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Maino C, Cereda M, Franco PN, Boraschi P, Cannella R, Gianotti LV, Zamboni G, Vernuccio F, Ippolito D. Cross-sectional imaging after pancreatic surgery: The dialogue between the radiologist and the surgeon. Eur J Radiol Open 2024; 12:100544. [PMID: 38304573 PMCID: PMC10831502 DOI: 10.1016/j.ejro.2023.100544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 12/29/2023] [Accepted: 12/29/2023] [Indexed: 02/03/2024] Open
Abstract
Pancreatic surgery is nowadays considered one of the most complex surgical approaches and not unscathed from complications. After the surgical procedure, cross-sectional imaging is considered the non-invasive reference standard to detect early and late compilations, and consequently to address patients to the best management possible. Contras-enhanced computed tomography (CECT) should be considered the most important and useful imaging technique to evaluate the surgical site. Thanks to its speed, contrast, and spatial resolution, it can help reach the final diagnosis with high accuracy. On the other hand, magnetic resonance imaging (MRI) should be considered as a second-line imaging approach, especially for the evaluation of biliary findings and late complications. In both cases, the radiologist should be aware of protocols and what to look at, to create a robust dialogue with the surgeon and outline a fitted treatment for each patient.
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Affiliation(s)
- Cesare Maino
- Department of Diagnostic Radiology, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, MB, Italy
| | - Marco Cereda
- Department of Surgery, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, MB, Italy
| | - Paolo Niccolò Franco
- Department of Diagnostic Radiology, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, MB, Italy
| | - Piero Boraschi
- Radiology Unit, Azienda Ospedaliero-Universitaria Pisana, 56124 Pisa, Italy
| | - Roberto Cannella
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BiND), University of Palermo, 90127 Palermo, Italy
| | - Luca Vittorio Gianotti
- Department of Surgery, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, MB, Italy
- School of Medicine, Università Milano-Bicocca, Piazza dell’Ateneo Nuovo, 1, 20100 Milano, Italy
| | - Giulia Zamboni
- Institute of Radiology, Department of Diagnostics and Public Health, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Federica Vernuccio
- University Hospital of Padova, Institute of Radiology, 35128 Padova, Italy
| | - Davide Ippolito
- Department of Diagnostic Radiology, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, MB, Italy
- School of Medicine, Università Milano-Bicocca, Piazza dell’Ateneo Nuovo, 1, 20100 Milano, Italy
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Bai XH, Yin J, Yu SY, Shu YP, Lu ZP, Jiang KR, Xu Q. Extracellular volume fraction derived from dual-energy CT: a potential predictor for acute pancreatitis after pancreatoduodenectomy. Eur Radiol 2024:10.1007/s00330-024-10750-3. [PMID: 38760508 DOI: 10.1007/s00330-024-10750-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/07/2024] [Accepted: 03/09/2024] [Indexed: 05/19/2024]
Abstract
OBJECTIVES To investigate the value of extracellular volume (ECV) fraction and fat fraction (FF) derived from dual- energy CT (DECT) for predicting postpancreatectomy acute pancreatitis (PPAP) after pancreatoduodenectomy (PD). METHODS This retrospective study included patients who underwent DECT and PD between April 2022 and September 2022. PPAP was determined according to the International Study Group for Pancreatic Surgery (ISGPS) definition. Iodine concentration (IC) and FF of the pancreatic parenchyma were measured on preoperative DECT. The ECV fraction was calculated from iodine map images of the equilibrium phase. The independent predictors for PPAP were assessed by univariate and multivariable logistic regression analysis and receiver operating characteristic (ROC) curve analysis. RESULTS Sixty-nine patients were retrospectively enrolled (median age, 60 years; interquartile range, 55-70 years; 47 men). Of these, nine patients (13.0%) developed PPAP. These patients had lower portal venous phase IC, equilibrium phase IC, FF, and ECV fraction, and higher pancreatic parenchymal-to-portal venous phase IC ratio and pancreatic parenchymal-to-equilibrium phase IC ratio, compared with patients without PPAP. After multivariable analysis, ECV fraction was independently associated with PPAP (odd ratio [OR], 0.87; 95% confidence interval [CI]: 0.79, 0.96; p < 0.001), with an area under the curve (AUC) of 0.839 (sensitivity 100.0%, specificity 58.3%). CONCLUSIONS A lower ECV fraction is independently associated with the occurrence of PPAP after PD. ECV fraction may serve as a potential predictor for PPAP after PD. CLINICAL RELEVANCE STATEMENT DECT-derived ECV fraction of pancreatic parenchyma is a promising biomarker for surgeons to preoperatively identify patients with higher risk for postpancreatectomy acute pancreatitis after PD and offer selective perioperative management. KEY POINTS PPAP is a complication of pancreatic surgery, early identification of higher-risk patients allows for risk mitigation. Lower DECT-derived ECV fraction was independently associated with the occurrence of PPAP after PD. DECT aids in preoperative PAPP risk stratification, allowing for appropriate treatment to minimize complications.
