1
|
Petrova E, Mazzella E, Wellner U, Keck T, Bausch D, Bechstein W, Schnitzbauer A. Monopolar electrocautery versus scalpel for pancreatic neck transection during open pancreatoduodenectomy: A retrospective, registry-based study. Surgery 2024:S0039-6060(24)00188-0. [PMID: 38789356 DOI: 10.1016/j.surg.2024.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/27/2024] [Accepted: 03/17/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND The method of transecting the pancreatic parenchyma during pancreatic resection may influence the rate of complications, including pancreatic fistula and bleeding. The objective of this study is to compare the transection of the pancreatic parenchyma during pancreatoduodenectomy with monopolar electrocautery versus scalpel in terms of postoperative complications. METHODS A retrospective analysis of patients with open pancreatoduodenectomy from the German DGAV StuDoQ|Pancreas registry (January 2013 to December 2021) was performed. Transection of the pancreatic parenchyma with a scalpel versus monopolar electrocautery was compared regarding postoperative pancreatic fistula B/C, post-pancreatectomy hemorrhage B/C, and major complications (Clavien-Dindo classification ≥3) rates. Multivariable analysis with adjustment for potential confounders and surgical center cluster effect was performed. RESULTS Overall, 6,752 patients were included in the study. In 4,072 (60.3%), transection was performed with a scalpel and, in 2,680 (39.7%), with electrocautery. Transection with electrocautery was associated with higher postoperative pancreatic fistula B/C (15.4% vs 12.8%; P = .003), post-pancreatectomy hemorrhage B/C (11% vs 7.4%; P < .001), and major complications (33.4% vs 29.6%; P = .001) rates. In the multivariable analysis, after adjustment for potential confounders and surgical center, the association of the transection method with postoperative pancreatic fistula B/C (odds ratio = 1.01; 95% CI, 0.79-1.2; P = .962), post-pancreatectomy hemorrhage B/C (odds ratio = 1.23; 95% CI, 0.94-1.6; P = .127), and major complications (odds ratio = 1.09; 95% CI, 0.93-1.27; P = .297) was not significant. CONCLUSION The study found no significant association between transection of the pancreatic parenchyma during open pancreatoduodenectomy with a scalpel compared with monopolar electrocautery regarding pancreatic fistula, postoperative bleeding, or overall major complication rates.
Collapse
Affiliation(s)
- Ekaterina Petrova
- Department of General, Visceral, Transplant, and Thoracic Surgery, Frankfurt University Hospital, Goethe University Frankfurt, Germany.
| | - Elena Mazzella
- Department of General, Visceral, Transplant, and Thoracic Surgery, Frankfurt University Hospital, Goethe University Frankfurt, Germany
| | - Ulrich Wellner
- Department of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Tobias Keck
- Department of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Dirk Bausch
- Department of Surgery, Marien Hospital Herne, University Hospital of Ruhr University Bochum, Herne, Germany
| | - Wolf Bechstein
- Department of General, Visceral, Transplant, and Thoracic Surgery, Frankfurt University Hospital, Goethe University Frankfurt, Germany
| | - Andreas Schnitzbauer
- Department of General, Visceral, Transplant, and Thoracic Surgery, Frankfurt University Hospital, Goethe University Frankfurt, Germany
| |
Collapse
|
2
|
Liu GH, Tan XY, Li JX, Zhong GH, Zhai JW, Li MY. A modified Blumgart anastomosis with a simple and practicable procedure after laparoscopic pancreaticoduodenectomy: our center's experience. BMC Surg 2023; 23:349. [PMID: 37974183 PMCID: PMC10655365 DOI: 10.1186/s12893-023-02221-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 10/06/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Laparoscopic pancreaticoduodenectomy(LPD) has become the goal of lots of minimally invasive surgical centers in recent years. Postoperative pancreatic fistula(POPF) is still the barrier to attaining the above goal. Thus, improving anastomosis techniques to reduce the rate of POPF has been a hotspot of surgery. Blumgart pancreaticojejunostomy is considered one of the best anastomosis procedures, with low rates of POPF. However, the original Blumgart pancreaticojejunostomy method is not easy for laparoscopic operation. In consequence, we modified a Blumgart pancreaticojejunostomy technique with a simple and practicable procedure and applied to LPD. METHODS We collected and retrospectively analyzed the perioperative clinical data of patients who underwent modified Blumgart anastomosis from February 2017 to September 2022. The above patients included 53 cases in open pancreaticojejunostomy(OPD) and 58 cases in LPD. After propensity score matching, 44 cases were included for comparison in each group. RESULTS After propensity score matching, the average time for pancreaticojejunostomy was about 30 min in the LPD group. The Clinically relevant POPF(CR-POPF) rate was 9.1%. The length of postoperative hospitalization was 13.1 days. Compared with the OPD group, The CR-POPF rate in the LPD group are not significant differences. But the postoperative length of hospital stay was significantly shorter in the LPD group. Besides, there were no other severely postoperative complications between two groups. CONCLUSION The modified Blumgart anastomosis technique applied to LPD in our Center not only has simple and convenient properties but also low rate of CR-POPF. And this method may be a good choice for surgeons to begin to carry out LPD.
Collapse
Affiliation(s)
- Guo-Hua Liu
- Department of Hepatobiliary Surgery, Affiliated Hospital, Guangdong Medical University, Zhanjiang, Guangdong, 524000, China
| | - Xiao-Yu Tan
- Department of Hepatobiliary Surgery, Affiliated Hospital, Guangdong Medical University, Zhanjiang, Guangdong, 524000, China
| | - Jia-Xing Li
- Department of Hepatobiliary Surgery, Affiliated Hospital, Guangdong Medical University, Zhanjiang, Guangdong, 524000, China
| | - Guo-Hui Zhong
- Department of Hepatobiliary Surgery, Affiliated Hospital, Guangdong Medical University, Zhanjiang, Guangdong, 524000, China
| | - Jing-Wei Zhai
- Department of Hepatobiliary Surgery, Affiliated Hospital, Guangdong Medical University, Zhanjiang, Guangdong, 524000, China
| | - Ming-Yi Li
- Department of Hepatobiliary Surgery, Affiliated Hospital, Guangdong Medical University, Zhanjiang, Guangdong, 524000, China.
