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Biesel EA, Kuesters S, Chikhladze S, Ruess DA, Hipp J, Hopt UT, Fichtner-Feigl S, Wittel UA. Surgical complications requiring late surgical revisions after pancreatoduodenectomy increase postoperative morbidity and mortality. Scand J Surg 2024; 113:88-97. [PMID: 37962167 DOI: 10.1177/14574969231206132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND Pancreatoduodenectomies are complex surgical procedures with considerable postoperative morbidity and mortality. Here, we describe complications and outcomes in patients requiring surgical revisions following pancreatoduodenectomy. METHODS A total of 1048 patients undergoing a pancreatoduodenectomy at our institution between 2002 and 2019 were analyzed retrospectively. All patients with surgical revisions were included. Revisions were divided into early and late using a cut-off of 5 days after the first surgery. Statistical significance was examined by using chi-square tests and Fisher's exact tests. Survival analysis was performed using Kaplan-Meier curves and log-rank tests. RESULTS A total of 150 patients with at least 1 surgical revision after pancreatoduodenectomy were included. Notably, 64 patients had a revision during the first 5 days and were classified as early revision. Compared with the 86 patients with late revisions, we found no differences concerning wound infections, delayed gastric emptying, or acute kidney failure. After late revisions, we found significantly more cases of sepsis (31.4% late versus 15.6% early, p = 0.020) and reintubation due to respiratory failure (33.7% versus 18.8%, p = 0.031). Postoperative mortality was significantly higher within the late revision group (23.2% versus 9.4%, p = 0.030). CONCLUSION Arising complications after pancreatoduodenectomy should be addressed as early as possible as patients requiring late surgical revisions frequently developed septic complications and multiorgan failure.
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Affiliation(s)
- Esther A Biesel
- Department of General and Visceral Surgery University Medical Center FreiburgUniversity of FreiburgHugstetter Str. 55 D-79106 Freiburg Germany
| | - Simon Kuesters
- Department of General and Visceral Surgery, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Sophia Chikhladze
- Department of General and Visceral Surgery, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Dietrich A Ruess
- Department of General and Visceral Surgery, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Julian Hipp
- Department of General and Visceral Surgery, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Ulrich T Hopt
- Department of General and Visceral Surgery, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Stefan Fichtner-Feigl
- Department of General and Visceral Surgery, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
| | - Uwe A Wittel
- Department of General and Visceral Surgery, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany
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Kuesters S, Sundheimer J, Wittel UA, Chikhladze S, Fichtner-Feigl S, Biesel EA. Pancreatic head resection for carcinoma of the ampulla vateri - better long-term prognosis, but more postoperative complications. Langenbecks Arch Surg 2024; 409:129. [PMID: 38632147 PMCID: PMC11024026 DOI: 10.1007/s00423-024-03319-7] [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: 12/06/2023] [Accepted: 04/10/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Pancreatoduodenectomies are complex surgical procedures with a considerable morbidity and mortality even in high-volume centers. However, postoperative morbidity and long-term oncological outcome are not only affected by the surgical procedure itself, but also by the underlying disease. The aim of our study is an analysis of pancreatoduodenectomies for patients with pancreatic ductal adenocarcinoma (PDAC) and ampullary carcinoma (CAMP) concerning postoperative complications and long-term outcome in a tertiary hospital in Germany. METHODS The perioperative and oncological outcome of 109 pancreatic head resections performed for carcinoma of the ampulla vateri was compared to the outcome of 518 pancreatic head resections for pancreatic ductal adenocarcinoma over a 20 year-period from January 2002 until December 2021. All operative procedures were performed at the University Hospital Freiburg, Germany. Patient data was analyzed retrospectively, using a prospectively maintained SPSS database. Propensity score matching was performed to adjust for differences in surgical and reconstruction technique. Primary outcome of our study was long-term overall survival, secondary outcomes were postoperative complications and 30-day postoperative mortality. Postoperative complications like pancreatic fistula (POPF), postpancreatectomy hemorrhage (PPH) and delayed gastric emptying (DGE) were graded following current international definitions. Survival was estimated using Kaplan Meier curves and log-rank tests. A p-value < 0.05 was considered statistically significant. RESULTS Operation time was significantly longer in PDAC patients (432 vs. 391 min, p < 0.001). The rate of portal vein resections was significantly higher in PDAC patients (p < 0.001). In CAMP patients, a pancreatogastrostomy as reconstruction technique was performed more frequently compared to PDAC patients (48.6% vs. 29.9%, p < 0.001) and there was a trend towards more laparoscopic surgeries in CAMP patients (p = 0.051). After propensity score matching, we found no difference in DGE B/C and PPH B/C (p = 0.389; p = 0.517), but a significantly higher rate of clinically relevant pancreatic fistula (CR-POPF) in patients with pancreatoduodenectomies due to ampullary carcinoma (30.7% vs. 16.8%, p < 0.001). Long-term survival was significantly better in CAMP patients (42 vs. 24 months, p = 0.003). CONCLUSION Patients with pancreatoduodenectomies due to ampullary carcinomas showed a better long-term oncological survival, by reason of the better prognosis of this tumor entity. However, these patients often needed a more elaborated postoperative treatment due to the higher rate of clinically relevant pancreatic fistula in this group.
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Affiliation(s)
- Simon Kuesters
- Department of General- and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
- Current address: Clinic for General-, Visceral- and Vascular Surgery, Fürst-Stirum-Klinik, Bruchsal, Germany
| | - Johanna Sundheimer
- Department of General- and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
| | - Uwe A Wittel
- Department of General- and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
| | - Sophia Chikhladze
- Department of General- and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
| | - Stefan Fichtner-Feigl
- Department of General- and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany
| | - Esther A Biesel
- Department of General- and Visceral Surgery, University of Freiburg Medical Center, Faculty of Medicine, Freiburg, Germany.
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Li Y, Liang Y, Deng Y, Cai ZW, Ma MJ, Wang LX, Liu M, Wang HW, Jiang CY. Application of omental interposition to reduce pancreatic fistula and related complications in pancreaticoduodenectomy: A propensity score-matched study. World J Gastrointest Surg 2022; 14:482-493. [PMID: 35734624 PMCID: PMC9160680 DOI: 10.4240/wjgs.v14.i5.482] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 03/16/2022] [Accepted: 04/24/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The life-threatening complications following pancreatoduodenectomy (PD), intra-abdominal hemorrhage, and postoperative infection, are associated with leaks from the anastomosis of pancreaticoduodenectomy. Although several methods have attempted to reduce the postoperative pancreatic fistula (POPF) rate after PD, few have been considered effective. The safety and short-term clinical benefits of omental interposition remain controversial.
AIM To investigate the safety and feasibility of omental interposition to reduce the POPF rate and related complications in pancreaticoduodenectomy.
METHODS In total, 196 consecutive patients underwent PD performed by the same surgical team. The patients were divided into two groups: An omental interposition group (127, 64.8%) and a non-omental interposition group (69, 35.2%). Propensity score-matched (PSM) analyses were performed to compare the severe complication rates and mortality between the two groups.
RESULTS Following PSM, the clinically relevant POPF (CR-POPF, 10.1% vs 24.6%; P = 0.025) and delayed postpancreatectomy hemorrhage (1.4% vs 11.6%; P = 0.016) rates were significantly lower in the omental interposition group. The omental interposition technique was associated with a shorter time to resume food intake (7 d vs 8 d; P = 0.048) and shorter hospitalization period (16 d vs 21 d; P = 0.031). Multivariate analyses showed that a high body mass index, nonapplication of omental interposition, and a main pancreatic duct diameter < 3 mm were independent risk factors for CR-POPF.
CONCLUSION The application of omental interposition is an effective and safe approach to reduce the CR-POPF rate and related complications after PD.
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Affiliation(s)
- Yang Li
- Department of General Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai 200040, China
| | - Yun Liang
- Department of General Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai 200040, China
- Department of Pancreatic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China
| | - Yao Deng
- Department of General Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai 200040, China
| | - Zhi-Wei Cai
- Department of General Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai 200040, China
| | - Ming-Jian Ma
- Department of General Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai 200040, China
| | - Long-Xiang Wang
- Department of General Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai 200040, China
| | - Meng Liu
- Department of General Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai 200040, China
| | - Hong-Wei Wang
- Department of General Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai 200040, China
| | - Chong-Yi Jiang
- Department of General Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai 200040, China
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Pedrazzoli S. Mitigation of the Postoperative Pancreatic Fistula After Pancreatoduodenectomy: Can We do Something Better? Ann Surg Oncol 2021; 29:753-754. [PMID: 34689264 DOI: 10.1245/s10434-021-10960-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 09/27/2021] [Indexed: 11/18/2022]
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Wang XX, Yan YK, Dong BL, Li Y, Yang XJ. Pancreatic outflow tract reconstruction after pancreaticoduodenectomy: a meta-analysis of randomized controlled trials. World J Surg Oncol 2021; 19:203. [PMID: 34229720 PMCID: PMC8262038 DOI: 10.1186/s12957-021-02314-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 06/22/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND To evaluate the outcomes of pancreaticogastrostomy and pancreaticojejunostomy after pancreatoduodenectomy with the help of a meta-analysis. METHODS Randomized controlled trials comparing pancreaticogastrostomy and pancreaticojejunostomy were searched electronically using PubMed, The Cochrane Library, and EMBASE. Fixed and random-effects were used to measure pooled estimates. Research indicators included pancreatic fistula, delayed gastric emptying, postoperative hemorrhage, intraperitoneal fluid collection, wound infection, overall postoperative complications, reoperation, and mortality. RESULTS Overall, 10 randomized controlled trials were included in this meta-analysis, with a total of 1629 patients. The overall incidences of pancreatic fistula and intra-abdominal collections were lower in the pancreaticogastrostomy group than in the pancreaticojejunostomy group (OR=0.73, 95% CI 0.55~0.96, p=0.02; OR=0.59, 95% CI 0.37~0.96, p=0.02, respectively). The incidence of B/C grade pancreatic fistula in the pancreaticogastrostomy group was lower than that in the pancreaticojejunostomy group, but no significant difference was observed (OR=0.61, 95%CI 0.34~1.09, p=0.09). Postoperative hemorrhage was more frequent in the pancreaticogastrostomy group than in the pancreaticojejunostomy group (OR=1.52; 95% CI 1.08~2.14, p=0.02). No significant differences in terms of delayed gastric emptying, wound infection, reoperation, overall postoperative complications, mortality, exocrine function, and hospital readmission were observed between groups. CONCLUSION This meta-analysis suggests that pancreaticogastrostomy reduces the incidence of postoperative pancreatic fistula and intraperitoneal fluid collection but increases the risk of postoperative hemorrhage compared with pancreaticojejunostomy.
