefore, we suggest the routine use of fluid drain cultures following PD.

Pancreatojejunostomy: standing on the shoulders of giants. A single centre retrospective analysis

Gaining experience in pancreatic surgery could be demanding especially when minimally invasive approach is used. Pancreatojejunostomy (PJ) is one of the most critical steps during pancreatoduodenectomy (PD). Our aim was to investigate the impact of a surgeon's experience in performing PJ, especially in a subgroup of patients undergoing laparoscopic PD (LPD). Data of consecutive patients undergoing PD from 2017 to 2022 were prospectively collected and retrospectively analyzed. Patients were divided into two groups: M group included patients in which PJ was performed by an experienced surgeon, D group included those receiving PJ by a less experienced one. The groups were compared in terms of postoperative outcomes. 187 patients were selected (157 in group M and 30 in group D). The cohorts differed in terms of median age (68 vs 74 years, p = 0.016), and previous abdominal surgery (41.4% vs 66.7%, p = 0.011), while no difference was found regarding risk of postoperative pancreatic fistula (POPF). The groups did not differ in terms of surgical outcomes. POPF rate was 15.9% and 10% in the M and D group (p = 0.578), respectively. Among patients undergoing laparoscopic PJ POPF rate was 16.0% and 17.7% in the M and D group (p = 0.867), respectively, without difference. No difference was found in terms of POPF in patients undergoing PD independently from the surgeon who performed the PJ, even during LPD. Moderate/high FRS, BMI > 30 kg/m2 and male sex, but not the surgeon who performed the PJ anastomosis, were independent predictors of POPF.

Risk Models for Developing Pancreatic Fistula After Pancreatoduodenectomy: Validation in a Nationwide Prospective Cohort

OBJECTIVE

To evaluate the performance of published fistula risk models by external validation, and to identify independent risk factors for postoperative pancreatic fistula (POPF).

BACKGROUND

Multiple risk models have been developed to predict POPF after pancreatoduodenectomy. External validation in high-quality prospective cohorts is, however, lacking or only performed for individual models.

METHODS

A post hoc analysis of data from the stepped-wedge cluster cluster-randomized Care After Pancreatic Resection According to an Algorithm for Early Detection and Minimally Invasive Management of Pancreatic Fistula versus Current Practice (PORSCH) trial was performed. Included were all patients undergoing pancreatoduodenectomy in the Netherlands (January 2018-November 2019). Risk models on POPF were identified by a systematic literature search. Model performance was evaluated by calculating the area under the receiver operating curves (AUC) and calibration plots. Multivariable logistic regression was performed to identify independent risk factors associated with clinically relevant POPF.

RESULTS

Overall, 1358 patients undergoing pancreatoduodenectomy were included, of whom 341 patients (25%) developed clinically relevant POPF. Fourteen risk models for POPF were evaluated, with AUCs ranging from 0.62 to 0.70. The updated alternative fistula risk score had an AUC of 0.70 (95% confidence intervals [CI]: 0.69-0.72). The alternative fistula risk score demonstrated an AUC of 0.70 (95% CI: 0.689-0.71), whilst an AUC of 0.70 (95% CI: 0.699-0.71) was also found for the model by Petrova and colleagues. Soft pancreatic texture, pathology other than pancreatic ductal adenocarcinoma or chronic pancreatitis, small pancreatic duct diameter, higher body mass index, minimally invasive resection and male sex were identified as independent predictors of POPF.

CONCLUSION

Published risk models predicting clinically relevant POPF after pancreatoduodenectomy have a moderate predictive accuracy. Their clinical applicability to identify high-risk patients and guide treatment strategies is therefore questionable.

No role for protease inhibitors as a mitigation strategy for postpancreatectomy acute pancreatitis (PPAP): Propensity score matching analysis

BACKGROUND

While the use of protease inhibitor gabexate mesylate (GM) is still controversial in acute pancreatitis, it has never been tested for postpancreatectomy acute pancreatitis (PPAP). This study aims to assess the impact of GM on postoperative serum hyperamylasaemia (POH) or PPAP after pancreatoduodenectomy (PD).