| |
Collapse
|
3
|
Dumitrascu T, Popescu I. Outcomes of Duct-to-Mucosa vs. Invagination Pancreatojejunostomy: Toward a Personalized Approach for Distal Pancreatic Stump Anastomosis in Central Pancreatectomy? J Pers Med 2023; 13:jpm13050858. [PMID: 37241028 DOI: 10.3390/jpm13050858] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/16/2023] [Accepted: 05/19/2023] [Indexed: 05/28/2023] Open
Abstract
(1) Background: The jejunum is primarily used for distal pancreatic stump anastomoses after central pancreatectomy (CP). The study aimed to compare duct-to-mucosa (WJ) and distal pancreatic invagination into jejunum anastomoses (PJ) after CP. (2) Methods: All patients with CP and jejunal anastomoses (between 1 January 2002 and 31 December 2022) were retrospectively assessed and compared. (3) Results: 29 CP were analyzed: WJ-12 patients (41.4%) and PJ-17 patients (58.6%). The operative time was significantly higher in the WJ vs. PJ group of patients (195 min vs. 140 min, p = 0.012). Statistically higher rates of patients within the high-risk fistula group were observed in the PJ vs. WJ group (52.9% vs. 0%, p = 0.003). However, no differences were observed between the groups regarding the overall, severe, and specific postpancreatectomy morbidity rates (p values ≥ 0.170). (4) Conclusions: The WJ and PJ anastomoses after CP were comparable in terms of morbidity rates. However, a PJ anastomosis appeared to fit better for patients with high-risk fistula scores. Thus, a personalized, patient-adapted technique for the distal pancreatic stump anastomosis with the jejunum after CP should be considered. At the same time, future research should explore gastric anastomoses' emerging role.
Collapse
Affiliation(s)
- Traian Dumitrascu
- Center of General Surgery and Liver Transplant, Fundeni Clinical Institute, Carol Davila University of Medicine and Pharmacy, 022328 Bucharest, Romania
| | - Irinel Popescu
- Center of General Surgery and Liver Transplant, Fundeni Clinical Institute, Titu Maiorescu University, 022328 Bucharest, Romania
| |
Collapse
|
4
|
Bellotti R, Cardini B, Strolz CJ, Stättner S, Oberhuber R, Braunwarth E, Resch T, Scheidl S, Margreiter C, Schneeberger S, Öfner D, Maglione M. Single Center, Propensity Score Matching Analysis of Different Reconstruction Techniques following Pancreatoduodenectomy. J Clin Med 2023; 12:3318. [PMID: 37176758 PMCID: PMC10179219 DOI: 10.3390/jcm12093318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Pancreatoduodenectomy is still hampered by significant morbidity. So far, there is no universally accepted technique aimed at minimizing postoperative complications. Herein, we compare three different reconstruction techniques. METHODS This is a retrospective study of a prospectively maintained database including 283 patients operated between January 2010 and December 2020. Three reconstruction techniques were compared: (1) the Neuhaus-style telescope pancreatojejunostomy, (2) the pancreatogastrostomy, and (3) the modified Blumgart-style, duct-to-mucosa pancreatojejunostomy. The primary endpoint consisted in determining the rates of clinically relevant postoperative pancreatic fistulas (CR-POPF); the secondary endpoints included 90 days morbidity and mortality rates. A propensity score matching analysis was used. RESULTS Rates of CR-POPF did not differ significantly between the groups (Neuhaus-style pancreatojejunostomy 16%, pancreatogastrostomy 17%, modified Blumgart-style pancreatojejunostomy 15%), neither in the unmatched nor in the matched analysis (p = 0.993 and p = 0.901, respectively). Similarly, no significant differences could be observed with regard to major morbidity (unmatched p = 0.596, matched p = 0.188) and mortality rates (unmatched p = 0.371, matched p = 0.209) within the first 90 days following surgery. Propensity-score matching analyses revealed, however, a higher occurrence of post-pancreatectomy hemorrhage after pancreatogastrostomy (p = 0.015). CONCLUSION Similar CR-POPF rates suggest no crucial role of the applied reconstruction technique. Increased incidence of intraluminal post-pancreatectomy hemorrhages following pancreatogastrostomy demands awareness for meticulous hemostasis.
Collapse
Affiliation(s)
- Ruben Bellotti
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Benno Cardini
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Carola J. Strolz
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Stefan Stättner
- Department of General, Visceral and Vascular Surgery, Salzkammergut Hospital, 4840 Vöcklabruck, Austria
| | - Rupert Oberhuber
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Eva Braunwarth
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Thomas Resch
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Stefan Scheidl
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Christian Margreiter
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Dietmar Öfner
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Manuel Maglione
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| |
Collapse
|
5
|
Prevention and Treatment of Grade C Postoperative Pancreatic Fistula. J Clin Med 2022; 11:jcm11247516. [PMID: 36556131 PMCID: PMC9784648 DOI: 10.3390/jcm11247516] [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: 11/10/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
Postoperative pancreatic fistula (POPF) is a troublesome complication after pancreatic surgeries, and grade C POPF is the most serious situation among pancreatic fistulas. At present, the incidence of grade C POPF varies from less than 1% to greater than 9%, with an extremely high postoperative mortality rate of 25.7%. The patients with grade C POPF finally undergo surgery with a poor prognosis after various failed conservative treatments. Although various surgical and perioperative attempts have been made to reduce the incidence of grade C POPF, the rates of this costly complication have not been significantly diminished. Hearteningly, several related studies have found that intra-abdominal infection from intestinal flora could promote the development of grade C POPF, which would help physicians to better prevent this complication. In this review, we briefly introduced the definition and relevant risk factors for grade C POPF. Moreover, this review discusses the two main pathways, direct intestinal juice spillover and bacterial translocation, by which intestinal microbes enter the abdominal cavity. Based on the abovementioned theory, we summarize the operation techniques and perioperative management of grade C POPF and discuss novel methods and surgical treatments to reverse this dilemma.