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Affiliation(s)
- Xiao-Han Bai
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, No 300, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Jie Yin
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, No 300, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Si-Yao Yu
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, No 300, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Yu-Ping Shu
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, No 300, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Zi-Peng Lu
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, No 300, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China
| | - Kui-Rong Jiang
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, No 300, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China.
| | - Qing Xu
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, No 300, Guangzhou Road, Nanjing, 210029, Jiangsu Province, China.
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De Pastena M, Bannone E, Fontana M, Paiella S, Esposito A, Casetti L, Landoni L, Tuveri M, Pea A, Casciani F, Zamboni G, Frigerio I, Marchegiani G, Butturini G, Malleo G, Salvia R. Thirty-day prevalence and clinical impact of fluid collections at the resection margin after distal pancreatectomy: Follow-up of a multicentric randomized controlled trial. Surgery 2024:S0039-6060(24)00191-0. [PMID: 38729888 DOI: 10.1016/j.surg.2024.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 01/17/2024] [Accepted: 03/18/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Postoperative fluid collections at the resection margin of the pancreatic stump are frequent after distal pancreatectomy, yet their clinical impact is unclear. The aim of this study was to assess the 30-day prevalence of postoperative fluid collections after distal pancreatectomy and the factors associated with a clinically relevant condition. METHODS Patients enrolled in a randomized controlled trial of parenchymal transection with either reinforced, triple-row staple, or ultrasonic dissector underwent routine magnetic resonance 30 days postoperatively. Postoperative fluid collection was defined as a cyst-like lesion of at least 1 cm at the pancreatic resection margin. Postoperative fluid collections requiring any therapy were defined as clinically relevant. RESULTS A total of 133 patients were analyzed; 69 were in the triple-row staple transection arm, and 64 were in the ultrasonic dissector transection arm. The overall 30-day prevalence of postoperative fluid collections was 68% (n = 90), without any significant difference between the two trial arms. Postoperative serum hyperamylasemia was more frequent in patients with postoperative fluid collections than those without (31% vs 7%, P = .001). Among the postoperative fluid collection population, an early postoperative pancreatic fistula (odds ratio 14.9, P = .002), post pancreatectomy acute pancreatitis (odds ratio 12.7, P = .036), and postoperative fluid collection size larger than 50 mm (odds ratio 6.6, P = .046) were independently associated with a clinically relevant postoperative fluid collection. CONCLUSION Postoperative fluid collections at the resection margin are common after distal pancreatectomy and can be predicted by early assessment of postoperative serum hyperamylasemia. A preceding pancreatectomy acute pancreatitis and/or postoperative pancreatic fistula and large collections (>50 mm) were associated with a clinically relevant postoperative fluid collection, representing targets for closer follow-up or earlier therapeutic interventions.
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Affiliation(s)
- Matteo De Pastena
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy. https://twitter.com/MatteoDePastena
| | - Elisa Bannone
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy. https://twitter.com/BannoneElisa
| | - Martina Fontana
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Alessandro Esposito
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Luca Casetti
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Luca Landoni
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Massimiliano Tuveri
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Antonio Pea
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy. https://twitter.com/Totuccio1983
| | - Fabio Casciani
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Giulia Zamboni
- Section of Radiology University of Verona Hospital Trust, Verona, Italy
| | | | - Giovanni Marchegiani
- Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padua, Padua, Italy. https://twitter.com/Gio_Marchegiani
| | | | - Giuseppe Malleo
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy. https://twitter.com/gimalleo
| | - Roberto Salvia
- Unit of Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy.