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Affiliation(s)
- Xin Xin Wang
- Department of General Surgery, Gansu Provincial Hospital, No. 204 Donggang West Road, Lanzhou, 730000, Gansu Province, China
- The 1st Clinical Medicine College, Gansu University of Chinese Medicine, Lanzhou, 730000, Gansu Province, China
| | - Yu Ke Yan
- Department of General Surgery, Gansu Provincial Hospital, No. 204 Donggang West Road, Lanzhou, 730000, Gansu Province, China
| | - Bao Long Dong
- Department of General Surgery, Gansu Provincial Hospital, No. 204 Donggang West Road, Lanzhou, 730000, Gansu Province, China
| | - Yuan Li
- Department of General Surgery, Gansu Provincial Hospital, No. 204 Donggang West Road, Lanzhou, 730000, Gansu Province, China
| | - Xiao Jun Yang
- Department of General Surgery, Gansu Provincial Hospital, No. 204 Donggang West Road, Lanzhou, 730000, Gansu Province, China.
- Peoples Clinical Medicine College, Lanzhou University, Lanzhou, 730000, Gansu Province, China.
- Gansu key Laboratory of Molecular Diagnostics and Precision Medicine for Surgical Oncology, Gansu Provincial Hospital, Lanzhou, 730000, Gansu Province, China.
- Gansu Research Center of Prevention and Control Project for Digestive Oncology, Gansu Provincial Hospital, Lanzhou, 730000, Gansu Province, China.
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Systematic review and meta-analysis of surgical drain management after the diagnosis of postoperative pancreatic fistula after pancreaticoduodenectomy: draining-tract-targeted works better than standard management. Langenbecks Arch Surg 2020; 405:1219-1231. [PMID: 33104886 PMCID: PMC7686010 DOI: 10.1007/s00423-020-02005-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 09/29/2020] [Indexed: 01/04/2023]
Abstract
Purpose Drains’ role after pancreaticoduodenectomy (PD) is debated by proponents of no drain, draining selected cases, and early drain removal. The aim of the study was to assess the effect of “standard” and “draining-tract-targeted” management of abdominal drains still in situ after diagnosing a postoperative pancreatic fistula (POPF). Methods PubMed and Scopus were searched for “pancreaticoduodenectomy or pancreatoduodenectomy or duodenopancreatectomy,” “Whipple,” “proximal pancreatectomy,” “pylorus-preserving pancreatectomy,” and “postoperative pancreatic fistula or POPF.”. Main outcomes included clinically relevant (CR) POPF, grade-C POPF, overall mortality, POPF-related mortality, and CR-POPF-related mortality. Secondary outcomes were incidence of radiological and/or endoscopic interventions, reoperations, and completion pancreatectomies. Results Overall, 12,089 studies were retrieved by the search of the English literature (01/01/1990–31/12/2018). Three hundred and twenty-six studies (90,321 patients) reporting ≥ 100 PDs and ≥ 10 PD/year were finally included into the study. Average incidences were obtained by averaging the incidence rates reported in the single articles. Pooled incidences were calculated by combining the number of events and the total number of patients considered in the various studies. These were then meta-analyzed using DerSimonian and Laird’s (1986) method. Pearson’s chi-squared test was used to compare pooled incidences between groups. Post hoc testing was used to see which groups differed. The meta-analyzed incidences were compared using a fixed effect for moderators. “Draining-tract-targeted” management showed a significant advantage over “standard” management in four clinically relevant outcomes out of eight according to pool analysis and in one of them according to meta-analysis. Conclusion Clinically, “draining-targeted” management of POPF should be preferred to “standard” management. Electronic supplementary material The online version of this article (10.1007/s00423-020-02005-8) contains supplementary material, which is available to authorized users.
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Chen TH, Su CH, Hsiao CY, Kao SY, Tsai PJ. Preemptive light sedation in intensive care unit may reduce pulmonary complications in geriatrics receiving pancreaticoduodenectomy. J Chin Med Assoc 2020; 83:661-668. [PMID: 32628429 DOI: 10.1097/jcma.0000000000000347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Patients undergoing pancreaticoduodenectomy (PD) for periampullary lesions are usually elderly with a high risk of postoperative morbidity and mortality. This retrospective cohort study investigated whether postoperative preemptive light sedation aids in recovery of elderly patients following PD. METHODS Ninety-nine geriatric patients undergoing PD at one hospital were enrolled from 2009 to 2018. Patients in the sedation group received mechanical ventilation support and preemptively light sedation with fentanyl and propofol or dexmedetomidine in the first 5 days postoperatively in the intensive care unit (ICU). Patients in the control group underwent early extubation and received morphine for pain control but no postoperative sedatives in the ordinary ward. Patients in the two groups were matched 1:1 using propensity scoring. The postoperative complication rate, surgical mortality, and postoperative hospital length of stay (LOS) were recorded. We also tested inflammation in an immortal human bronchial epithelial cell line. RESULTS After 1:1 matching, 40 patients in the sedation group were compared with 40 patients in the control group. The sedation group had a significantly lower pulmonary complication rate and fewer patients with postoperative gastroparesis. Both groups had similar postoperative hospital LOS and identical surgical mortality rates. Patients in the sedation group had significantly better postoperative quality of life, including less pain and less heartbeat variation. In vitro cell experiments supported the above clinical observations, showing that adequate use of sedatives could significantly elevate the cell viability rate, protect cells from damage, decrease interleukin-6 production, and reduce inflammation. CONCLUSION Postoperative preemptive light sedation in the ICU in geriatric patients following PD may not only reduce the rates of postoperative pulmonary complications and gastroparesis but also improve postoperative quality of life without prolonging the postoperative hospital LOS.
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Affiliation(s)
- Tien-Hua Chen
- Institute of Anatomy and Cell Biology, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Trauma Center, Department of Surgery, Taipei Veterans General Hospital, Taiwan, ROC
- Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, Taiwan, ROC
| | - Cheng-Hsi Su
- Department of Surgery, Cheng Hsin General Hospital, Taipei, Taiwan, ROC
| | - Chen-Yuan Hsiao
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan, ROC
- Landseed International Hospital, Taoyuan, Taiwan, ROC
| | - Shih-Yi Kao
- Ten-Chan General Hospital Zhongli, Taoyuan, Taiwan, ROC
| | - Pei-Jiun Tsai
- Institute of Anatomy and Cell Biology, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Trauma Center, Department of Surgery, Taipei Veterans General Hospital, Taiwan, ROC
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taiwan, ROC
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Yanagimoto H, Satoi S, Yamamoto T, Toyokawa H, Hirooka S, Yui R, Yamaki S, Ryota H, Inoue K, Michiura T, Matsui Y, Kwon AH. Clinical Impact of Preoperative Cholangitis after Biliary Drainage in Patients who Undergo Pancreaticoduodenectomy on Postoperative Pancreatic Fistula. Am Surg 2020. [DOI: 10.1177/000313481408000122] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The objective of this study was to examine whether the development of cholangitis after preoperative biliary drainage (PBD) can increase the incidence of postoperative pancreatic fistula (POPF). The study population included 185 consecutive patients who underwent pancreaticoduodenectomy from April 2006 to March 2011. All patients were divided into two groups, which consisted of a “no PBD” group (73 patients) and a PBD group (112 patients). Moreover, the PBD group was divided into a “cholangitis” group (21 patients) and a “no cholangitis” group (91 patients). Clinical background, clinical outcome, and postoperative complications were compared between groups. All patients received prophylactic antibiotics using cefmetazole until 1 or 2 days postoperatively. There was no difference between noncholangitis and non-PBD groups except the frequency of overall POPF. Clinically relevant POPF and drain infection occurred in the cholangitis group significantly more than in the noncholangitis group ( P < 0.05). Univariate and multivariate analyses showed that development of preoperative cholangitis after preoperative biliary drainage and small pancreatic duct (less than 3 mm diameter) were independent risk factors for clinically relevant POPF. The frequency of clinically relevant POPF was 8 per cent (eight of 99) in patients without two risk factors, 19 per cent (15 of 80) in patients with one risk factor, and 50 per cent (three of six) in patients with both risk factors. The development of preoperative cholangitis after PBD was closely associated with the development of clinically relevant POPF under the limited use of prophylactic antibiotics.