METHODS

Consecutive patients developing POH after PD between 2016 and 2021 were included. According to GM administration, patients were divided into GM-treated and control (CTR) groups. GM was administered from postoperative day 1-3 in POH patients who underwent surgery before 2017. A 2:1 propensity matching was used to minimize the risk of bias.

RESULTS

Overall, 264 patients with POH were stratified in the GM (59 patients) and CTR (104 patients) cohorts, which showed balanced baseline characteristics after matching. No difference in postoperative complications was observed between the groups (all p > 0.05), except for PPAP occurrence, which was significantly higher in the GM group (37% vs. 22%, p = 0.037). A total of 45 patients (28%) evolved to PPAP. Comparing PPAP patients in the GM and CTR groups, no significant differences in POPF, relaparotomy, and mortality (all p > 0.09) were found. No difference in intravenous crystalloid administration was found in patients with PPAP, whether or not they developed major complications or pancreatic fistula (p > 0.05) CONCLUSION: Protease inhibitor seems ineffective in preventing a PPAP after PD once a POH has occurred. Further studies are needed to achieve benchmarks for treating PPAP and identify mitigation strategies to prevent the evolution of POH into additional morbidity.

Preoperative Fistula Risk Prediction Using Computed Tomography Image Before Pancreatoduodenectomy

BACKGROUND

Although many formulas for predicting postoperative pancreatic fistula (POPF) have been introduced, POPF is generally predicted during pancreatic surgery due to pancreatic texture. This study was designed to verify the correlation between Hounsfield units (HU) and pancreatic texture and to suggest a fistula risk score (FRS) that can be used before surgery.

METHODS

Data from 545 patients who underwent pancreatoduodenectomy for malignant disease between January 2008 and December 2019 were retrospectively reviewed. The HU level of the pancreas was measured, and odds ratio (OR) of the HU for POPF was analyzed. Additionally, the assessed HU was compared with the pancreatic texture (soft vs. hard) and calculated cutoff level. Finally, the preoperatively chosen pancreatic texture according to HU level was applied to the FRS formula (preoperative-FRS: p-FRS), and the results were compared with a previously reported FRS formula (updated alternative-FRS: ua-FRS).

RESULTS

The Hounsfield unit levels were correlated with clinically relevant POPF (CR-POPF) (odds ratio [OR]: 1.04 (1.01-1.07), p = 0.015). In the receiver operating characteristic curve, the HU showed significant prediction potential for pancreatic texture (area under the curve [AUC]: 0.744, p < 0.001). The p-FRS also showed acceptable results in predicting CR-POPF (AUC = 0.702, p < 0.001). There was no statistically significant difference in the DeLong's test compared with the ua-FRS (p = 0.314). In the Hosmer-Lemeshow test, observed probabilities were correlated with predicted probabilities (p = 0.596).

CONCLUSIONS

The HU level on preoperative computed tomography (CT) is a predictive factor for POPF and could represent for pancreatic texture.

Safety and feasibility of modified duct-to-mucosa pancreaticojejunostomy during pancreatoduodenectomy: A retrospective cohort study

BACKGROUND

Pancreatoduodenectomy (PD) is the most effective surgical procedure to remove a pancreatic tumor, but the prevalent postoperative complications, including postoperative pancreatic fistula (POPF), can be life-threatening. Thus far, there is no consensus about the prevention of POPF.

AIM

To determine possible prognostic factors and investigate the clinical effects of modified duct-to-mucosa pancreaticojejunostomy (PJ) on POPF development.

METHODS

We retrospectively collected and analyzed the data of 215 patients who underwent PD between January 2017 and February 2022 in our surgery center. The risk factors for POPF were analyzed by univariate analysis and multivariate logistic regression analysis. Then, we stratified patients by anastomotic technique (end-to-side invagination PJ vs modified duct-to-mucosa PJ) to conduct a comparative study.