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Wang TG, Tian L, Zhang XL, Zhang L, Zhao XL, Kong DS. Gradient inflammation in the pancreatic stump after pancreaticoduodenectomy: Two case reports and review of literature. World J Clin Cases 2024; 12:1649-1659. [PMID: 38576729 PMCID: PMC10989426 DOI: 10.12998/wjcc.v12.i9.1649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/26/2023] [Accepted: 03/07/2024] [Indexed: 03/25/2024] Open
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) contributes significantly to morbidity and mortality after pancreaticoduodenectomy (PD). However, the underlying mechanisms remain unclear. This study explored this pathology in the pancreatic stumps and elucidated the mechanisms of POPF following PD. CASE SUMMARY Pathological analysis and 16S rRNA gene sequencing were performed on specimens obtained from two patients who underwent complete pancreatectomy for grade C POPF after PD. Gradient inflammation is present in the pancreatic stump. The apoptosis was lower than that in the normal pancreas. Moreover, neutrophil-dominated inflammatory cells are concentrated in the ductal system. Notably, neutrophils migrated through the ductal wall in acinar duct metaplasia-formed ducts. Additionally, evidence indicates that gut microbes migrate from the digestive tract. Gradient inflammation occurs in pancreatic stumps after PD. CONCLUSION The mechanisms underlying POPF include high biochemical activity in the pancreas, mechanical injury, and digestive reflux. To prevent POPF and address pancreatic inflammation and reflux, breaking the link with anastomotic dehiscence is practical.
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Affiliation(s)
- Tie-Gong Wang
- Department of Surgery, Cangzhou Central Hospital, Cangzhou 061000, Hebei Province, China
| | - Liang Tian
- Department of Pathology, Cangzhou Central Hospital, Cangzhou 061000, Hebei Province, China
| | - Xiao-Ling Zhang
- Department of Pathology, Cangzhou Central Hospital, Cangzhou 061000, Hebei Province, China
| | - Lei Zhang
- Department of Surgery, Cangzhou Central Hospital, Cangzhou 061000, Hebei Province, China
| | - Xiu-Lei Zhao
- Department of Surgery, Cangzhou Central Hospital, Cangzhou 061000, Hebei Province, China
| | - De-Shuai Kong
- Department of Surgery, Cangzhou Central Hospital, Cangzhou 061000, Hebei Province, China
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Aronen A, Aittoniemi J, Huttunen R, Siiki A, Antila A, Sand J, Laukkarinen J. P-suPAR may reflect the inflammatory response after pancreatic surgery. Pancreatology 2024; 24:146-151. [PMID: 38000982 DOI: 10.1016/j.pan.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 11/10/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND Several different scoring systems have been developed to predict post-pancreatectomy complications. Currently used inflammatory markers are of only limited value in predicting complications after pancreatic surgery. Plasma soluble urokinase plasminogen activator receptor (P-suPAR) is a prognostic biomarker associated with different inflammatory conditions. The aim of this study was to investigate P-suPAR levels before and after pancreatic surgery. METHODS One hundred and seventy-six patients evaluated for pancreatic surgery due to suspected malignant or premalignant lesion were recruited for this study at Tampere University Hospital between 2016 and 2021. P-suPAR was analyzed before the planned operation and on postoperative days (PODs) one and three. RESULTS One hundred and thirty-three patients [median age 67 (range 33-84) years, 50 % male] underwent a pancreatic surgery procedure. Compared to preoperative values [median 3.7 (IQR 3.1-4.7) ng/mL], P-suPAR was significantly lower on PODs 1 [3.2 (2.5-3.9) ng/mL; p < 0.001] and 3 [3.2 (2.7-4.1) ng/mL; p < 0.001]. P-suPAR on POD 1 was significantly lower in patients with postoperative pancreatic fistula (POPF) [2.6 (2.1-3.4) ng/mL] than in patients with no POPF [3.2 (2.6-3.8) ng/mL; p = 0.007]. Similar decreases in P-suPAR values were seen in patients with postoperative acute pancreatitis (POAP) and surgical site infection (SSI). CONCLUSIONS After pancreatic surgery, P-suPAR level on POD 1 is significantly lower in patients with POPF, POAP or SSI. P-suPAR is decreased after pancreatic resection in all patients. This type of postoperative P-suPAR profile has not previously been described, and may reflect the compensatory anti-inflammatory reaction following the initial systemic inflammatory reaction caused by surgical trauma.