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Affiliation(s)
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | | | | | - Satoshi Hirooka
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Rintaro Yui
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - So Yamaki
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Hironori Ryota
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Kentaro Inoue
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Taku Michiura
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Yoichi Matsui
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - A-Hon Kwon
- Department of Surgery, Kansai Medical University, Osaka, Japan
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Taniguchi K, Matsuyama R, Yabushita Y, Homma Y, Ota Y, Mori R, Morioka D, Endo I. Prophylactic drain management after pancreaticoduodenectomy without focusing on the drain fluid amylase level: A prospective validation study regarding criteria for early drain removal that do not include the drain fluid amylase level. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:950-961. [DOI: 10.1002/jhbp.746] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/26/2020] [Accepted: 04/01/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Koichi Taniguchi
- Department of Gastroenterological Surgery Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Ryusei Matsuyama
- Department of Gastroenterological Surgery Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Yasuhiro Yabushita
- Department of Gastroenterological Surgery Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Yuki Homma
- Department of Gastroenterological Surgery Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Yohei Ota
- Department of Gastroenterological Surgery Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Ryutaro Mori
- Department of Gastroenterological Surgery Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Daisuke Morioka
- Department of Gastroenterological Surgery Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery Yokohama City University Graduate School of Medicine Yokohama Japan
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Mori R, Matsuyama R, Taniguchi K, Goto K, Miyake K, Hiratani S, Homma Y, Ohta Y, Kumamoto T, Morioka D, Endo I. Efficacy of prolonged elemental diet therapy after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: A pilot prospective randomized trial (UMIN000004108). Clin Nutr ESPEN 2019; 34:116-124. [PMID: 31677701 DOI: 10.1016/j.clnesp.2019.07.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 07/31/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUNDS AND AIMS This randomized clinical trial examined efficacy of prolonged elemental diet (ED) therapy after pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC), which often causes postoperative malnutrition leading to worsened short- and long-term outcomes. METHODS Thirty-nine patients with PDAC receiving PD was randomly assigned to prolonged ED group (PEDG) and control group (CG). Fat-free ED (Elental®, EA Pharma CO., Ltd., Tokyo, Japan) via tube jejunostomy was initiated on postoperative day 1 and increased to maintain with 600 kcal/day in addition to oral intake. ED was discontinued if sufficient oral intake was achieved in CG but continued during 3 postoperative months in PEDG. Primary outcome was complication necessitating readmission. Secondary outcomes were nutritional parameters, relative dose intensity (RDI) in cases of adjuvant chemotherapy, and survival outcomes. RESULTS Twenty patients were assigned to CG and 19 to PEDG. Cumulative post-discharge readmission rate was significantly lower in PEDG than in CG (PEDG vs CG; 12.6% vs 43.7% at 12-post-discharge-month; p = 0.018). Total calorie and ED-derived protein intakes were significantly larger in PEDG than in CG up to 3-postoperative-month but thereafter similar among groups. Lymphocyte counts were significantly increased and neutrophil-to-lymphocyte-ratio (NLR) was significantly reduced in PEDG than in CG at 2-, 3-, and 6-postoperative-month. However, other outcome measures did not differ among groups. CONCLUSION This trial failed to show survival benefit of prolonged ED therapy but demonstrated its favorable effect on increased lymphocyte counts, reduced NLR, and prevention of complications necessitating readmission, those which may lead to survival benefit with some modifications.
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Affiliation(s)
- Ryutaro Mori
- Department of Gastroenterological Surgery, Yokohama City University, Yokohama, Japan
| | - Ryusei Matsuyama
- Department of Gastroenterological Surgery, Yokohama City University, Yokohama, Japan
| | - Koichi Taniguchi
- Department of Gastroenterological Surgery, Yokohama City University, Yokohama, Japan
| | - Koki Goto
- Department of Gastroenterological Surgery, Yokohama City University, Yokohama, Japan
| | - Kentaro Miyake
- Department of Gastroenterological Surgery, Yokohama City University, Yokohama, Japan
| | - Seigo Hiratani
- Department of Gastroenterological Surgery, Yokohama City University, Yokohama, Japan
| | - Yuki Homma
- Department of Gastroenterological Surgery, Yokohama City University, Yokohama, Japan
| | - Yohei Ohta
- Department of Gastroenterological Surgery, Yokohama City University, Yokohama, Japan
| | - Takafumi Kumamoto
- Department of Gastroenterological Surgery, Yokohama City University, Yokohama, Japan
| | - Daisuke Morioka
- Department of Gastroenterological Surgery, Yokohama City University, Yokohama, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University, Yokohama, Japan.
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Liu T, Sun S, Gao H, Gao Y, Xu Q, Liu X, Miao Y, Wei J. CT-guided percutaneous catheter drainage of pancreatic postoperative collections. MINIM INVASIV THER 2019; 29:269-274. [PMID: 31304803 DOI: 10.1080/13645706.2019.1641524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: To examine the clinical characteristics of fluid collections after pancreatic surgery and evaluate the safety and effectiveness of CT-guided percutaneous catheter drainage (CT-PCD).Material and methods: A retrospective, cross-sectional study was carried out. 51 patients enrolled in this study underwent CT-PCD for collections after pancreatic surgery. The clinical and imaging data were collected and analysed.Results: In all 51 cases, CT scans showed that the samples were collected from the upper abdomen in 94.1% (48/51) of the patients. Apparent clinical symptoms before puncture manifested in 88.2% (45/51) of the patients. The average interval between surgery and puncture was 14.3 ± 7.9 days. In 76.4% (39/51) of the patients, the abdominal drainage catheter inserted during surgery was still not removed during CT-PCD. Amylase levels in drainage fluid were more than three times that of serum amylase in 66.7% (24/36) of the patients. The drainage fluid of 37 patients was sent for bacterial cultures; of these, 64.9% (24/37) tested positive. Full recovery after single puncture procedure occurred in 84.3% (43/51) of the patients. The incidence of puncture-related complications was 3.9%.Conclusions: Pancreatic postoperative collections requiring clinical puncture were mostly located in the upper abdomen. CT-PCD is a safe technique with good therapeutic effects in patients with collections.
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Affiliation(s)
- Tongtai Liu
- The Pancreas Center of the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Shuwen Sun
- The Department of Radiology of thee First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Hao Gao
- The Pancreas Center of the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Yong Gao
- The Pancreas Center of the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Qing Xu
- The Department of Radiology of thee First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Xisheng Liu
- The Department of Radiology of thee First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Yi Miao
- The Pancreas Center of the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Jishu Wei
- The Pancreas Center of the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
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12
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Satoi S, Yamamoto T, Yanagimoto H, Yamaki S, Kosaka H, Hirooka S, Kotsuka M, Ryota H, Michiura T, Inoue K, Matsui Y. Does modified Blumgart anastomosis without intra-pancreatic ductal stenting reduce post-operative pancreatic fistula after pancreaticojejunostomy? Asian J Surg 2018; 42:343-349. [PMID: 30087009 DOI: 10.1016/j.asjsur.2018.06.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 04/19/2018] [Accepted: 06/22/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Post-operative pancreatic fistula (POPF) is one of the most common and serious complications after pancreaticoduodenectomy (PD). The aim of this study is to retrospectively compare clinically relevant (CR) POPF and other complications after pacreaticojejunostomy (PJ) after modified Kakita (m-Kakita) or modified Blumgart (m-Blumgart) anastomoses without stenting in a single institution. METHODS One hundred twenty-eight patients underwent PJ using m-Kakita anastomoses (two interrupted penetrating sutures) between January 2009 and December 2011. One hundred eighteen patients underwent m-Blumgart anastomoses (two transpancreatic/jejunal seromuscular sutures to cover the pancreatic stump with jejunal serosa) between January 2014 and December 2015. Demographics, clinical characteristics, and post-operative mortality and morbidity were retrospectively compared between the two groups. RESULTS There were no significant differences in demographics or clinical characteristics between the two groups except operative time. A significantly lower rate of CR-POPF was found in the m-Blumgart group relative to the m-Kakita group (10% vs. 19%, p = 0.038). Univariate and multivariate analyses revealed that the m-Blumgart anastomosis and fistula risk category (Negligible, Low) were independently protective against CR-POPF (p < 0.05). CONCLUSION This retrospective single-center study demonstrated that the modified Blumgart method without pancreatic duct stenting was associated with a lower rate of CR-POPF.
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Affiliation(s)
- Sohei Satoi
- Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan.
| | - Tomohisa Yamamoto
- Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
| | - Hiroaki Yanagimoto
- Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
| | - So Yamaki
- Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
| | - Hisashi Kosaka
- Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
| | - Satoshi Hirooka
- Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
| | - Masaya Kotsuka
- Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
| | - Hironori Ryota
- Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
| | - Taku Michiura
- Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
| | - Kentaro Inoue
- Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
| | - Yoichi Matsui
- Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
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Abstract
The objective of this study is to diminish postoperative complications after pylorus-preserving pancreaticoduodenectomy. Pylorus-preserving pancreaticoduodenectomy is still associated with major complications, especially leakage at pancreatojejunostomy and delayed gastric emptying. Traditional pylorus-preserving pancreaticoduodenectomy was performed in group A, while the novel procedure, an antecolic vertical duodenojejunostomy and internal pancreatic drainage with omental wrapping, was performed in group B (n = 40 each). We compared the following characteristics between the 2 groups: operation time, blood loss, time required before removal of nasogastric tube and resumption of food intake, length of hospital stay, and postoperative complications. The novel procedure required less time and was associated with less blood loss (both P < 0.0001). In the comparison of the 2 groups, group B showed less time for removal of nasogastric tubes and resumption of food intake, shorter hospital stays, and fewer postoperative complications (all P < 0.0001). The novel procedure appears to be a safe and effective alternative to traditional pancreaticoduodenectomy techniques.