Collapse
|
6
|
Boralkar AK, Rafe A, Varudkar AS, Vikram Singh K. Pancreatico-Gastrostomy: A Modified Two-Layered Technique. Cureus 2022; 14:e26227. [PMID: 35891860 PMCID: PMC9308108 DOI: 10.7759/cureus.26227] [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] [Accepted: 06/23/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction: Pancreato-duodenal resections are commonly done for periampullary carcinomas. The outcome of the procedure is decided by pancreato-enterostomy. Pancreato-jejunostomy (PJ) has been employed largely as pancreato-enterostomy. Recently, there has been a renewed interest in pancreato-gastrostomy (PG). The debate continues on the choice of reconstruction. Methods: A hundred cases of periampullary carcinoma were subjected to modified pancreatico-gastrostomy. The pancreatico-gastrectomy was evaluated by drain fluid amylase done on days 1, 3, and 5 post-operatively and clinical findings. The leaks were classified according to the International Study Group of Pancreatic Fistula (ISGPF) classification of biochemical leaks, postoperative pancreatic fistula (POPF) B and POPF C. The leaks were evaluated against pancreatic factors like duct diameter, consistency of the pancreas, the thickness of the pancreatic neck, and duct location. Observations: Eighty percent of patients had no leaks. The biochemical leak was seen in 10% of cases. POPF B and C were observed at 5% each. Mortality was 3%. The diameter of the pancreatic duct of more than 3 mm and the firm consistency of the pancreas were favourable factors in the outcome of the anastomosis. Conclusion: A modified pancreatico-gastrostomy technique appears to be technically feasible and safe. The leak rates and mortality appear to be low. We need a higher number of patients to confirm the efficacy of this modified pancreatico-enterostomy.
Collapse
|
7
|
Hai H, Li Z, Zhang Z, Cheng Y, Liu Z, Gong J, Deng Y. Duct-to-mucosa versus other types of pancreaticojejunostomy for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy. Cochrane Database Syst Rev 2022; 3:CD013462. [PMID: 35289922 PMCID: PMC8923262 DOI: 10.1002/14651858.cd013462.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula is a common and serious complication following pancreaticoduodenectomy. Duct-to-mucosa pancreaticojejunostomy has been used in many centers to reconstruct pancreatic digestive continuity following pancreatoduodenectomy, however, its efficacy and safety are uncertain. OBJECTIVES To assess the benefits and harms of duct-to-mucosa pancreaticojejunostomy versus other types of pancreaticojejunostomy for the reconstruction of pancreatic digestive continuity in participants undergoing pancreaticoduodenectomy, and to compare the effects of different duct-to-mucosa pancreaticojejunostomy techniques. SEARCH METHODS We searched the Cochrane Library (2021, Issue 1), MEDLINE (1966 to 9 January 2021), Embase (1988 to 9 January 2021), and Science Citation Index Expanded (1982 to 9 January 2021). SELECTION CRITERIA We included all randomized controlled trials (RCTs) that compared duct-to-mucosa pancreaticojejunostomy with other types of pancreaticojejunostomy (e.g. invagination pancreaticojejunostomy, binding pancreaticojejunostomy) in participants undergoing pancreaticoduodenectomy. We also included RCTs that compared different types of duct-to-mucosa pancreaticojejunostomy in participants undergoing pancreaticoduodenectomy. DATA COLLECTION AND ANALYSIS Two review authors independently identified the studies for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CIs). For all analyses, we used the random-effects model. We used the Cochrane RoB 1 tool to assess the risk of bias. We used GRADE to assess the certainty of the evidence for all outcomes. MAIN RESULTS We included 11 RCTs involving a total of 1696 participants in the review. One RCT was a dual-center study; the other 10 RCTs were single-center studies conducted in: China (4 studies); Japan (2 studies); USA (1 study); Egypt (1 study); Germany (1 study); India (1 study); and Italy (1 study). The mean age of participants ranged from 54 to 68 years. All RCTs were at high risk of bias. Duct-to-mucosa versus any other type of pancreaticojejunostomy We included 10 RCTs involving 1472 participants comparing duct-to-mucosa pancreaticojejunostomy with invagination pancreaticojejunostomy: 732 participants were randomized to the duct-to-mucosa group, and 740 participants were randomized to the invagination group after pancreaticoduodenectomy. Comparing the two techniques, the evidence is very uncertain for the rate of postoperative pancreatic fistula (grade B or C; RR 1.45, 95% CI 0.64 to 3.26; 7 studies, 1122 participants; very low-certainty evidence), postoperative mortality (RR 0.77, 95% CI 0.39 to 1.49; 10 studies, 1472 participants; very low-certainty evidence), rate of surgical reintervention (RR 1.12, 95% CI 0.65 to 1.95; 10 studies, 1472 participants; very low-certainty evidence), rate of postoperative bleeding (RR 0.85, 95% CI 0.51 to 1.42; 9 studies, 1275 participants; very low-certainty evidence), overall rate of surgical complications (RR 1.12, 95% CI 0.92 to 1.36; 5 studies, 750 participants; very low-certainty evidence), and length of hospital stay (MD -0.41 days, 95% CI -1.87 to 1.04; 4 studies, 658 participants; very low-certainty evidence). The studies did not report adverse events or quality of life outcomes. One type of duct-to-mucosa pancreaticojejunostomy versus a different type of duct-to-mucosa pancreaticojejunostomy We included one RCT involving 224 participants comparing duct-to-mucosa pancreaticojejunostomy using the modified Blumgart technique with duct-to-mucosa pancreaticojejunostomy using the traditional interrupted technique: 112 participants were randomized to the modified Blumgart group, and 112 participants were randomized to the traditional interrupted group after pancreaticoduodenectomy. Comparing the two techniques, the evidence is very uncertain for the rate of postoperative pancreatic fistula (grade B or C; RR 1.51, 95% CI 0.61 to 3.75; 1 study, 210 participants; very low-certainty evidence), postoperative mortality (there were no deaths in either group; 1 study, 210 participants; very low-certainty evidence), rate of surgical reintervention (RR 1.93, 95% CI 0.18 to 20.91; 1 study, 210 participants; very low-certainty evidence), rate of postoperative bleeding (RR 2.89, 95% CI 0.12 to 70.11; 1 study, 210 participants; very low-certainty evidence), overall rate of surgical complications (RR 1.10, 95% CI 0.80 to 1.51; 1 study, 210 participants; very low-certainty evidence), and length of hospital stay (15 days versus 15 days; 1 study, 210 participants; very low-certainty evidence). The study did not report adverse events or quality of life outcomes. AUTHORS' CONCLUSIONS The evidence is very uncertain about the effects of duct-to-mucosa pancreaticojejunostomy compared to invagination pancreaticojejunostomy on any of the outcomes, including rate of postoperative pancreatic fistula (grade B or C), postoperative mortality, rate of surgical reintervention, rate of postoperative bleeding, overall rate of surgical complications, and length of hospital stay. The evidence is also very uncertain whether duct-to-mucosa pancreaticojejunostomy using the modified Blumgart technique is superior, equivalent or inferior to duct-to-mucosa pancreaticojejunostomy using the traditional interrupted technique. None of the studies reported adverse events or quality of life outcomes.