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Affiliation(s)
- Anu Aronen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Finland; Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland
| | | | - Reetta Huttunen
- Department of Internal Medicine, Tampere University Hospital, Finland
| | - Antti Siiki
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Finland
| | - Anne Antila
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Finland
| | - Juhani Sand
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Finland
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Finland; Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland.
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6
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Shasheendra Y, Ahmed Z, Shetty MG, Hazarathaiah N, Rebala P, Rao GV. Association of Postoperative Hyperamylasemia With Clinically Relevant Postoperative Pancreatic Fistula in Pancreatoduodenectomy. Cureus 2024; 16:e53257. [PMID: 38435944 PMCID: PMC10904686 DOI: 10.7759/cureus.53257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2024] [Indexed: 03/05/2024] Open
Abstract
Background In this study, we aimed to determine the association between postoperative hyperamylasemia (POH) and clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD). Methodology A prospective observational study of 140 consecutive PDs between March 2020 and March 2022 was conducted. POH was defined as an elevation in serum pancreatic amylase levels above the institutional upper limit of normal on postoperative day (POD) 1 (>100 U/L). CR-POPF was defined as the International Study Group of Pancreatic Surgery Grade B or C POPF. The primary outcome was the rate of CR-POPF in the study population. The trial was prospectively registered with Clinicaltrials.gov (NCT04514198). Results In our study, 93 (66.42%) patients had POH (serum amylase >100 U/L). CR-POPF developed in 48 (34.28%) patients: 40 type B and 8 type C. CR-POPF rate was 43.01% (40/93) in patients with POH compared to 17.02% (8/47) in patients without POH (p = 0.0022). Patients with POH had a mean serum amylase of 422.7 ± 358.21 U/L on POD1 compared to 47.2 ± 20.19 U/L in those without POH (p < 0.001). Serum amylase >100 U/L on POD1 was strongly associated with developing CR-POPF (odds ratio = 3.71; 95% confidence interval = 1.31-10.37) on logistic regression, with a sensitivity and specificity of 83.3% and 42.4%, respectively. Blood loss >350 mL, pancreatic duct size <3 mm, and elevated POD1 serum amylase >100 U/L were predictive of CR-POPF on multivariate analysis (p < 0.001). Conclusions An elevated serum amylase on POD1 may help identify patients at risk for developing POPF following PD.
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Affiliation(s)
| | - Zeeshan Ahmed
- Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, IND
| | - Mahesh G Shetty
- Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, IND
| | | | - Pradeep Rebala
- Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, IND
| | - Guduru V Rao
- Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, IND
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Kumar AH, Pamecha V, Patil NS, Mohapatra N, Kilambi R, Sinha PK. Efficacy of rectal indomethacin in prevention of post-operative hyperamylasemia following pancreatoduodenectomy: a randomized controlled trial. Langenbecks Arch Surg 2023; 409:23. [PMID: 38157074 DOI: 10.1007/s00423-023-03212-9] [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] [Received: 09/19/2023] [Accepted: 12/20/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Post-operative hyperamylasemia (POH) following pancreatoduodenectomy (PD) may play a key role in pathogenesis of post-operative pancreatic fistula (POPF). Aim of the current study was to evaluate efficacy of perioperative administration of indomethacin in preventing POH. METHODS Single-center, double-blind, randomized controlled trial (RCT) conducted on consecutive patients undergoing PD. Patients received either 100 mg of indomethacin per-rectally at induction of anesthesia or standard care. Primary endpoint was incidence of POH in the two arms. POH was defined as postoperative day (POD) 1 serum amylase (S. amylase) levels greater than the upper limit of normal. RESULTS After exclusion 44 patients were randomized. The two arms were comparable for preoperative and intraoperative parameters. POH was noted in 20/44 (45.5%) with significantly lower incidence of POH (60.9% vs. 28.6%, p = 0.032) in intervention arm (IA). Median S. amylase, POD 1, 3, and 5 drain amylase, and incidence of clinically relevant POPF (CR-POPF) were lower in IA but failed to reach statistical significance (30.4% vs. 14.3%, p = 0.18). The severity of delayed gastric emptying (DGE) was significantly lower in the IA (grade B/C DGE 23.8% vs. 47.8%, p = 0.023). Evaluation of risk factors for POH showed IA to confer an independent protective effect and increased risk with soft pancreas. CONCLUSION Perioperative per-rectal indomethacin administration is effective in decreasing the incidence of POH following pancreatoduodenectomy.