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Dong Z, Xu J, Wang Z, Petrov MS, Cochrane Upper GI and Pancreatic Diseases Group. Stents for the prevention of pancreatic fistula following pancreaticoduodenectomy. Cochrane Database Syst Rev 2016; 2016:CD008914. [PMID: 27153248 PMCID: PMC7156907 DOI: 10.1002/14651858.cd008914.pub3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Several studies have demonstrated that the use of pancreatic duct stents following pancreaticoduodenectomy is associated with a lower risk of pancreatic fistula. However, to date there is a lack of accord in the literature on whether the use of stents is beneficial and, if so, whether internal or external stenting, with or without replacement, is preferable. This is an update of a systematic review. OBJECTIVES To determine the efficacy of pancreatic stents in preventing pancreatic fistula after pancreaticoduodenectomy. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Web of Science, and four major Chinese biomedical databases up to November 2015. We also searched several major trials registers. SELECTION CRITERIA Randomized controlled trials (RCTs) comparing the use of stents (either internal or external) versus no stents, and comparing internal stents versus external stents, replacement versus no replacement following pancreaticoduodenectomy. DATA COLLECTION AND ANALYSIS Two review authors independently extracted the data. The outcomes studied were incidence of pancreatic fistula, need for reoperation, length of hospital stay, overall complications, and in-hospital mortality. We showed the results as risk ratio (RR) or mean difference (MD), with 95% confidence interval (CI). We assessed the quality of evidence using GRADE (http://www.gradeworkinggroup.org/). MAIN RESULTS We included eight studies (1018 participants). The average age of the participants ranged from 56 to 68 years. Most of the studies were conducted in single centers in Japan (four studies), China (two studies), France (one study), and the USA (one study). The risk of bias was low or unclear for most domains across the studies. Stents versus no stentsThe effect of stents on reducing pancreatic fistula in people undergoing pancreaticoduodenectomy was uncertain due to the low quality of the evidence (RR 0.67, 95% CI 0.39 to 1.14; 605 participants; 4 studies). The risk of in-hospital mortality was 3% in people who did receive stents compared with 2% (95% CI 1% to 6%) in people who had stents (RR 0.73, 0.28 to 1.94; 605 participants; 4 studies; moderate-quality evidence). The effect of stents on reoperation was uncertain due to wide confidence intervals (RR 0.67, 0.36 to 1.22; 512 participants; 3 studies; moderate-quality evidence). We found moderate-quality evidence that using stents reduces total hospital stay by just under four days (mean difference (MD) -3.68, 95% CI -6.52 to -0.84; 605 participants; 4 studies). The risk of delayed gastric emptying, wound infection, and intra-abdominal abscess was uncertain (gastric emptying: RR 0.75, 95% CI 0.24 to 2.35; moderate-quality evidence) (wound infection: RR 0.73, 95% CI 0.40 to 1.32; moderate-quality evidence) (abscess: RR 1.38, 0.49 to 3.85; low-quality evidence). Subgroup analysis by type of stent provided limited evidence that external stents lead to lower risk of fistula compared with internal stents. External versus internal stentsThe effect of external stents on the risk of pancreatic fistula, reoperation, delayed gastric emptying, and intra-abdominal abscess compared with internal stents was uncertain due to low-quality evidence (fistula: RR 1.44, 0.94 to 2.21; 362 participants; 3 studies) (reoperation: RR 2.02, 95% CI 0.38 to 10.79; 319 participants; 3 studies) (gastric emptying: RR 1.65, 0.66 to 4.09; 362 participants; 3 studies) (abscess: RR 1.91, 95% CI 0.80 to 4.58; 362 participants; 3 studies). The rate of in-hospital mortality was lower in studies comparing internal and external stents than in those comparing stents with no stents. One death occurred in the external-stent group (RR 0.33, 0.01 to 7.99; low-quality evidence). There were no cases of pancreatitis in participants who had internal stents compared with three in those who had external stents (RR 0.15, 0.01 to 2.73; low-quality evidence). The difference between internal and external stents on total hospital stay was uncertain due to the wide confidence intervals around the average effect of 1.7 days fewer with internal stents (9.18 days fewer to 5.84 days longer; 262 participants; 2 studies; low-quality evidence). The analysis of wound infection could not exclude a protective effect with either approach (RR 1.41, 0.44 to 4.48; 319 participants; 2 studies; moderate-quality evidence). Operative replacement of pancreatic juice versus not replacing pancreatic juice There was insufficient evidence available from a small trial to ascertain the effect of replacing pancreatic juice. AUTHORS' CONCLUSIONS This systematic review has identified limited evidence on the effects of stents. We have not been able to identify convincing direct evidence of superiority of external over internal stents. We found a limited number of RCTs with small sample sizes. Further RCTs on the use of stents after pancreaticoduodenectomy are warranted.
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Affiliation(s)
- Zhiyong Dong
- The First Affiliated Hospital of Jinan UniversityDepartment of SurgeryNo.613, HuangPu Avenu WestGuangzhouGuangdongChina510630
- Affiliated Hospital of Pu Tian UniversityDepartment of SurgeryNo. 999, Dongzhen RoadPutianFujian ProvinceChina351100
- The First Affiliated Hospital of Guangxi Medical UniversityHepato‐Pancreato‐Biliary SurgeryNanningChina
| | - Jing Xu
- The First Affiliated Hospital of Guangxi Medical UniversityHepato‐Pancreato‐Biliary SurgeryNanningChina
| | - Zhen Wang
- The First Affiliated Hospital of Guangxi Medical UniversityDepartment of Gastrointestinal SurgeryNo.6, Shuang Yong RoadNanningGuangxiChina530021
| | - Maxim S Petrov
- The University of AucklandDepartment of SurgeryPrivate Bag 92019AucklandNew Zealand1142
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15
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Halloran CM, Platt K, Gerard A, Polydoros F, O'Reilly DA, Gomez D, Smith A, Neoptolemos JP, Soonwalla Z, Taylor M, Blazeby JM, Ghaneh P. PANasta Trial; Cattell Warren versus Blumgart techniques of panreatico-jejunostomy following pancreato-duodenectomy: Study protocol for a randomized controlled trial. Trials 2016; 17:30. [PMID: 26772736 PMCID: PMC4714471 DOI: 10.1186/s13063-015-1144-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Accepted: 12/23/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Failure of the pancreatic remnant anastomosis to heal following pancreato-duodenectomy is a major cause of significant and life-threatening complications, notably a post-operative pancreatic fistula. Recently, non-randomized trials have shown superiority of a most intuitive anastomosis (Blumgart technique), which involves both a duct-to-mucosa and a full-thickness pancreatic "U" stitch, in effect a mattress stitch, over a standard duct-mucosa technique (Cattell-Warren). The aim of this study is to examine if these findings remain within a randomized setting. METHODS/DESIGN The PANasta trial is a randomized, double-blinded multi-center study, whose primary aim is to assess whether a Blumgart pancreatic anastomosis (trial intervention) is superior to a Cattell-Warren pancreatic anastomosis (control intervention), in terms of pancreatic fistula rates. Patients with suspected malignancy of the pancreatic head, in whom a pancreato-duodenectomy is recommended, would be recruited from several UK specialist regional centers. The hypothesis to be tested is that a Blumgart anastomosis will reduce fistula rate from 20 to 10 %. Subjects will be stratified by research site, pancreatic consistency and diameter of pancreatic duct; giving a sample size of 253 per group. The primary outcome measure is fistula rate at the pancreatico-jejunostomy. Secondary outcome measures are: entry into adjuvant therapy, mortality, surgical complications, non-surgical complications, hospital stay, cancer-specific quality of life and health economic assessments. Enrolled patients will undergo pancreatic resection and be randomized immediately prior to pancreatic reconstruction. The operation note will only record "anastomosis constructed as per PANasta trial randomization," thus the other members of the trial team and patient are blinded. An inbuilt internal pilot study will assess the ability to randomize patients, while the construction of an operative manual and review of operative photographs will maintain standardization of techniques. DISCUSSION The PANasta trial will be the first multi-center randomized controlled trial (RCT) comparing two types of duct-to-mucosa pancreatic anastomosis with surgical quality assurance. TRIAL REGISTRATION ISRCTN52263879 . Date of registration 15 January 2015.
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Affiliation(s)
- Christopher M Halloran
- National Institutes of Health Research Liverpool Pancreas Biomedical Research Unit and Clinical Directorate of General Surgery, Royal Liverpool and Broadgreen University Hospitals NHS Trust and the University of Liverpool, Liverpool, L69 3GA, UK.
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, The Duncan Building, Daulby Street, Liverpool, L69 3GA, UK.
| | - Kellie Platt
- Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Block C Waterhouse Building, 1-3 Brownlow Street, Liverpool, L69 3GL, UK.
| | - Abbie Gerard
- Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Block C Waterhouse Building, 1-3 Brownlow Street, Liverpool, L69 3GL, UK.
| | - Fotis Polydoros
- Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Block C Waterhouse Building, 1-3 Brownlow Street, Liverpool, L69 3GL, UK.
| | - Derek A O'Reilly
- Department of Surgery, Manchester Royal Infirmary, Oxford Rd, Manchester, M13 9WL, UK. Derek.O'
| | - Dhanwant Gomez
- Queen's Medical Center, Derby Road, Nottingham, NG7 2UH, UK.
| | - Andrew Smith
- Department of Pancreatic Surgery, Abdominal Medicine and Surgery CSU, St James's University Hospital, 3rd Floor Bexley Wing, Leeds, LS9 7TF, UK.
| | - John P Neoptolemos
- National Institutes of Health Research Liverpool Pancreas Biomedical Research Unit and Clinical Directorate of General Surgery, Royal Liverpool and Broadgreen University Hospitals NHS Trust and the University of Liverpool, Liverpool, L69 3GA, UK.
- Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Block C Waterhouse Building, 1-3 Brownlow Street, Liverpool, L69 3GL, UK.
| | - Zahir Soonwalla
- Churchill Hospital, Oxford University Hospitals NHS Trust, Headington, Oxford, OX3 7LJ, UK.
| | - Mark Taylor
- Mater Hospital, Belfast Health and Social care Trust, Crumlin Rd, Belfast, BT12 6AB, UK.
| | - Jane M Blazeby
- Bristol Center for Surgical Research, School of Social and Community Medicine, University of Bristol, BS8 2PS and University Hospitals Bristol NHS Foundation Trust, Bristol, BS2 8HW, UK.
| | - Paula Ghaneh
- National Institutes of Health Research Liverpool Pancreas Biomedical Research Unit and Clinical Directorate of General Surgery, Royal Liverpool and Broadgreen University Hospitals NHS Trust and the University of Liverpool, Liverpool, L69 3GA, UK.
- Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Block C Waterhouse Building, 1-3 Brownlow Street, Liverpool, L69 3GL, UK.