Collapse
Affiliation(s)
- Hua Hai
- Department of Operating Room, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhuyin Li
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ziwei Zhang
- Chongqing Medical University, Chongqing, China
| | - Yao Cheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Zuojin Liu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Jianping Gong
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yilei Deng
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| |
Collapse
|
8
|
Pancreaticojejunostomy Conducive to Biological Healing in Minimally Invasive Pancreaticoduodenectomy. J Gastrointest Surg 2022; 26:1967-1981. [PMID: 35546220 PMCID: PMC9489565 DOI: 10.1007/s11605-022-05339-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/10/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pancreaticojejunostomy, an independent risk factor for pancreatic fistula, is the cause of several postoperative complications of pancreaticoduodenectomy. As suturing in minimally invasive surgery is difficult to perform, more simplified methods are needed to guarantee a safe pancreatic anastomosis. The concept of "biological healing" proposed in recent years has changed the conventional understanding of the anastomosis, which recommends rich blood supply, low tension, and loose sutures in the reconstruction of the pancreatic outflow tract. METHODS A literature search was conducted in PubMed for articles on pancreaticojejunostomy published between January 2014 and December 2021. After following a due selection process, several techniques developed in accordance with the concept of biological healing that were found suitable for minimally invasive surgery and their related clinical outcomes were described in this review. RESULTS The incidence of clinically relevant pancreatic fistula associated with the presented techniques did not exceed 15.9%, indicating superior results compared to Cattell-Warren double-layer duct-to-mucosa anastomosis (incidence: approximately 20%). The features and drawbacks of these approaches have been enumerated from the viewpoint of biological healing. CONCLUSIONS This review described several modified pancreaticojejunostomy techniques with the advantages of a simplified procedure and a lower incidence of pancreatic fistula. Surgeons can choose to apply them in clinical practice to improve patient prognosis.
Collapse
|
9
|
Lee KF, Wong KKC, Lo EYJ, Kung JWC, Lok HT, Chong CCN, Wong J, Lai PBS, Ng KKC. What is the pancreatic duct size limit for a safe duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy? A retrospective study. Ann Hepatobiliary Pancreat Surg 2021; 26:84-90. [PMID: 34903678 PMCID: PMC8901978 DOI: 10.14701/ahbps.21-054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 08/12/2021] [Accepted: 09/06/2021] [Indexed: 11/17/2022] Open
Abstract
Backgrounds/Aims Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) remains a dreadful complication. Duct-to-mucosa pancreaticojejunostomy (DTMPJ) is a commonly performed anastomosis after PD. This study aims to evaluate whether there is a size limit of pancreatic duct below which POPF rate increases significantly after DTMPJ. Methods A retrospective study was performed from a database with prospectively collected data on consecutive patients undergoing DTMPJ. Results Between the years 2003 and 2019, a total of 288 patients with DTMPJ were recruited. POPF occurred in 56.3% of the patients, of which 43.8% were biochemical leak, 8.7% were grade B, and 1.4% were grade C. Overall operative morbidity was 51.4%, of which 19.1% were major complications. Five patients (1.7%) died within 90 days of operation. Patients with grade B/C POPF had significantly soft pancreas (p < 0.001), smaller duct size (p = 0.031), and a diagnosis of carcinoma of the pancreas (p = 0.027). When a clinically significant POPF rate was analysed based on the pancreatic duct diameter, pancreatic duct size ≤ 1 mm had the highest POPF rate (35.7%). There was a significant difference in POPF rate between adjacent ductal diameter ≤ 1 mm and > 1 mm to 2 mm (35.7% vs 13.3%; p = 0.040). Multivariable analysis showed that for the soft pancreas, pancreatic duct diameter ≤ 1 mm was the only significant predictive factor for POPF (p = 0.027). Conclusions DTMPJ can be safely performed for pancreatic duct > 1 mm without significantly increased POPF risk.
Collapse
Affiliation(s)
- Kit-Fai Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Kandy Kam Cheung Wong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Eugene Yee Juen Lo
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Janet Wui Cheung Kung
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Hon-Ting Lok
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Charing Ching Ning Chong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - John Wong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Paul Bo San Lai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Kelvin Kwok Chai Ng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| |
Collapse
|
10
|
Higashiguchi T, Kato H, Yasuoka H, Ito M, Asano Y, Kawabe N, Arakawa S, Shimura M, Koike D, Hayashi C, Ochi T, Kamio K, Kawai T, Utsumi T, Nagata H, Kondo Y, Tochii D, Horiguchi A. A preserved pancreatic exocrine function after pancreatectomy may be a crucial cause of pancreatic fistula: paradoxical results of the 13C-trioctanoin breath test in the perioperative period. Surg Today 2021; 52:580-586. [PMID: 34529132 DOI: 10.1007/s00595-021-02371-w] [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: 04/26/2021] [Accepted: 07/08/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The aim of this study was to elucidate the association between pancreatic fistula (PF) and the sequential changes in the perioperative exocrine function after pancreatectomy. METHODS The subjects were 96 patients who underwent a 13C-trioctanoin breath test before and 1 month after pancreatectomy, between 2006 and 2018. We retrospectively compared the pre- and postoperative fat absorption levels between patients with PF (PF group; n = 17) and without PF (non-PF group; n = 79) using the breath test. RESULTS The preoperative level of 13C-trioctanoin absorption (%dose/h) was comparable between the non-PF and PF groups (36.5 vs. 36.9). In the non-PF group, 13C-trioctanoin absorption was significantly decreased after surgery in comparison to the preoperative setting (post-operative 28.5; pre-operative 36.5; p < 0.0001), whereas these values were comparable (post-operative 36.9; pre-operative 34.5; p = 0.129) in the PF group. Moreover, postoperative absorption in the PF group was significantly better than that in the non-PF group (34.5 vs. 28.5%, p = 0.0003). The maximum drain amylase level was significantly higher in patients with a 13C-trioctanoin absorption level (%dose/h) of ≥ 30 in comparison to patients with levels of < 30 (2502 vs. 398 U/L, p = 0.001). CONCLUSION PF did not exacerbate the pancreatic exocrine function in the early postoperative period, and the acceleration or preservation of the exocrine function after surgery may be an important cause of PF.