RESULTS

A total of 108 patients received traditional end-to-side invagination PJ, and 107 received modified duct-to-mucosa PJ. Overall, 58.6% of patients had various complications, and 0.9% of patients died after PD. Univariate and multivariate logistic regression analyses showed that anastomotic approaches, main pancreatic duct (MPD) diameter and pancreatic texture were significantly associated with the incidence of POPF. Additionally, the POPF incidence and operation time in patients receiving modified duct-to-mucosa PJ were 11.2% and 283.4 min, respectively, which were significantly lower than those in patients receiving traditional end-to-side invagination PJ (27.8% and 333.2 minutes).

CONCLUSION

Anastomotic approach, MPD diameter and pancreatic texture are major risk factors for POPF development. Compared with traditional end-to-side invagination PJ, modified duct-to-mucosa PJ is a simpler and more efficient technique that results in a lower incidence of POPF. Further studies are needed to validate our findings and explore the clinical applicability of our technique for laparoscopic and robotic PD.

Pancreaticogastrostomy versus Pancreaticojejunostomy and the Proposal of a New Postoperative Pancreatic Fistula Risk Score

Despite the substantial decrease in mortality rates following a pancreaticoduodenectomy to less than 5%, morbidity rates remain significant, reaching even 73%. Postoperative pancreatic fistula is one of the most frequent major complications and is significantly associated with other complications, including patient death. Currently, there is no consensus regarding the ideal type of pancreatic anastomosis, as the question of the choice between a pancreaticogastrostomy and pancreaticojejunostomy is still open. Furthermore, worldwide implementation of an ideal pancreatic fistula risk prediction score is missing. Our study found several significant predictive factors for the postoperative occurrence of fistulas, such as the soft consistency of the pancreas, non-dilated Wirsung duct, important intraoperative blood loss, other perioperative complications, preoperative patient hypoalbuminemia, and patient weight loss. Our study also revealed that for patients who exhibit fistula risk factors, pancreaticogastrostomy demonstrates a significantly lower pancreatic fistula rate than pancreaticojejunostomy. The occurrence of pancreatic fistulas has been significantly associated with the development of other postoperative major complications, and patient death. As the current pancreatic fistula risk scores proposed by various authors have not been consensually validated, we propose a simple, easy-to-use, and sensitive score for the risk prediction of postoperative pancreatic fistula occurrence based on important predictors from statistical analyses that have also been found to be significant by most of the reported studies. The new pancreatic fistula risk score proposed by us could be extremely useful for improved therapeutic management of cephalic pancreaticoduodenectomy patients.

Hepatic Artery Anomalies in Pancreaticoduodenectomy: Outcomes from a High-Volume Center

INTRODUCTION

Hepatic artery anomalies (HAA) may have an impact on surgical and oncological outcomes of patients undergoing pancreaticoduodenectomy (PD).

METHODS

Patients who underwent PD at our institution between July 2015 and January 2020 were retrospectively reviewed and classified into two groups: group 1, with presence of HAA, and group 2, with no HAA. A weighted logistic regression model was employed to assess the association between HAA and postoperative complications, and to assess the association between HAA and R status in patients with pancreatic cancer.

RESULTS

502 patients were considered for analysis, with 75 (15%) of them in group 1. They had either an accessory (n = 28, 40.8%) or replaced (n = 26, 36.6%) right hepatic artery. Most patients underwent surgery for a malignancy (n = 451; 90%); among them, vascular resection was performed in 69 cases (15%). The presence of a HAA was reported at preoperative imaging only in 4 cases (5%) and the aberrant vessel was preserved in 72% of patients. At weighted multivariable logistic regression analysis, HAA were not associated to higher odds of morbidity (odds ratio [OR]: 0.753, 95% confidence interval [CI]: 0.543-1.043) nor to R1 status in case of pancreatic cancer (OR: 1.583, 95% CI: 0.979-2.561).

CONCLUSION

At our institution, the presence of HAA does not have an impact on postoperative outcomes or affects oncological clearance after PD. Hospitals', surgeons', volume and systematic review of preoperative imaging are all factors that help reduce possible adverse events.