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Affiliation(s)
- Anubhav Harshit Kumar
- Department of Hepatopancreatobiliary Surgery & Liver Transplant, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Viniyendra Pamecha
- Department of Hepatopancreatobiliary Surgery & Liver Transplant, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.
| | - Nilesh Sadashiv Patil
- Department of Hepatopancreatobiliary Surgery & Liver Transplant, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Nihar Mohapatra
- Department of Hepatopancreatobiliary Surgery & Liver Transplant, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Ragini Kilambi
- Department of Hepatopancreatobiliary Surgery & Liver Transplant, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Piyush Kumar Sinha
- Department of Hepatopancreatobiliary Surgery & Liver Transplant, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
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Rykina-Tameeva N, Samra JS, Sahni S, Mittal A. Non-Surgical Interventions for the Prevention of Clinically Relevant Postoperative Pancreatic Fistula-A Narrative Review. Cancers (Basel) 2023; 15:5865. [PMID: 38136409 PMCID: PMC10741911 DOI: 10.3390/cancers15245865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/06/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Clinically relevant postoperative pancreatic fistula (CR-POPF) is the leading cause of morbidity and mortality after pancreatic surgery. Post-pancreatectomy acute pancreatitis (PPAP) has been increasingly understood as a precursor and exacerbator of CR-POPF. No longer believed to be the consequence of surgical technique, the solution to preventing CR-POPF may lie instead in non-surgical, mainly pharmacological interventions. Five databases were searched, identifying eight pharmacological preventative strategies, including neoadjuvant therapy, somatostatin and its analogues, antibiotics, analgesia, corticosteroids, protease inhibitors, miscellaneous interventions with few reports, and combination strategies. Two further non-surgical interventions studied were nutrition and fluids. New potential interventions were also identified from related surgical and experimental contexts. Given the varied efficacy reported for these interventions, numerous opportunities for clarifying this heterogeneity remain. By reducing CR-POPF, patients may avoid morbid sequelae, experience shorter hospital stays, and ensure timely delivery of adjuvant therapy, overall aiding survival where prognosis, particularly in pancreatic cancer patients, is poor.