Collapse
Affiliation(s)
- Takahiko Higashiguchi
- Department of Gastroenterological Surgery, Bantane Hospital, Fujita Health University School of Medicine, Nagoya, Japan
| | - Hiroyuki Kato
- Department of Gastroenterological Surgery, Bantane Hospital, Fujita Health University School of Medicine, Nagoya, Japan.
| | - Hironobu Yasuoka
- Department of Gastroenterological Surgery, Bantane Hospital, Fujita Health University School of Medicine, Nagoya, Japan
| | - Masahiro Ito
- Department of Gastroenterological Surgery, Bantane Hospital, Fujita Health University School of Medicine, Nagoya, Japan
| | - Yukio Asano
- Department of Gastroenterological Surgery, Bantane Hospital, Fujita Health University School of Medicine, Nagoya, Japan
| | - Norihiko Kawabe
- Department of Gastroenterological Surgery, Bantane Hospital, Fujita Health University School of Medicine, Nagoya, Japan
| | - Satoshi Arakawa
- Department of Gastroenterological Surgery, Bantane Hospital, Fujita Health University School of Medicine, Nagoya, Japan
| | - Masahiro Shimura
- Department of Gastroenterological Surgery, Bantane Hospital, Fujita Health University School of Medicine, Nagoya, Japan
| | - Daisuke Koike
- Department of Gastroenterological Surgery, Bantane Hospital, Fujita Health University School of Medicine, Nagoya, Japan
| | - Chihiro Hayashi
- Department of Gastroenterological Surgery, Bantane Hospital, Fujita Health University School of Medicine, Nagoya, Japan
| | - Takayuki Ochi
- Department of Gastroenterological Surgery, Bantane Hospital, Fujita Health University School of Medicine, Nagoya, Japan
| | - Kenshiro Kamio
- Department of Gastroenterological Surgery, Bantane Hospital, Fujita Health University School of Medicine, Nagoya, Japan
| | - Toki Kawai
- Department of Gastroenterological Surgery, Bantane Hospital, Fujita Health University School of Medicine, Nagoya, Japan
| | - Toshiaki Utsumi
- Department of Gastroenterological Surgery, Bantane Hospital, Fujita Health University School of Medicine, Nagoya, Japan
| | - Hidetoshi Nagata
- Department of Gastroenterological Surgery, Bantane Hospital, Fujita Health University School of Medicine, Nagoya, Japan
| | - Yuka Kondo
- Department of Gastroenterological Surgery, Bantane Hospital, Fujita Health University School of Medicine, Nagoya, Japan
| | - Daisuke Tochii
- Department of Gastroenterological Surgery, Bantane Hospital, Fujita Health University School of Medicine, Nagoya, Japan
| | - Akihiko Horiguchi
- Department of Gastroenterological Surgery, Bantane Hospital, Fujita Health University School of Medicine, Nagoya, Japan
| |
Collapse
|
11
|
Outcome of pancreatic anastomoses during pancreatoduodenectomy in two national audits. Surgery 2021; 170:1799-1806. [PMID: 34373107 DOI: 10.1016/j.surg.2021.06.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/10/2021] [Accepted: 06/24/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Evidence on the optimal pancreatic anastomosis during pancreatoduodenectomy is inconclusive. Large multicenter and nationwide registries may provide additional insights. The study compared the practice and outcome of different pancreatic anastomoses during pancreatoduodenectomy, focusing on the rate of postoperative pancreatic fistula, in two large audits of pancreatic surgery. METHODS Posthoc analysis of patients after pancreatoduodenectomy in the Dutch Pancreatic Cancer Audit and the German DGAV StuDoQ|Pancreas registries (January 2014 to December 2017). Postoperative pancreatic fistula (International Study Group of Pancreatic Surgery B/C), postpancreatectomy hemorrhage (International Study Group of Pancreatic Surgery B/C) and Clavien-Dindo ≥3 complications rates were compared for the three most common anastomoses: duct-to-mucosa pancreatojejunostomy, non-duct-to-mucosa pancreatojejunostomy, and non-duct-to-mucosa pancreatogastrostomy. Multivariable adjustment for potential confounders was performed. RESULTS Overall, 6,149 patients were included. The most common anastomosis was duct-to-mucosa pancreatojejunostomy (duct-to-mucosa pancreatojejunostomy 59.8%, non-duct-to-mucosa pancreatojejunostomy 21.1%, non-duct-to-mucosa pancreatogastrostomy 12.4%). The overall postoperative pancreatic fistula rate was 14%: duct-to-mucosa pancreatojejunostomy 12.9%, non-duct-to-mucosa pancreatojejunostomy 14.4% (P = .162), non-duct-to-mucosa pancreatogastrostomy 18.3% (P < .001). The rate of postpancreatectomy hemorrhage was the lowest after duct-to-mucosa pancreatojejunostomy: duct-to-mucosa pancreatojejunostomy 6.9%, non-duct-to-mucosa pancreatojejunostomy 10% (P < .001), non-duct-to-mucosa pancreatogastrostomy 17.9% (P < .001). The rate of Clavien-Dindo ≥3 complications was the lowest after duct-to-mucosa pancreatojejunostomy: duct-to-mucosa pancreatojejunostomy 28%, non-duct-to-mucosa pancreatojejunostomy 32.7% (P = .002), non-duct-to-mucosa pancreatogastrostomy 43.1% (P < .001). In the multivariable analysis, the risk of postoperative pancreatic fistula did not differ significantly between the three anastomoses. The risk of hemorrhage (odds ratio 2.4, 95% confidence interval 1.6-3.5, P < .001) and Clavien-Dindo ≥3 (odds ratio 1.6, 95% confidence interval 1.2-2.1, P = .001) remained significantly higher only for non-duct-to-mucosa pancreatogastrostomy. CONCLUSION Data from two national audits showed no difference in the risk-adjusted postoperative pancreatic fistula rate among the three most used pancreatic anastomoses during pancreatoduodenectomy. Pancreatogastrostomy was inferior to pancreatojejunostomy regarding bleeding and overall major complications.