Machine learning versus logistic regression for the prediction of complications after pancreatoduodenectomy

BACKGROUND

Machine learning is increasingly advocated to develop prediction models for postoperative complications. It is, however, unclear if machine learning is superior to logistic regression when using structured clinical data. Postoperative pancreatic fistula and delayed gastric emptying are the two most common complications with the biggest impact on patient condition and length of hospital stay after pancreatoduodenectomy. This study aimed to compare the performance of machine learning and logistic regression in predicting pancreatic fistula and delayed gastric emptying after pancreatoduodenectomy.

METHODS

This retrospective observational study used nationwide data from 16 centers in the Dutch Pancreatic Cancer Audit between January 2014 and January 2021. The area under the curve of a machine learning and logistic regression model for clinically relevant postoperative pancreatic fistula and delayed gastric emptying were compared.

RESULTS

Overall, 799 (16.3%) patients developed a postoperative pancreatic fistula, and 943 developed (19.2%) delayed gastric emptying. For postoperative pancreatic fistula, the area under the curve of the machine learning model was 0.74, and the area under the curve of the logistic regression model was 0.73. For delayed gastric emptying, the area under the curve of the machine learning model and logistic regression was 0.59.

CONCLUSION

Machine learning did not outperform logistic regression modeling in predicting postoperative complications after pancreatoduodenectomy.

Postoperative pancreatitis and pancreatic fistulae: a review of current evidence

OBJECTIVES

Postoperative pancreatic fistula (POPF) represents one of the most severe complications following pancreatic surgery. Despite being a leading cause of morbidity and mortality, its pathophysiology is poorly understood. In recent years, there has been growing evidence to support the role of postoperative or post-pancreatectomy acute pancreatitis (PPAP) in the development of POPF. This article reviews the contemporary literature on POPF pathophysiology, risk factors, and prevention strategies.

METHODS

A literature search was conducted using electronic databases, including Ovid Medline, EMBASE, and Cochrane Library, to retrieve relevant literature published between 2005 and 2023. A narrative review was planned from the outset.

RESULTS

A total of 104 studies fulfilled criteria for inclusion. Forty-three studies reported on technical factors predisposing to POPF, including resection and reconstruction technique and adjuncts for anastomotic reinforcement. Thirty-four studies reported on POPF pathophysiology. There is compelling evidence to suggest that PPAP plays a critical role in the development of POPF. The acinar component of the remnant pancreas should be regarded as an intrinsic risk factor; meanwhile, operative stress, remnant hypoperfusion, and inflammation represent common mechanisms for acinar cell injury.

CONCLUSIONS

The evidence base for PPAP and POPF is evolving. Future POPF prevention strategies should look beyond anastomotic reinforcement and target underlying mechanisms of PPAP development.

Effects of intraoperative fluid balance during pancreatoduodenectomy on postoperative pancreatic fistula: an observational cohort study

BACKGROUND

Perioperative fluid management during major abdominal surgery has been controversial. Postoperative pancreatic fistula (POPF) is a critical complication of pancreaticoduodenectomy (PD). We conducted a retrospective cohort study to analyze the impact of intraoperative fluid balance on the development of POPF.

METHODS

This retrospective cohort study enrolled 567 patients who underwent open pancreaticoduodenectomy, and the demographic, laboratory, and medical data were recorded. All patients were categorized into four groups according to quartiles of intraoperative fluid balance. Multivariate logistic regression and restricted cubic splines (RCSs) were used to analyze the relationship between intraoperative fluid balance and POPF.

RESULTS

The intraoperative fluid balance of all patients ranged from -8.47 to 13.56 mL/kg/h. A total of 108 patients reported POPF, and the incidence was 19.0%. After adjusting for potential confounders and using restricted cubic splines, the dose‒response relationship between intraoperative fluid balance and POPF was found to be statistically insignificant. The incidences of bile leakage, postpancreatectomy hemorrhage, and delayed gastric emptying were 4.4%, 20.8%, and 14.8%, respectively. Intraoperative fluid balance was not associated with these abdominal complications. BMI ≥ 25 kg/m², preoperative blood glucose < 6 mmol/L, long surgery time, and lesions not located in the pancreas were independent risk factors for POPF.