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16
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Lee JG, Lee SH, Lim JH, Park JS, Yoon DS, Kim KS. Is Pancreaticoduodenectomy Feasible for Recurrent Remnant Bile Duct Cancer Following Bile Duct Segmental Resection? J Gastrointest Surg 2015; 19:2138-45. [PMID: 26341821 DOI: 10.1007/s11605-015-2927-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 08/13/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND When bile duct cancer recurs after surgery, treatment options are limited. This study examines the usefulness of reoperative pancreaticoduodenectomy for recurrent cancer after initial segmental bile duct resection. METHODS Six patients (5 males, 1 females; median age 65 years) who underwent pancreaticoduodenectomy for recurrent remnant bile duct cancer following segmental bile duct resection were included: 4 underwent surgery at Severance Hospital and 2 at Gangnam Severance Hospital from January 2000 to December 2013. Medical records data were retrospectively reviewed, including demographics, type of first and second surgery, radicality of resection, TNM stage, adjuvant treatments, complications, and survival. Kaplan-Meier curves were used to analyze survival. RESULTS The median interval between operations was 57 (range 7-95) months. Median operation time was 6.9 (range 5.2-12.8) h, blood loss was 400 (range 50-1170) mL, intensive care unit stay was 1 (range 1-2) day, and postoperative hospital stay was 33 (range 15-55) days. No patient died. Four had severe complications. The median survival after pancreaticoduodenectomy was 16 (range 5-89) months. Four patients had recurrence. T stage, N stage, and resection radicality influenced survival. CONCLUSION Pancreaticoduodenectomy is reasonable for recurrent remnant bile duct cancer following segmental bile duct resection, particularly for patients with no distant metastasis, locally confined recurrence, and good general condition.
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Affiliation(s)
- Jae Geun Lee
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.
| | - Sung Hwan Lee
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.
| | - Jin Hong Lim
- Department of Surgery, Yongin Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.
| | - Joon Seong Park
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.
| | - Dong Sup Yoon
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea.
| | - Kyung Sik Kim
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea. .,Department of Surgery, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
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17
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Yardimci S, Kara YB, Tuney D, Attaallah W, Ugurlu MU, Dulundu E, Yegen ŞC. A Simple Method to Evaluate Whether Pancreas Texture Can Be Used to Predict Pancreatic Fistula Risk After Pancreatoduodenectomy. J Gastrointest Surg 2015; 19:1625-31. [PMID: 25982120 DOI: 10.1007/s11605-015-2855-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 05/04/2015] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Soft pancreas is one of the most important risk factor for postoperative pancreatic fistula after pancreatoduodenectomy. The aim of this study is to investigate whether pancreatic attenuation index utilized to assess the pancreatic texture with computed tomography can be used to predict the risk of developing a clinically relevant postoperative pancreatic fistula after pancreatoduodenectomy. METHODS We reviewed 76 consecutive patients undergoing pancreatoduodenectomy between 2012 and 2014. The pancreatic attenuation index is found by dividing the pancreas density by the spleen density achieved with non-enhanced computed tomography. The independent predictors of clinically relevant postoperative pancreatic fistula were investigated. RESULTS Clinically relevant postoperative pancreatic fistula occurred in 13 patients (17.1%). The group of patients with postoperative pancreatic fistula is compared with the group of patients without postoperative pancreatic fistula in terms of age, gender, body mass index, the American Society of Anesthesiologists (ASA) score, smoking, alcohol consumption, medical comorbidities, preoperative biliary drainage, type of anastomosis, and pancreatic duct size and pancreatic attenuation index. Univariate analyses have shown a significant difference in relation to chronic obstructive pulmonary disease and pancreatic attenuation index. The multivariate analyses showed that only pancreatic attenuation index was associated with a high postoperative pancreatic fistula rate (P = 0.012). CONCLUSION A preoperative non-contrast computed tomography scan evaluating pancreatic attenuation index could help to predict the occurrence of clinically significant postoperative pancreatic fistula after pancreatoduodenectomy.
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Affiliation(s)
- Samet Yardimci
- Department of General Surgery, Marmara University Pendik Education and Research Hospital, Mimar Sinan C. Marmara Universitesi Pendik EAH Genel Cerrahi Klinigi, Ust Kaynarca, Pendik, Istanbul, Turkey,
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18
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Yamashita K, Sasaki T, Itoh R, Kato D, Hatano N, Soejima T, Ishii K, Takenawa T, Hiromatsu K, Yamashita Y. Pancreatic fistulae secondary to trypsinogen activation by Pseudomonas aeruginosa infection after pancreatoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:454-62. [PMID: 25678202 DOI: 10.1002/jhbp.223] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 01/13/2015] [Indexed: 01/27/2023]
Abstract
BACKGROUND Pancreatic fistula after pancreatoduodenectomy (PD) is associated with high mortality and morbidity. Trypsinogen activation and bacteria, although hypothesized to be interrelated etiopathogenetically, have not had their relationship and pathogenic mechanisms elucidated. This study investigated bacterial involvement in pancreatic juice activation perioperatively after PD at sites of pancreatic fistula formation. METHODS Fifty patients underwent PD; postoperative pancreatic fistulae were graded based on the International Study Group for Pancreatic Fistula grading criteria. Bacteria were isolated from cultures of drainage fluid. Digested peptides from trypsinogen and bacterial culture supernatants underwent sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) separation and mass spectrometric analysis. Zymography was used to detect the trypsinogen activator. RESULTS Pseudomonas aeruginosa and Enterobacter cloacae isolated from drainage fluid in patients with grades B and C pancreatic fistulae could cause trypsinogen activation. Trypsinogen activation by P. aeruginosa and E. cloacae were preventable by the use of a serine protease inhibitor in vitro. A protease in the supernatant from P. aeruginosa-positive cultures acted as the trypsinogen activator. CONCLUSIONS Infection with P. aeruginosa perioperatively to PD entails secretion of a protease activator of trypsinogen to trypsin. Bacterial infection control in the perioperative PD period could be crucial to prevent development of pancreatic fistula.
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Affiliation(s)
- Kanefumi Yamashita
- Department of Gastroenterological Surgery, Fukuoka University School of Medicine, Nanakuma 7-45-1, Jonan-ku, Fukuoka 814-0180, Japan
| | - Takamitsu Sasaki
- Department of Gastroenterological Surgery, Fukuoka University School of Medicine, Nanakuma 7-45-1, Jonan-ku, Fukuoka 814-0180, Japan.
| | - Ryota Itoh
- Department of Microbiology and Immunology, Fukuoka University School of Medicine, Jonan-ku, Fukuoka, Japan
| | - Daisuke Kato
- Department of Gastroenterological Surgery, Fukuoka University School of Medicine, Nanakuma 7-45-1, Jonan-ku, Fukuoka 814-0180, Japan
| | - Naoya Hatano
- Integrated Center for Mass Spectrometry, Kobe University, Kobe, Hyogo, Japan
| | - Toshinori Soejima
- Department of Microbiology and Immunology, Fukuoka University School of Medicine, Jonan-ku, Fukuoka, Japan
| | - Kazunari Ishii
- Department of Microbiology and Immunology, Fukuoka University School of Medicine, Jonan-ku, Fukuoka, Japan
| | - Tadaomi Takenawa
- Integrated Center for Mass Spectrometry, Kobe University, Kobe, Hyogo, Japan
| | - Kenji Hiromatsu
- Department of Microbiology and Immunology, Fukuoka University School of Medicine, Jonan-ku, Fukuoka, Japan
| | - Yuichi Yamashita
- Department of Gastroenterological Surgery, Fukuoka University School of Medicine, Nanakuma 7-45-1, Jonan-ku, Fukuoka 814-0180, Japan
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Pancreaticojejunostomy with double-layer continuous suturing is associated with a lower risk of pancreatic fistula after pancreaticoduodenectomy: a comparative study. Int J Surg 2014; 13:84-89. [PMID: 25481836 DOI: 10.1016/j.ijsu.2014.11.034] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 11/25/2014] [Indexed: 01/11/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) remains a leading cause of morbidity and mortality after pancreaticoduodenectomy (PD). Thus, a number of technical modifications regarding the pancreatoenteric anastomosis after PD have been proposed to reduce POPF rate. In this article we focused on evaluating whether the double layer continuous suture technique was better than the double layer interrupted suture technique in pancreatic-enteric anastomosis after PD. MATERIAL AND METHODS From 2012 to 2013, 114 patients (67 men and 47 women) underwent a pancreatic-enteric anastomosis after PD were analysed. There were 79 patients using the double layer continuous suture technique and 35 patients were using the double layer interrupted suture technique. The operation time, intraoperative blood loss, initial postoperative day of oral feeding, postoperative hospital stay and the presence of main early complications (pancreatic fistulas) were evaluated by chi-square test or unpaired t-test in this study. RESULTS Pancreatic fistulas occurred in patients with double layer continuous suture was 17.14%(6/35), and in those with interrupted suture was 39.24%(31/79) (p<0.05). Grade A of POPF was found in 4 patients (4/35, 11.43%) of the double layer continuous suture group and in 5 patients (5/79, 6.33%) of the double layer interrupted suture group. Grade B of POPF was identified only in 1 patients (1/35, 2.83%) of the double layer continuous suture group and in 23 patients (23/79, 29.11%) of the double layer interrupted suture group. The presence of Grade C pancreatic fistulas was only documented in one patient in the double layer continuous suture group and 3 patients in the interrupted suture group. No operative or in-hospital deaths occurred. CONCLUSIONS The double-layer continuous suturing after PD is safe, reliable, rapid, favorable and associated with a lower risk of pancreatic fistula than the double layer interrupted suture.