Collapse
|
12
|
Li Y, Hua R. The optimal choice for pancreatic anastomosis after pancreaticoduodenectomy: a network meta-analysis. Minerva Surg 2021; 77:65-71. [PMID: 34160171 DOI: 10.23736/s2724-5691.21.08802-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Postoperative pancreatic fistula (POPF) remains a major cause of morbidity following pancreaticoduodenectomy (PD). This network meta-analysis (NMA) compared techniques of pancreatic anastomosis following PD to determine the technique with the best outcome profile. EVIDENCE ACQUISITION A systematic literature search was performed on the Scopus, EMBASE, Medline and Cochrane databases to identify RCTs employing the international study group of pancreatic fistula(ISGPF) definition of POPF. The main outcomes were POPF and clinically relevant POPF. RESULTS Three techniques of pancreatic anastomosis following PD were directly compared in 16 RCTs comprising 2365 patients. EVIDENCE SYNTHESIS Overall, 929 patients underwent duct-to-mucosa pancreaticojejunostomy(PJ DTM), 760 patients invagination pancreaticojejunostomy(PJ Inv), and 676 patients underwent pancreatogastrostomy(PG). The results of comparisons of POPF, clinically relevant POPF, biliary leakage, delayed gastric emptying(DGE), in hospital mortality, internal hemorrhage, reoperation in our network meta-analysis suggested there were no significant differences among the 3 procedures. CONCLUSIONS There are no significant differences among PJ DTM, PJ Inv and PG in the prevention of POPF, clinically relevant POPF, biliary leakage, DGE, internal hemorrhage and reoperation. However, further randomized controlled trials should be undertaken to ascertain these findings.
Collapse
Affiliation(s)
- Yujie Li
- Department of General Surgery, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, China.,Ningbo institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China.,Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Ningbo, China
| | - Rong Hua
- Department of Pancreaticobiliary Surgery, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China -
| |
Collapse
|
13
|
Comparison of Blumgart Anastomosis with Duct-to-Mucosa Anastomosis and Invagination Pancreaticojejunostomy After Pancreaticoduodenectomy: A Single-Center Propensity Score Matching Analysis. J Gastrointest Surg 2021; 25:411-420. [PMID: 31997074 DOI: 10.1007/s11605-020-04528-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 01/22/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Blumgart anastomosis is a method of pancreaticojejunostomy after pancreaticoduodenectomy (PD) which combines the principle of duct-to-mucosa anastomosis with an invagination technique of the pancreas. METHODS Retrospective study involving consecutive patients who underwent pancreaticoduodenectomy for pancreatic head cancer. Data predictive of pancreatic fistula and postoperative outcomes were collected. The patients were divided into three groups and were compared based on the type of pancreatic anastomosis performed: Blumgart anastomosis (BA), duct-to-mucosa anastomosis (DtoM), and invagination pancreaticojejunostomy (PJ). The primary endpoint was to determine the occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF). The secondary endpoints were to determine whether postoperative pancreatic fistula grade C (POPF C) and/or severe complications occurred as well as to determine the reoperation rate and 30- and 90-day mortality. A propensity score matching analysis was used. RESULTS Using propensity score matching (PSM), the occurrence of CR-POPF was not significantly different between the BA (21.6%) and the other pancreatic anastomoses (all 31.1%, DtoM = 27.0%; PJ = 35.1%). However, the BA significantly reduced (1) severe complications (0 versus 35.1%; P < 0.001) and 90-day mortality (0% versus 12.2%; P = 0.028) with respect to all anastomoses; (2) severe complications (0% versus 29.7%; P < 0.001), POPF grade C (0% versus 16.2%; P = 0.025), and reoperation (2.7% versus 16.2%; P = 0.056) with respect to DtoM; and (3) severe complications (0% versus 40.5%; P < 0.001) and 90-day mortality (0% versus 13.5%; P = 0.054) with respect to PJ. CONCLUSIONS Applying the PSM analysis for the first time, the present study seemed to suggest that the BA succeeded in minimizing severe complications after PD.
Collapse
|
14
|
Cao Z, Luo W, Qiu J, Liu Y, Zheng L, Zhang T. Is Invagination Anastomosis More Effective in Reducing Clinically Relevant Pancreatic Fistula for Soft Pancreas After Pancreaticoduodenectomy Under Novel Fistula Criteria: A Systematic Review and Meta-Analysis. Front Oncol 2020; 10:1637. [PMID: 32974203 PMCID: PMC7471255 DOI: 10.3389/fonc.2020.01637] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/27/2020] [Indexed: 12/20/2022] Open
Abstract
Objective: To define the effectiveness of different anastomosis on clinically relevant postoperative fistula in patients with soft pancreas using the newest version of the fistula definition and criteria. Background: Different criteria of clinically relevant postoperative pancreatic fistula (POPF) result in the optimal anastomosis technique remaining controversial. Methods: PubMed, Embase, Web of Science, the Cochrane Central Library, and ClinicalTrials.gov were systematically searched up to 20 April 2020, and were evaluated by Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Randomized controlled trials comparing duct-to-mucosa anastomosis vs. invagination anastomosis in pancreatic surgery were included. Result: Seven studies involving 1,110 participants were included. Using the postoperative pancreatic fistula definition provided by the International Study Group of Pancreatic Surgery 2016, the incidence rate of grade B/C pancreatic fistula was significantly lower in patients experiencing invagination anastomosis than in those undergoing duct-to-mucosa anastomosis. Four of seven trials comparing invagination with duct-to-mucosa anastomosis in patients with a soft pancreas showed that invagination was significantly better than duct-to-mucosa anastomosis in controlling pancreatic fistula formation, but no significant difference was detected between the two anastomosis techniques in patients with a hard pancreas. No significant difference in the length of hospital stay or postoperative mortality rate was found between the two methods. Conclusion: This study demonstrated superiority of invagination anastomosis over duct-to-mucosa anastomosis in reducing the risk of Grade B/C postoperative pancreatic fistula using the ISGPS 2016 definition, but it does not significantly reduce the mortality rate or length of hospital stay. The effect of invagination in reducing pancreatic fistula formation is obvious in patients with a soft pancreas, but there is no significant difference between the two anastomosis techniques in patients with a hard pancreas. We found a lower rate of clinically relevant postoperative pancreatic fistula in the invagination group, in patients with a soft pancreas.