CONCLUSION

The study did not find a significant association between intraoperative fluid balance and POPF. Well-designed multicenter studies are necessary to explore the association between intraoperative fluid balance and POPF.

PREDICTION OF EXTERNAL PANCREATIC FISTULA DEVELOPMENT IN PATIENTS WITH ACUTE INFECTED NECROTISING PANCREATITIS

OBJECTIVE

The aim: To search for risk factors for the development of external pancreatic fistula (EPF) in patients with acute infected necrotizing pancreatitis.

PATIENTS AND METHODS

Materials and methods: A prospective single-center observational study was conducted with the participation of 160 adult patients with infected acute necrotizing pancreatitis (ANP) who required intervention at different stages of the disease. Depending on the amylase activity of the drainage secretions, the groups with and without diagnosed EPF were compared according to 15 demographic, clinical, laboratory and instrumental parameters of the disease. To identify predictors of the risk of developing EPF in ANP, a regression logistic analysis was performed and logistic regression models were built for each factor attribute.

RESULTS

Results: We did not find statistically significant differences in the indicators characterising patients on the first day of illness, as well as in the comparison of indicators characterising local complications of AP, the timing of AP infection, the incidence of sepsis and the level of PON in sepsis. When comparing the groups by the frequency of the type of microbial agent of infected APB, no statistically significant differences were found. Comparative pairwise analysis between the groups by morphological characteristics revealed statistical differences in the frequency of focal superficial and transmural PN (p < 0.001). Next, we performed a regression logistic analysis and built logistic regression models for each factor attribute, namely age, gender, BMI, BISAP score and Charlson comorbidity index, morphological characteristics of necrotizing pancreatitis. After univariate regression analysis, a statistically significant association between the depth of PN and the risk of developing PFN was found (OR 2.7 (1.4-5.2), p=0.001).

CONCLUSION

Conclusions: We found that the risk of developing an external pancreatic fistula was associated with the depth of pancreatic necrosis.

Prognostic Value of Neoadjuvant Chemotherapy in Patients with Borderline Resectable Pancreatic Carcinoma Followed by Pancreatectomy with Portal Vein Resection and Reconstruction with Venous Allograft

BACKGROUND

Neo-adjuvant chemotherapy (NAC) represents one of the current research hotspots in the field of pancreatic ductal adenocarcinoma (PDAC). The aim of this study is to evaluate the prognostic value of NAC in patients with borderline resectable pancreatic cancer (BRPC) followed by pancreatectomy with portal vein (PV) resection and reconstruction with venous allograft (VAG).

METHODS

Medical records of patients with BPRC who underwent pancreatectomy with concomitant PV resection and reconstruction with VAG between April 2013 and March 2021 were analyzed retrospectively. Outcomes of patients with and without NAC (NAC, Group 1 vs. non-NAC, Group 2) were compared with focus on R0 resection rates, morbidity, and survival.

RESULTS

Of the 77 patients with pancreatectomy, PV resection and reconstruction with VAG were identified. Overall survival (OS) rates of 0.5-, 1-, and 2-year were 80.5%, 59.7%, and 31.2%, respectively (median survival time, MST, 14 months). Of these, 24 patients (Group 1) underwent operation following received NAC, and the remaining 53 patients did not (Group 2). The R0 resection rate of vascular margin was 100% vs. 84.9% (p = 0.04), respectively. Morbidity of post-operative pancreatic fistula (POPF) was 0% vs. 17.8% (p = 0.07), respectively. The OS of 0.5-, 1- and 2-year and MST of 2 groups were 83.3%, 66.7%, 41.7%, 16 months, and 79.2%, 55.6%, 26.4%, 13 months, respectively. Multivariate analysis revealed that carbohydrate antigen 19-9 (CA19-9) serum level and postoperative chemotherapy were independent prognostic factors in patients with BRPC after surgery.