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Fontes PRO, Waechter FL, Nectoux M, Sampaio JA, Teixeira UF, Pereira-Lima L. Low mortality rate in 97 consecutive pancreaticoduodenectomies: the experience of a group. ARQUIVOS DE GASTROENTEROLOGIA 2014; 51:29-33. [PMID: 24760061 DOI: 10.1590/s0004-28032014000100007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Accepted: 11/04/2013] [Indexed: 12/21/2022]
Abstract
CONTEXT Pancreaticoduodenectomy is the procedure of choice for resectable cancer of the periampullary region. These tumors account for 4% of deaths from cancer, being referred to as one of the lowest survival rates at 5 years. Surgery remains a complex procedure with substantial morbidity and mortality. Despite reports of up to 30% mortality rates, in centers of excellence it have been identified as less than 5%. Recent studies show that pancreaticojejunostomy represents the "Achilles' heel" of the procedure. OBJECTIVE To evaluate the post-operative 30 days morbidity and mortality rates. METHODS Retrospective analysis of 97 consecutive resected patients between July, 2000 and December, 2012. All patients were managed by the same group, and data were obtained from specific database service. The main objective was to evaluate the 30-day mortality rate, but we also studied data of surgical specimen, need for vascular resection and postoperative complications (gastric stasis, pancreatic fistula, pneumonia and reoperation rate). RESULTS Thirty-day mortality rate was 2.1% (two patients). Complete resection with no microscopic residual tumor was obtained in 93.8% of patients, and in 67.3% of cases pathology did not detected metastatic nodes. Among postoperative complications were reported 6% of prolonged gastric stasis, 10.3% of pneumonia, 10.3% of pancreatic fistula and 1% of infection in the drain pathway. Two patients underwent reoperation due to bleeding and infected hematoma caused by pancreatic fistula, and another for intestinal obstruction because of adhesions at postoperative day 12. CONCLUSIONS The pancreaticoduodenectomy as treatment procedure for periampullary cancers has a low morbidity and mortality rate in services with experience in Hepato-Pancreato-Biliary surgery, remaining as first-line treatment in resectable patients.
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Affiliation(s)
- Paulo Roberto Ott Fontes
- Universidade Federal de Ciências de Saúde de Porto Alegre, UFCSPA ? Departamento de Clínica Cirúrgica, Porto Alegre, RS, Brasil
| | - Fábio Luiz Waechter
- Universidade Federal de Ciências de Saúde de Porto Alegre, UFCSPA ? Departamento de Clínica Cirúrgica, Porto Alegre, RS, Brasil
| | - Mauro Nectoux
- Universidade Federal de Ciências de Saúde de Porto Alegre, UFCSPA ? Departamento de Clínica Cirúrgica, Porto Alegre, RS, Brasil
| | - José Artur Sampaio
- Universidade Federal de Ciências de Saúde de Porto Alegre, UFCSPA ? Departamento de Clínica Cirúrgica, Porto Alegre, RS, Brasil
| | - Uirá Fernandes Teixeira
- Universidade Federal de Ciências de Saúde de Porto Alegre, UFCSPA ? Departamento de Clínica Cirúrgica, Porto Alegre, RS, Brasil
| | - Luiz Pereira-Lima
- Universidade Federal de Ciências de Saúde de Porto Alegre, UFCSPA ? Departamento de Clínica Cirúrgica, Porto Alegre, RS, Brasil
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Harnoss JC, Ulrich AB, Harnoss JM, Diener MK, Büchler MW, Welsch T. Use and results of consensus definitions in pancreatic surgery: a systematic review. Surgery 2013; 155:47-57. [PMID: 24694359 DOI: 10.1016/j.surg.2013.05.035] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 05/28/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND Because of the lack of standardized definitions of complications in gastrointestinal operations, consensus definitions have been developed in recent years. The aim of the current study was to systematically review the available consensus definitions and to report their use, acceptance, and results. METHODS A systematic search of the literature was conducted of the Medline, Cochrane, and ISI Web of Science databases. All articles published until August 2011 and that applied the identified consensus definitions were considered. Inclusion criteria for quantitative analysis were studies with correct usage of the definition and 100 or more patients who were treated after the year 2000. RESULTS Seven consensus definitions were identified: postoperative pancreatic fistula, postpancreatectomy hemorrhage, delayed gastric emptying, posthepatectomy liver failure, bile leakage after hepatobiliary and pancreatic surgery, posthepatectomy hemorrhage, and anastomotic leakage after anterior resection of the rectum. Of 1,637 articles retrieved from the literature search, 59 articles that correctly applied the definitions met the inclusion criteria. Subanalyses were feasible for definitions after pancreatic surgery. According to the consensus definitions, the median complication rates of retrospective studies were 21.9% (postoperative pancreatic fistula, n = 11,244 patients), 5.9% (postpancreatectomy hemorrhage, n = 3,311 patients), and 22.8% (delayed gastric emptying, n = 4,553 patients) after pancreatic resections. The incidences were not substantially different in prospective trials. Validation was performed for all three definitions, demonstrating that the severity grades significantly correlated with the clinical course of the patients. CONCLUSION The available consensus definitions were increasingly cited and facilitate scientific comparability and transparency if appropriately applied. The present data update the incidences of major pancreatic complications.
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Affiliation(s)
- Julian C Harnoss
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Alexis B Ulrich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
| | - Jonathan M Harnoss
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thilo Welsch
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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Yamaki S, Satoi S, Toyokawa H, Yanagimoto H, Yamamoto T, Hirooka S, Yui R, Inoue K, Matsui Y, Kwon AH. The clinical role of critical pathway implementation for pancreaticoduodenectomy in 179 patients. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 20:271-8. [PMID: 22407192 DOI: 10.1007/s00534-012-0506-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND/PURPOSE In June 2004, a critical pathway for patients undergoing pancreaticoduodenectomy (PD) was introduced. The objective of this study was to determine the clinical value of critical pathway implementation. METHODS 256 consecutive patients who underwent PD between 2000 and 2010 were divided into 4 groups by date of operation as follows; group A (n = 77), the pre-pathway group; group B (n = 51), the CP implementation group who were managed according to departmental guidelines; group C (n = 78), the group who had no stenting in the reconstruction of PD; and group D (n = 50), the group who had reinforcement of the pancreaticojejunostomy. The success rates of clinical outcomes and post-operative morbidity were compared between each group, year by year and every 50 patients. RESULTS The success rates of clinical outcomes, including the timings of nasogastric tube removal, discontinuation of prophylactic anti-microbial agent, drain removal, starting oral intake, and patient discharge, were significantly improved in group B relative to group A, and in group C relative to group B. There were no significant differences in mortality and morbidity between any of the groups. All clinical outcomes reached a plateau at 2-3 years or 100-150 patients' operations after critical pathway implementation. CONCLUSIONS Long-term use of a critical pathway is associated with improved clinical outcomes. A certain period of time or volume of patients is needed for this improvement in clinical outcomes to reach a plateau, which indicates achieving standardization of peri-operative management.
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Affiliation(s)
- So Yamaki
- Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
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External stent versus no stent for pancreaticojejunostomy: a meta-analysis of randomized controlled trials. J Gastrointest Surg 2013; 17:1516-25. [PMID: 23568149 DOI: 10.1007/s11605-013-2187-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 03/18/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND The effectiveness of an external pancreatic duct stent for reduction of the pancreatic fistula after pancreaticoduodenectomy remains controversial. METHODS MEDLINE, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials were searched for eligible randomized controlled trials (RCTs). Reviews of each trial were conducted and data were extracted. The primary outcome was pancreatic fistula. Statistical pooling used the fixed or random effects model and reported as risk ratio (RR) or mean difference (MD) with the corresponding 95 % confidence intervals (CI). RESULTS Four RCTs including a total of 416 patients were detected. Methodological quality assessment revealed a better quality of all analyzed trials. Placing an external stent across pancreaticojejunal anastomosis could significantly reduce the incidence of pancreatic fistula (RR = 0.57, 95 % CI = 0.41-0.80, P = 0.001, I (2) = 0 %), overall morbidity (RR = 0.79, 95 % CI = 0.64-0.98, P = 0.03), and the length of hospital stay (MD = -3.98 days, 95 % CI = -6.42 to -1.54, P = 0.001, I (2) = 13 %). No significant difference was found in terms of hospital mortality, delayed gastric emptying, operation time, operative blood loss, blood replacement, and reoperation rate. CONCLUSIONS This meta-analysis provides compelling evidence that the application of an external pancreatic duct stent after pancreaticoduodenectomy can decrease the incidence of pancreatic leakage when compared with no stent. Moreover, the external drainage of pancreatic juice is associated with lower postoperative overall morbidity and shorter hospital stay.
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Yui R, Satoi S, Toyokawa H, Yanagimoto H, Yamamoto T, Hirooka S, Yamaki S, Ryota H, Michiura T, Inoue K, Matsui Y, Kwon AH. Less morbidity after introduction of a new departmental policy for patients who undergo open distal pancreatectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 21:72-7. [PMID: 23804436 DOI: 10.1002/jhbp.4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The aim of this study was to retrospectively compare morbidity and mortality before and after introduction of a new departmental policy for patients who undergo distal pancreatectomy. METHODS We have introduced the use of an ultrasonically-activated device in distal pancreatectomy, an "early removal of drains" policy and perioperative management using a clinical pathway since May 2006. Group A consisted of 52 consecutive patients from 2000 to February 2006. Group B consisted of 57 consecutive patients from May 2006 to 2010. RESULTS Although there was no difference in the fluid collection rate within 30 postoperative days (Group A, 44% vs. Group B, 35%), the rates of intra-abdominal abscess (A, 19% vs. B, 4%) and grade 3/4 of the Clavien classification (A, 23% vs. B, 9%) in Group B were significantly lower than in Group A (P < 0.05). Time of drain removal (median 3 days vs. 8 days) and length of in-hospital stay (median 8 days vs. 17 days) in Group B were significantly shorter than in Group A (P < 0.001). CONCLUSION The implementation of new departmental guidelines for distal pancreatectomy was closely associated with a low frequency of intra-abdominal abscess and grade 3/4 Clavien score, resulting in a shorter in-hospital stay.