Collapse
Affiliation(s)
- Zhe Cao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenhao Luo
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiangdong Qiu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yueze Liu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lianfang Zheng
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Taiping Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,Clinical Immunology Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
15
|
Han IW, Cho K, Ryu Y, Shin SH, Heo JS, Choi DW, Chung MJ, Kwon OC, Cho BH. Risk prediction platform for pancreatic fistula after pancreatoduodenectomy using artificial intelligence. World J Gastroenterol 2020; 26:4453-4464. [PMID: 32874057 PMCID: PMC7438201 DOI: 10.3748/wjg.v26.i30.4453] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/13/2020] [Accepted: 07/30/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Despite advancements in operative technique and improvements in postoperative managements, postoperative pancreatic fistula (POPF) is a life-threatening complication following pancreatoduodenectomy (PD). There are some reports to predict POPF preoperatively or intraoperatively, but the accuracy of those is questionable. Artificial intelligence (AI) technology is being actively used in the medical field, but few studies have reported applying it to outcomes after PD.
AIM To develop a risk prediction platform for POPF using an AI model.
METHODS Medical records were reviewed from 1769 patients at Samsung Medical Center who underwent PD from 2007 to 2016. A total of 38 variables were inserted into AI-driven algorithms. The algorithms tested to make the risk prediction platform were random forest (RF) and a neural network (NN) with or without recursive feature elimination (RFE). The median imputation method was used for missing values. The area under the curve (AUC) was calculated to examine the discriminative power of algorithm for POPF prediction.
RESULTS The number of POPFs was 221 (12.5%) according to the International Study Group of Pancreatic Fistula definition 2016. After median imputation, AUCs using 38 variables were 0.68 ± 0.02 with RF and 0.71 ± 0.02 with NN. The maximal AUC using NN with RFE was 0.74. Sixteen risk factors for POPF were identified by AI algorithm: Pancreatic duct diameter, body mass index, preoperative serum albumin, lipase level, amount of intraoperative fluid infusion, age, platelet count, extrapancreatic location of tumor, combined venous resection, co-existing pancreatitis, neoadjuvant radiotherapy, American Society of Anesthesiologists’ score, sex, soft texture of the pancreas, underlying heart disease, and preoperative endoscopic biliary decompression. We developed a web-based POPF prediction platform, and this application is freely available at http://popfrisk.smchbp.org.
CONCLUSION This study is the first to predict POPF with multiple risk factors using AI. This platform is reliable (AUC 0.74), so it could be used to select patients who need especially intense therapy and to preoperatively establish an effective treatment strategy.
Collapse
Affiliation(s)
- In Woong Han
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea
| | - Kyeongwon Cho
- Medical Artificial Intelligence Research Center, Department of Medical Device Management and Research, SAIHST, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea
| | - Youngju Ryu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea
| | - Sang Hyun Shin
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea
| | - Jin Seok Heo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea
| | - Dong Wook Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea
| | - Myung Jin Chung
- Medical Artificial Intelligence Research Center, Department of Medical Device Management and Research, SAIHST, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea
| | - Oh Chul Kwon
- Artificial Intelligence Research Center, Medical DataBase Incorporated, Seoul 06048, South Korea
| | - Baek Hwan Cho
- Medical Artificial Intelligence Research Center, Department of Medical Device Management and Research, SAIHST, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, South Korea
| |
Collapse
|
16
|
Yang H, Ren Y, Yu Z, Zhou H, Zhang S, Luo C, Jiao Z. Pancreatic fistula after pancreatoduodenectomy due to compression of the superior mesenteric vessels: a case report. BMC Surg 2020; 20:170. [PMID: 32723381 PMCID: PMC7389644 DOI: 10.1186/s12893-020-00828-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 07/17/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatic fistula is a common complication after pancreaticoduodenectomy, which could be caused by: soft pancreatic tissue, pancreatic duct diameter < 3 mm and body mass index ≥25 kg/m2. Here we report a case of pancreatic fistula due to obstruction of the jejunal loop due to compression of the jejunal loop by the superior mesenteric vessels. CASE PRESENTATION A 68-year-old man was admitted to our ward due to intermittent epigastric distension and pain. After various examinations and treatments, he was diagnosed with middle bile duct cancer. Pancreaticoduodenectomy was performed, and pancreaticojejunostomy and hepaticojejunostomy were completed by lifting the jejunal loop from behind the superior mesenteric vessels to the upper region of the colon. On postoperative day 9, the patient developed acute diffuse peritonitis, and on postoperative day 10, the patient underwent a second exploratory laparotomy, during which it was confirmed that the pancreatic fistula was caused by obstruction of the jejunal loop due to compression of the jejunal loop by the superior mesenteric vessels, then the patient recovered and was discharged alive after retrograde drainage in the jejunum. CONCLUSIONS The superior mesenteric vessels after pancreaticoduodenal surgery can compress the jejunal loop and cause obstruction leading to serious complications, and it is recommended that general surgeons should avoid lifting the jejunal loop from the posterior aspect of the superior mesenteric vessels to complete the anastomosis.