CONCLUSION

NAC might improve the R0 resection rate and POPF in patients with BRPC who underwent pancreatectomy with concomitant PV resection and reconstruction with VAG. Survival benefit exists in patients with BRPC who received NAC before pancreatectomy. Postoperative chemotherapy also had a favorable effect on OS of BRPC patients. Elevated CA 19-9 serum level is associated with poor prognosis, even after NAC-combining operation.

Pure biliary leak vs. pancreatic fistula associated: non-identical twins following pancreatoduodenectomy

BACKGROUND

Biliary leak (BL) after pancreatoduodenectomy (PD) may have diffrent severity depending on its association with postoperative pancreatic fistula (POPF).

METHODS

Data of 2715 patients undergoing PD between 2011 and 2020 at two European third-level referral Centers for pancreatic surgery were retrospectively reviewed. These included BL incidences, grading, outcomes, specific treatments, and association with POPF.

RESULTS

BL occurred in 6% of patients undergoing PD. Among 143 BL patients, 47% had an associated POPF and 53% a pure BL. Major morbidity (64% vs 36%) and mortality (19% vs 4%) were higher in POPF-associated BL group (all P< 0.01). Day of BL onset was similar between groups (POD 2 vs 3; P = 0.2), while BL closure occurred earlier in pure BL (POD 12 vs 23; P < 0.01). Conservative treatment was more frequent (55% vs 15%; P < 0.01), and the rate of percutaneous and/or trans-hepatic drain placement was lower (30% vs 16%; P = 0.04) in pure BL group. Relaparotomy was more common in POPF-associated BL group (42% VS 17%; P < 0.01) but was performed earlier in pure BL (POD 2 vs 10; P = 0.02).

CONCLUSIONS

Pure BL represents a more benign entity, managed conservatively in half of the cases.

Is routine CT scan after pancreaticoduodenectomy a useful tool in the early detection of complications? A single center retrospective analysis

PURPOSE

The clinical impact of routine CT imaging after pancreaticoduodenectomy (PD) has not been properly investigated. The aim of this study was to investigate the role of routine CT scan after PD for the detection of postoperative complications.

METHODS

Prospectively collected data of consecutive patients undergoing PD and receiving routine postoperative CT imaging were retrospectively analyzed. The primary endpoint was accuracy of CT imaging in identifying major complications. The secondary endpoint was identification of preoperative and intraoperative factors associated with severe complications. A subgroup analysis of CT scan accuracy in identifying severe complications in patients stratified by fistula risk score (FRS) and presence of early clinical alterations was also performed.

RESULTS

A total of 145 patients were included. Routine CT scan had low specificity (Sp = 0.36) and high sensitivity (Sn = 0.98) for predicting major complications, with an accuracy of 0.57. At multivariate logistic regression analysis, only fistula moderate-high FRS (p = 0.029) was independently associated with severe complications. In patients with negligible-low FRS, CT scan showed a Sp of 0.63 and a Sn of 1.0 with an accuracy of 0.69. In patients with moderate-high FRS, CT scan had a Sp of 0.19, a Sn of 0.97 and an accuracy of 0.5. In the 20 (14%) patients with negligible-low FRS and no clinical alterations, no deaths or readmissions occurred regardless of CT findings, while one severe complication occurred in the positive CT scan group. In all other groups, no deaths or readmissions occurred in case of negative CT, with only one severe complication in the moderate-high FRS group with clinical alterations. In case of positive CT, the rate of severe complications was 47% in case of negligible-low FRS and clinical alterations, 40% in case of moderate-high FRS with no clinical alterations, and 45% in case of moderate-high FRS and clinical alterations.

CONCLUSIONS

Routine postoperative CT scan after PD should not be performed in patients with negligible-low FRS and no clinical alterations. In all other patients, a negative CT scan appears to be highly accurate in identifying patients who will have an uneventful course and who could benefit from early discharge.