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Affiliation(s)
- Rintaro Yui
- Department of Surgery, Kansai Medical University, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
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Dong Z, Xu J, Wang Z, Petrov MS. Stents for the prevention of pancreatic fistula following pancreaticoduodenectomy. Cochrane Database Syst Rev 2013:CD008914. [PMID: 23801548 DOI: 10.1002/14651858.cd008914.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Several studies have demonstrated that the use of pancreatic duct stents following pancreaticoduodenectomy is associated with a lower risk of pancreatic fistula. However, to date, there is a lack of accord in the literature on whether the use of stents is beneficial and, if so, whether internal or external stenting is preferable. OBJECTIVES To determine the efficacy of pancreatic stents in preventing pancreatic fistula after pancreaticoduodenectomy. SEARCH METHODS The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, ISI Web of Science and four major Chinese biomedical databases were searched up to February 2011. We also searched four major trials registers. SELECTION CRITERIA Randomized controlled trials (RCTs) comparing the use of stents (either internal or external) versus no stents, and comparing internal stents versus external stents following pancreaticoduodenectomy. DATA COLLECTION AND ANALYSIS Two authors extracted the data independently. The outcomes studied were incidence of pancreatic fistula, need for reoperation, length of hospital stay, overall complications, and in-hospital mortality. The results were shown as relative risk (RR) with 95% confidence interval (CI). MAIN RESULTS A total of 656 patients were included in the systematic review. Overall, the use of stents (both external and internal) was not associated with a statistically significant change in any of the studied outcomes. In a subgroup analysis, it was found that the use of external, but not internal, stents is associated with a significant reduction in the incidence of pancreatic fistulae (RR 0.33; 95% CI 0.11 to 0.98, P = 0.04), the incidence of complications (RR 0.48; 95% CI 0.25 to 0.92, P = 0.03) and length of hospital stay (RR -0.57; 95% CI -0.94 to -0.21, P = 0.002). In RCTs on the use of internal versus external stents, no statistically significant difference was found in terms of any of the studied outcomes. AUTHORS' CONCLUSIONS This systematic review suggests that the use of external stents following pancreaticoduodenectomy may be beneficial. However, only a limited number of RCTs with rather small sample sizes were available. Further RCTs on the use of stents after pancreaticoduodenectomy are warranted.
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Affiliation(s)
- Zhiyong Dong
- Hepato-Pancreato-Biliary Surgery, The First AffiliatedHospital of GuangxiMedical University, Nanning, China
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Honda G, Kurata M, Okuda Y, Kobayashi S, Yamaguchi T, Matsumoto H, Nakano D, Takahashi K. Novel Device for Pancreaticojejunostomy via a Pure Laparoscopic Approach. J Am Coll Surg 2013; 216:e73-6. [DOI: 10.1016/j.jamcollsurg.2013.02.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Revised: 02/15/2013] [Accepted: 02/19/2013] [Indexed: 01/22/2023]
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The impact of internal or external transanastomotic pancreatic duct stents following pancreaticojejunostomy. Which one is better? A meta-analysis. J Gastrointest Surg 2012; 16:2322-35. [PMID: 23011201 DOI: 10.1007/s11605-012-1987-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The use of pancreatic duct stent to improve postoperative outcomes of pancreatic anastomosis remains a matter of debate, and the value of stenting when performing anastomosis for normal pancreas (soft and duct less than 3 mm) needs further study. The aim of the present meta-analysis was to evaluate the perioperative outcomes of patients with stenting during pancreatic anastomosis and compare the effect of external stent with that of internal stent indirectly. METHODS A systematic literature search (EMBASE, MEDLINE, PubMed, The Cochrane Library, and Web of Science) was performed to identify studies evaluating external stent or internal stent. Included literature was assessed and extracted by two independent reviewers. A meta-analysis including comparative studies providing data on patients with and without external stenting or internal stenting during pancreaticojejunostomy anastomosis was performed. RESULTS Thirteen articles including 1,867 patients were identified for inclusion: five randomized controlled trials study and eight observational clinical studies. Meta-analyses revealed that use of external stent was associated with a significantly decreased risk for pancreatic fistula in total (odds ratio (OR) 0.47; 95 % confidence interval (CI) 0.31-0.71; P = 0.0004; I (2) = 3 %), pancreatic fistula in normal pancreas(OR 0.5; 95 % CI 0.30-0.82; P = 0.007; I (2) = 5 %), and overall morbidity(OR 0.64; 95 % CI 0.45-0.90; P = 0.01; I (2) = 0 %); however, the meta-analysis showed that there were no significant differences between internal stenting and non-stenting groups as regards perioperative outcomes and that in fact it may increase pancreatic fistula rate in normal pancreas(OR 1.97; 95 % CI 1.05-3.69; P = 0.03; I (2) = 0 %). CONCLUSIONS The results of this analysis demonstrate a trend toward reduced pancreatic fistula with the use of external pancreatic stents in pancreaticojejunostomy. An internal stent does not impact development of fistula and that in fact it was not useful in a soft pancreas. Our conclusion may be limited to stenting during the duct-to-mucosa pancreaticojejunostomy anastomosis, and the value of stenting during invagination anastomosis needs further study.
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The use of the continuous suture technique in dunking pancreatojejunostomy without stenting. Surg Today 2012; 43:1008-12. [DOI: 10.1007/s00595-012-0363-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2011] [Accepted: 07/05/2012] [Indexed: 12/17/2022]
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Denbo JW, Orr WS, Zarzaur BL, Behrman SW. Toward defining grade C pancreatic fistula following pancreaticoduodenectomy: incidence, risk factors, management and outcome. HPB (Oxford) 2012; 14:589-93. [PMID: 22882195 PMCID: PMC3461384 DOI: 10.1111/j.1477-2574.2012.00486.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In 2005 the International Study Group for Pancreatic Fistula (ISGPF) created a definition and grading system for pancreatic fistulae (PF) in which grade C denotes the most severe and potentially life-threatening type. Factors and outcomes associated with grade C fistulae have been ill defined. METHODS Systematic searches of PubMed and EMBASE were conducted by two independent reviewers utilizing the keywords 'pancreaticoduodenectomy' (PD) and 'pancreatic fistula'. Inclusion criteria were: (i) a sample of ≥100 patients; (ii) consecutive accrual of all pathologies, and (iii) use of the ISGPF definition and grading system. Quality appraisal and data extraction were performed using pilot-tested templates. RESULTS Fourteen articles describing a total of 2706 PDs met the study entrance criteria. Pancreatic fistulae occurred in 479 patients (18%) and included 71 grade C PF that were directly responsible for 25 deaths (35% mortality rate). Only two studies analysed risk factors; these found soft pancreatic texture and histology other than adenocarcinoma to be the most common risk factors. Ten studies reported management strategies and indicated that 51% of patients required reoperation. CONCLUSIONS Grade C PF: (i) accounts for 15% of fistulae following PD and has an associated mortality rate of 35%; (ii) occurs most commonly in pathology associated with a soft remnant, and (iii) requires reoperation in approximately one half of patients. The published literature incompletely describes grade C PF.
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Affiliation(s)
- Jason W Denbo
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
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Xiong JJ, Altaf K, Mukherjee R, Huang W, Hu WM, Li A, Ke NW, Liu XB. Systematic review and meta-analysis of outcomes after intraoperative pancreatic duct stent placement during pancreaticoduodenectomy. Br J Surg 2012; 99:1050-61. [PMID: 22622664 DOI: 10.1002/bjs.8788] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2012] [Indexed: 02/05/2023]
Abstract
BACKGROUND Postoperative pancreatic leakage after pancreaticoduodenectomy is often serious. Although some studies have suggested that stenting the anastomosis can reduce the incidence of this complication, the value of stenting in the setting of pancreaticoduodenectomy remains unclear. METHODS Studies comparing outcomes of stent versus no stent, and internal versus external stent placement for pancreaticoduodenectomy were eligible for inclusion. Pooled odds ratios (ORs) with 95 per cent confidence intervals were calculated using fixed- or random-effects models. RESULTS From a search of the literature published between January 1973 and September 2011, five randomized clinical trials (RCTs) and 11 non-randomized observational clinical studies (OCS) involving 1726 patients were selected for inclusion in this review. Meta-analysis of RCTs revealed that placing a stent in the pancreatic duct did not reduce the incidence of postoperative pancreatic fistula. External stents had no advantage over internal stents in terms of clinical outcome. Subgroup analyses revealed that use of an external stent significantly reduced the incidence of pancreatic fistula (RCTs: OR 0·42, 0·24 to 0·76, P = 0·004; OCS: OR 0·43, 0·27 to 0·68, P < 0·001), delayed gastric emptying (RCTs: OR 0·41, 0·19 to 0·87, P = 0·02) and postoperative morbidity (RCTs: OR 0·55, 0·34 to 0·89, P = 0·02) compared with no stent. CONCLUSION Pancreatic duct stenting did not reduce the incidence of pancreatic fistula and other complications in pancreaticoduodenectomy compared with no stenting. Although no difference was found between external and internal stents in terms of efficacy, external stents seemed to reduce the incidence of pancreatic fistula compared with control.
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Affiliation(s)
- J J Xiong
- Department of Hepato-Biliary-Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
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Motoi F, Egawa S, Rikiyama T, Katayose Y, Unno M. Randomized clinical trial of external stent drainage of the pancreatic duct to reduce postoperative pancreatic fistula after pancreaticojejunostomy. Br J Surg 2012; 99:524-31. [PMID: 22497024 DOI: 10.1002/bjs.8654] [Citation(s) in RCA: 155] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) remains one of the most common causes of morbidity following pancreaticoduodenectomy (PD). This randomized trial examined whether external stent drainage of the pancreatic duct decreases the rate of POPF after PD and subsequent pancreaticojejunostomy (PJ). METHODS Consecutive patients who underwent PD with subsequent construction of a duct-to-mucosa PJ were randomized into a stented and a non-stented group. The primary outcome was the incidence of clinically relevant POPF. Secondary outcomes were morbidity and mortality rates, and hospital stay. RESULTS Of 114 PD procedures, 93 were suitable for inclusion in the study after informed consent. The rate of clinically relevant POPF was significantly lower in the stented group than in the non-stented group: three of 47 (6 per cent) versus ten of 46 (22 per cent) (P = 0·040). Among patients with a dilated duct, rates of POPF were similar in both groups. Among patients with a non-dilated duct, clinically relevant POPF was significantly less common in the stented group than in the non-stented group: two of 21 (10 per cent) versus eight of 20 (40 per cent) (P = 0·033). No significant differences in morbidity or mortality were observed. Univariable analysis identified body mass index (BMI), pancreatic cancer,pancreatic texture, pancreatic duct size and duct stenting as risk factors related to clinically relevant POPF. Multivariable analysis taking these five factors into account identified high BMI (risk ratio(RR) 11·45; P = 0·008), non-dilated duct (RR 5·33; P = 0·046) and no stent (RR 10·38; P = 0·004) as significant risk factors. CONCLUSION External duct stenting reduced the risk of clinically relevant POPF after PD and subsequent duct-to-mucosa PJ.