Collapse
Affiliation(s)
- Hanteng Yang
- Department of General Surgery, Lanzhou University Second Hospital, No.82 Cuiyingmen, Lanzhou, 730030, Gansu, China
| | - Yanxian Ren
- Department of General Surgery, Lanzhou University Second Hospital, No.82 Cuiyingmen, Lanzhou, 730030, Gansu, China
| | - Zeyuan Yu
- Department of General Surgery, Lanzhou University Second Hospital, No.82 Cuiyingmen, Lanzhou, 730030, Gansu, China
| | - Huinian Zhou
- Department of General Surgery, Lanzhou University Second Hospital, No.82 Cuiyingmen, Lanzhou, 730030, Gansu, China
| | - Shuze Zhang
- Department of General Surgery, Lanzhou University Second Hospital, No.82 Cuiyingmen, Lanzhou, 730030, Gansu, China
| | - Changjiang Luo
- Department of General Surgery, Lanzhou University Second Hospital, No.82 Cuiyingmen, Lanzhou, 730030, Gansu, China
| | - Zuoyi Jiao
- Department of General Surgery, Lanzhou University Second Hospital, No.82 Cuiyingmen, Lanzhou, 730030, Gansu, China. .,Cuiying Biomedical Research Center, Lanzhou University Second Hospital, No.82 Cuiyingmen, Lanzhou, 730030, Gansu, China.
| |
Collapse
|
17
|
Hayama S, Senmaru N, Hirano S. Delayed gastric emptying after pancreatoduodenectomy: comparison between invaginated pancreatogastrostomy and pancreatojejunostomy. BMC Surg 2020; 20:60. [PMID: 32245470 PMCID: PMC7118865 DOI: 10.1186/s12893-020-00707-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 02/28/2020] [Indexed: 02/07/2023] Open
Abstract
Background The association between delayed gastric emptying (DGE) after pancreatoduodenectomy (PD) and pancreatic reconstruction technique remain unclear. The aim of this study is to investigate whether the occurrence of DGE differs between pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG). Methods A total of 83 patients who underwent subtotal stomach-preserving pancreatoduodenectomy was retrospectively analyzed, and the factors associated with clinically relevant DGE were explored. These patients were divided into a PG group and a PJ group according to the pancreatic reconstruction. DGE occurrence and its association with intra-abdominal complications was compared between the two types of pancreatic reconstruction. Results The overall incidence of DGE was 27.7%. Intra-abdominal complications including pancreatic fistula were strongly associated with DGE. As to the pancreatic reconstruction, DGE developed more frequently in the PG than in the PJ. In addition, DGE with intra-abdominal complications tended to be more frequent in PG, despite the fact that intra-abdominal complications occurred at a similar frequency in both groups. Conclusions Intra-abdominal complications were strongly associated with DGE. As to the pancreatic reconstruction, DGE developed more frequently in the PG than in the PJ. We speculate that intra-abdominal complications affected patients with PG more and resulted in frequent occurrence of DGE.
Collapse
Affiliation(s)
- S Hayama
- Department of Surgery, Steel Memorial Muroran Hospital, 1-45 Chiribetucyo, Muroran, Hokkaido, 050-0076, Japan. .,Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15, W-7, Kita-ku, Sapporo, Japan.
| | - N Senmaru
- Department of Surgery, Steel Memorial Muroran Hospital, 1-45 Chiribetucyo, Muroran, Hokkaido, 050-0076, Japan.,Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15, W-7, Kita-ku, Sapporo, Japan
| | - S Hirano
- Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, N-15, W-7, Kita-ku, Sapporo, Japan
| |
Collapse
|
18
|
Xiang Y, Wu J, Lin C, Yang Y, Zhang D, Xie Y, Yao X, Zhang X. Pancreatic reconstruction techniques after pancreaticoduodenectomy: a review of the literature. Expert Rev Gastroenterol Hepatol 2019; 13:797-806. [PMID: 31282769 DOI: 10.1080/17474124.2019.1640601] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Postoperative pancreatic fistula is the most troublesome complication after pancreaticoduodenectomy, and is an on-going area of concern for pancreatic surgeons. The specific pancreatic reconstruction technique is an important factor influencing the development of postoperative pancreatic fistula after pancreaticoduodenectomy. Areas covered: In this paper, we briefly introduced the definition and relevant influencing factors of postoperative pancreatic fistula. We performed a search of all meta-analyses published in the last 5 years and all published randomized controlled trials comparing different pancreatic anastomotic techniques, and we evaluated the advantages and disadvantages of different techniques. Expert opinion: No individual anastomotic method can completely avoid postoperative pancreatic fistula. Selecting specific techniques tailored to the patient's situation intraoperatively may be key to reducing the incidence of postoperative pancreatic fistula.
Collapse
Affiliation(s)
- Yien Xiang
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Jiacheng Wu
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Chao Lin
- b Department of Hepatobiliary and Pancreatic Surgery, Jilin University Third Affiliated Hospital , Changchun , Jilin , CN
| | - Yongsheng Yang
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Dan Zhang
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Yingjun Xie
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Xiaoxiao Yao
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| | - Xuewen Zhang
- a Department of Hepatobiliary and Pancreatic Surgery, Jilin University Second Hospital , Changchun , Jilin , CN
| |
Collapse
|
19
|
Kawaida H, Kono H, Hosomura N, Amemiya H, Itakura J, Fujii H, Ichikawa D. Surgical techniques and postoperative management to prevent postoperative pancreatic fistula after pancreatic surgery. World J Gastroenterol 2019; 25:3722-3737. [PMID: 31391768 PMCID: PMC6676555 DOI: 10.3748/wjg.v25.i28.3722] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/20/2019] [Accepted: 06/26/2019] [Indexed: 02/06/2023] Open
Abstract
Postoperative pancreatic fistula (POPF) is one of the most severe complications after pancreatic surgeries. POPF develops as a consequence of pancreatic juice leakage from a surgically exfoliated surface and/or anastomotic stump, which sometimes cause intraperitoneal abscesses and subsequent lethal hemorrhage. In recent years, various surgical and perioperative attempts have been examined to reduce the incidence of POPF. We reviewed several well-designed studies addressing POPF-related factors, such as reconstruction methods, anastomotic techniques, stent usage, prophylactic intra-abdominal drainage, and somatostatin analogs, after pancreaticoduodenectomy and distal pancreatectomy, and we assessed the current status of POPF. In addition, we also discussed the current status of POPF in minimally invasive surgeries, laparoscopic surgeries, and robotic surgeries.
Collapse
Affiliation(s)
- Hiromichi Kawaida
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, Yamanashi 409-3898, Japan
| | - Hiroshi Kono
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, Yamanashi 409-3898, Japan
| | - Naohiro Hosomura
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, Yamanashi 409-3898, Japan
| | - Hidetake Amemiya
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, Yamanashi 409-3898, Japan
| | - Jun Itakura
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, Yamanashi 409-3898, Japan
| | - Hideki Fujii
- Department of Surgery, Kofu Manicipal Hospital, Yamanashi 400-0832, Japan
| | - Daisuke Ichikawa
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, Yamanashi 409-3898, Japan
| |
Collapse
|