Early biochemical predictors of clinically relevant pancreatic fistula after distal pancreatectomy: a role for serum amylase and C-reactive protein

BACKGROUND

Recent evidence suggests that pancreatic inflammation plays a pivotal role in the occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy but few data are available for distal pancreatectomy (DP). The aim of this study was to evaluate the impact of early biochemical markers on the occurrence of CR-POPF after DP.

METHODS

Clinical and laboratory data for 432 consecutive DP patients were reviewed. Serum amylase was evaluated on postoperative day (POD) 1, and drain fluid amylase (DFA) and C-reactive protein (CRP) were evaluated on POD 2 and 3. Receiver operator characteristic (ROC) curves were performed for all biochemical markers and an area under the curve (AUC) was computed. Multivariable regression analyses to identify the factors associated with CR-POPF and severe postoperative morbidity (Clavien-Dindo grade ≥ 3) were performed.

RESULTS

At 90 days after surgery, CR-POPF occurred in 155 (36%) patients, severe complications in 66 (15%) patients. ROC curve analyses showed that DFA on POD2 had the largest AUC (0.753, p < 0.001), followed by serum amylase on POD 1 (0.651, p < 0.001), serum CRP on POD3 (0.644, p < 0.001), and CRP change between POD 2 and POD 3 (0.644, p < 0.001). Multivariable analysis identified male gender (OR 2.29, 95% CI 1.36-3.86; p = 0.002), DFA ≥ 1500 U/L on POD2 (OR 4.63, 95% CI 2.72-7.89; p < 0.001), serum amylase ≥ 100 U/L on POD 1 (OR 1.72, 95% CI 1.01-2.93; p = 0.046), and CRP increase by at least 25 mg/L on POD 3 compared to the previous day (OR 1.89, 95% CI 1.11-3.21; p = 0.019) as independent predictors of CR-POPF, yielding a valid regression model (AUC 0.765, 95% CI 0.714-0.816, p < 0.001).

CONCLUSIONS

Postoperative serum amylase and CRP trajectory represent useful early biochemical markers for CR-POPF in addition to DFA. Our findings suggest that these laboratory tests should be incorporated into clinical practice to aid postoperative patient and drain management.

[Surgery for periampullary pancreatic cancer]

Periampulläre Neoplasien sind eine heterogene Gruppe verschiedener Tumorentitäten der periampullären Region, von denen das Pankreasadenokarzinom mit 60–70 % am häufigsten ist. Wie typisch für Pankreaskarzinome zeichnen sich periampulläre Pankreaskarzinome durch ein aggressives Wachstum und eine frühe systemische Progression aus. Aufgrund ihrer besonderen Lage in unmittelbarer Nähe zur Papilla Vateri treten Symptome in eher früherem Tumorstadium auf, sodass die Therapiemöglichkeiten und Prognose insgesamt günstiger sind als bei Pankreaskarzinomen anderer Lokalisation. Trotzdem unterscheiden sich die Therapieprinzipien bei periampullären Pankreaskarzinomen nicht wesentlich von den Standards bei Pankreaskarzinomen anderer Lokalisation. Ein potenziell kurativer Therapieansatz beim nichtmetastasierten periampullären Pankreaskarzinom ist multimodal und besteht aus der Durchführung einer partiellen Duodenopankreatektomie als radikale onkologische Resektion in Kombination mit einer systemischen, meist adjuvant verabreichten Chemotherapie. Bei Patienten mit günstigen prognostischen Faktoren kann hierdurch ein Langzeitüberleben erzielt werden. Zudem wurden mit der Weiterentwicklung der Chirurgie und Systemtherapie auch potenziell kurative Therapiekonzepte für fortgeschrittene, früher irresektable Tumoren etabliert, welche nun nach Durchführung einer neoadjuvanten Therapie oft einer Resektion zugeführt werden können. In diesem Beitrag werden die aktuellen chirurgischen Prinzipien der radikalen onkologischen Resektion periampullärer Pankreaskarzinome im Kontext der multimodalen Therapie dargestellt und ein Ausblick auf mögliche künftige Entwicklungen der Therapie gegeben.