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Affiliation(s)
- F Motoi
- Division of Gastroenterological Surgery, Department of Surgery, Graduate School of Medicine, Tohoku University, 1-1 Seiryo-machi, Aoba-ku, Sendai980-8574, Japan.
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Aziz AM, Abbas A, Gad H, Al-Saif OH, Leung K, Meshikhes AWN. Pancreaticoduodenectomy in a tertiary referral center in Saudi Arabia: a retrospective case series. J Egypt Natl Canc Inst 2012; 24:47-54. [PMID: 23587232 DOI: 10.1016/j.jnci.2011.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Accepted: 12/26/2011] [Indexed: 12/20/2022] Open
Abstract
CONTEXT Perioperative outcome of pancreaticoduodenectomy is related to work load volume and to whether the procedure is carried out in a tertiary specialized hepato-pancreatico-biliary (HPB) unit. OBJECTIVE To evaluate the perioperative outcome associated with pancreaticoduodenectomy in a newly established HPB unit. PATIENTS Analysis of 32 patients who underwent pancreaticoduodenectomy (PD) for benign and malignant indications. DESIGN Retrospective collection of data on preoperative, intraoperative and postoperative care of all patients undergoing PD. RESULTS Thirty-two patients (16 male and 16 female) with a mean age of 59.5±12.7years were analyzed. The overall morbidity rate was high at 53%. The most common complication was wound infection (n=11; 34.4%). Pancreatic and biliary leaks were seen in 5 (15.6%) and 2 (6.2%) cases, respectively, while delayed gastric emptying was recorded in 7 (21.9%). The female sex was not associated with increased morbidity. Presence of co-morbid illness, pylorus-preserving PD, intra-operative blood loss ⩾1L, and perioperative blood transfusion were not associated with significantly increased morbidity. The overall hospital mortality was 3.1% and the cumulative overall (OS) and disease free survival (DFS) at 1year were 80% and 82.3%, respectively. The cumulative overall survival for pancreatic cancer vs ampullary tumor at 1year were 52% vs 80%, respectively. CONCLUSION PD is associated with a low risk of operative death when performed by specialized HPB surgeons even in a tertiary referral hospital. However, the postoperative morbidity rate remains high, mostly due to wound infection. Further improvement by reducing postoperative infection may help curtail the high postoperative morbidity.
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Affiliation(s)
- Amr Mostafa Aziz
- Section of Hepato-pancreatico-biliary Surgery, King Fahad Specialist Hospital, Dammam 31444, Eastern Province, Saudi Arabia.
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Shimoda M, Katoh M, Yukihiro I, Kita J, Sawada T, Kubota K. Body Mass Index is a Risk Factor of Pancreatic Fistula after Pancreaticoduodenectomy. Am Surg 2012. [DOI: 10.1177/000313481207800237] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Pancreatic fistula (PF) after pancreaticoduodenectomy (PD) is still a severe complication and a challenging problem. The common risk factors are the soft pancreas and small pancreatic duct of the remnant pancreas. Those two risk factors were recognized during surgery. On the other hand, a preoperatively determined risk factor of PF is unclarified. We conducted a retrospective analysis of 203 patients consecutively treated by PD from April 2000 to October 2010. PF was defined according to the criteria of the International Study Group of Pancreatic Fistula. Clinical and pre-and intraoperative data were compared between PF and non-PF patients. The recommended cutoff value of body mass index (BMI) as 20 kg/m2 was defined by receiver operating characteristic curve analysis. PF occurred in 53 (26.1%) of 203 patients. In univariate analysis, BMI and soft remnant pancreas were found to be risk factors of PF ( P = 0.027, P = 0.005). In multivariate analysis, BMI and soft pancreas were also risk factors of PF ( P = 0.040, P = 0.005). Patients with PF had a significantly longer hospital stay than non-PF patients ( P = 0.005). High BMI and soft pancreas were significant risk factors for PF.
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Affiliation(s)
- Mitsugi Shimoda
- Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Masato Katoh
- Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Iso Yukihiro
- Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Junji Kita
- Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Tokihiko Sawada
- Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan
| | - Keiichi Kubota
- Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan
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Katsuno A, Aimoto T, Uchida E, Tabata Y, Miyamoto M, Tajiri T. The Controlled Release of Basic Fibroblast Growth Factor Promotes a Rapid Healing of Pancreaticojejunal Anastomosis with Potent Angiogenesis and Accelerates Apoptosis in Granulation Tissue. J Surg Res 2011; 167:166-72. [PMID: 19766245 DOI: 10.1016/j.jss.2009.05.042] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2009] [Revised: 05/09/2009] [Accepted: 05/20/2009] [Indexed: 10/20/2022]
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Satoi S, Yanagimoto H, Toyokawa H. Use of the new ultrasonically curved shear in pancreaticoduodenectomy for periampullary cancer. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2011; 18:609-14. [DOI: 10.1007/s00534-011-0370-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Sohei Satoi
- Department of Surgery; Kansai Medical University; 2-3-1 Shin-machi Hirakata Osaka 573-1191 Japan
| | - Hiroaki Yanagimoto
- Department of Surgery; Kansai Medical University; 2-3-1 Shin-machi Hirakata Osaka 573-1191 Japan
| | - Hideyoshi Toyokawa
- Department of Surgery; Kansai Medical University; 2-3-1 Shin-machi Hirakata Osaka 573-1191 Japan
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Dong Z, Petrov MS, Xu J, Wang Z. Stents for the prevention of pancreatic fistula following pancreaticoduodenectomy. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2011. [DOI: 10.1002/14651858.cd008914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Abstract
OBJECTIVES To examine whether pressure-tight reinforcement of pancreaticojejunostomy (PJ) using polyglycolic acid (PGA) mesh and fibrin glue sealant can reduce the incidence of postoperative pancreatic fistula (POPF). METHODS The study population included 128 consecutive patients who underwent pancreaticoduodenectomy between September 2006 and January 2010. Postoperative mortality and morbidity among 50 patients who underwent reinforcement of PJ anastomosis using PGA mesh and fibrin glue were compared with 78 patients (historical controls). RESULTS The 2 groups demonstrated no significant differences in frequencies of overall or septic complications, reoperation, or in-hospital death. No significant difference in the frequency of POPF, delayed gastric emptying, or intra-abdominal abscess was found between groups. There was no difference between the 2 groups in the number of necessary interventions, and no bleeding complications or POPF-related mortality occurred. The median length of postoperative in-hospital stay between the 2 groups was similar: 13 days (range, 8-101 days) versus 14 days (range, 8-61 days). Similar findings were observed in a subgroup analysis consisting of patients with a pancreatic duct diameter smaller than 3 mm. CONCLUSION This retrospective single-center study showed that reinforcement of PJ anastomosis using PGA mesh and fibrin glue provided no significant benefit in reducing the frequency of POPF.
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Abstract
OBJECTIVES After standardization of the perioperative management of pancreaticoduodenectomy, we retrospectively compared results in nonstented pancreaticojejunostomy with external-stented pancreaticojejunostomy. METHODS The study population included 129 consecutive patients who underwent pancreaticoduodenectomy between 2004 and 2008. The postoperative mortality and morbidity were compared between 51 patients with restrictive use of external stenting (group A) and 78 patients without external stenting (group B). The patient with a pancreatic duct of less than 3 mm in diameter was 31% in group A and 46% in group B. RESULTS There were no differences in postoperative morbidity and mortality between the 2 groups. Although the frequency of overall postoperative pancreatic fistula development was significantly higher in group B than in group A (44% vs 27%, P = 0.0004), there was no difference in grade B/C postoperative pancreatic fistula rate (group A: 5.9% vs group B: 14.1%). The length of in-hospital stay in group B was significantly shorter than group A (13 vs 24 days, P < 0.0001). There were no differences in postoperative morbidity and mortality between subgroups that were consisted of patients with small pancreatic duct diameter. CONCLUSION This retrospective single-center study showed that nonstented duct-to-mucosa anastomosis was a safe procedure and was associated with a shortened in-hospital stay.
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Li Z, Zhang Z, Hu W, Zeng Y, Liu X, Mai G, Zhang Y, Lu H, Tian B. Pancreaticoduodenectomy with preoperative obstructive jaundice: drainage or not. Pancreas 2009; 38:379-86. [PMID: 19258915 DOI: 10.1097/mpa.0b013e31819f638b] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES In this study, we determined whether preoperative biliary drainage should be routinely performed in patients with jaundice. METHODS The 342 patients undergoing pancreaticoduodenectomy between June 2004 and June 2008 were analyzed. Of these patients, 303 without biliary drainage were divided into 4 groups: (1) no jaundice, (2) mild jaundice, (3) moderate jaundice, and (4) severe jaundice. Multiple preoperative, intraoperative, and postoperative variables were examined. Postoperative complications were stratified by severity according to the modified Clavien classification. RESULTS Patients with jaundice had a higher incidence in subsequent complications than those with no jaundice. The complications were stratified by severity. Compared with those in group 1, patients in groups 2, 3, and 4 had more complications just in grade 2 (15.6%, 23.1%, 28.3%, and 40.0%, respectively, P = 0.046), but not other more severe grades including 3a, 3b, 4a, 4b, and 5; all of the complications in this grade could be conservatively treated and cured without requiring surgical, endoscopic, or radiological intervention. The incidences of infection and overall complications were higher in patients with drainage than those without, but neither difference was statistically significant. CONCLUSIONS Preoperative drainage should not routinely be performed in patients with jaundice scheduled for pancreaticoduodenectomy, and immediate surgery is preferable.
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Affiliation(s)
- Zhenjun Li
- Department of Hepatobiliopancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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