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Affiliation(s)
- Nadya Rykina-Tameeva
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW 2065, Australia
| | - Jaswinder S. Samra
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Upper GI Surgical Unit, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
- Upper GI Surgical Unit, North Shore Private Hospital, St Leonards, NSW 2065, Australia
- Australian Pancreatic Centre, St Leonards, NSW 2065, Australia
| | - Sumit Sahni
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW 2065, Australia
- Australian Pancreatic Centre, St Leonards, NSW 2065, Australia
| | - Anubhav Mittal
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Upper GI Surgical Unit, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
- Upper GI Surgical Unit, North Shore Private Hospital, St Leonards, NSW 2065, Australia
- Australian Pancreatic Centre, St Leonards, NSW 2065, Australia
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9
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Gajda M, Grudzińska E, Szmigiel P, Czopek P, Rusinowski C, Putowski Z, Mrowiec S. Risk Factors of Postoperative Acute Pancreatitis and Its Impact on the Postoperative Course after Pancreaticoduodenectomy-10 Years of Single-Center Experience. Life (Basel) 2023; 13:2344. [PMID: 38137945 PMCID: PMC10744948 DOI: 10.3390/life13122344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 11/30/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Clinically relevant acute postoperative pancreatitis (CR-PPAP) after pancreaticoduodenectomy (PD) is a complication that may lead to the development of local and systemic consequences. The study aimed to identify risk factors for CR-PPAP and assess the impact of CR-PPAP on the postoperative course after PD. METHODS The study retrospectively analyzed data from 428 consecutive patients who underwent PD at a single center between January 2013 and December 2022. The presence of increased amylase activity in plasma, above the upper limit of normal 48 h after surgery, was checked. CR-PPAP was diagnosed when accompanied by disturbing radiological features and/or symptoms requiring treatment. We investigated the relationship between the occurrence of CR-PPAP and the development of postoperative complications after PD, and possible predictors of CR-PPAP. RESULTS The postoperative follow-up period was 90 days. Of the 428 patients, 18.2% (n = 78) had CR-PPAP. It was associated with increased rates of CR-POPF, delayed gastric emptying, occurrence of intra-abdominal collections, postoperative hemorrhage, peritonitis, and septic shock. Patients who developed CR-PPAP were more often reoperated (37.17% vs. 6.9%, p < 0.0001)) and had increased postoperative mortality (14.1% vs. 5.74%, p < 0.0001). Soft pancreatic parenchyma, intraoperative blood loss, small diameter of the pancreatic duct, and diagnosis of adenocarcinoma papillae Vateri were independent risk factors for CR-PPAP and showed the best performance in predicting CR-PPAP. CONCLUSIONS CR-PPAP is associated with an increased incidence of postoperative complications after PD, worse treatment outcomes, and an increased risk of reoperation and mortality. Pancreatic consistency, intraoperative blood loss, width of the duct of Wirsung, and histopathological diagnosis can be used to assess the risk of CR-PPAP. Amylase activity 48 h after surgery > 161 U/L is highly specific in the diagnosis of CR-PPAP.
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Affiliation(s)
- Magdalena Gajda
- Department of Gastrointestinal Surgery, Medical University of Silesia, 40-752 Katowice, Poland; (M.G.)
| | - Ewa Grudzińska
- Department of Gastrointestinal Surgery, Medical University of Silesia, 40-752 Katowice, Poland; (M.G.)
| | - Paweł Szmigiel
- Department of Gastrointestinal Surgery, Medical University of Silesia, 40-752 Katowice, Poland; (M.G.)
| | - Piotr Czopek
- Department of Gastrointestinal Surgery, Medical University of Silesia, 40-752 Katowice, Poland; (M.G.)
| | - Cezary Rusinowski
- Department of Gastrointestinal Surgery, Medical University of Silesia, 40-752 Katowice, Poland; (M.G.)
| | - Zbigniew Putowski
- Center for Intensive and Perioperative Care, Jagiellonian University, 31-007 Cracow, Poland
| | - Sławomir Mrowiec
- Department of Gastrointestinal Surgery, Medical University of Silesia, 40-752 Katowice, Poland; (M.G.)
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10
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Bannone E, Pulvirenti A, Marchegiani G, Vacca PG, Marchetti A, Cattelani A, Salvia R, Bassi C. No role for protease inhibitors as a mitigation strategy for postpancreatectomy acute pancreatitis (PPAP): Propensity score matching analysis. Pancreatology 2023; 23:904-910. [PMID: 37839921 DOI: 10.1016/j.pan.2023.09.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 09/18/2023] [Accepted: 09/28/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND While the use of protease inhibitor gabexate mesylate (GM) is still controversial in acute pancreatitis, it has never been tested for postpancreatectomy acute pancreatitis (PPAP). This study aims to assess the impact of GM on postoperative serum hyperamylasaemia (POH) or PPAP after pancreatoduodenectomy (PD). METHODS Consecutive patients developing POH after PD between 2016 and 2021 were included. According to GM administration, patients were divided into GM-treated and control (CTR) groups. GM was administered from postoperative day 1-3 in POH patients who underwent surgery before 2017. A 2:1 propensity matching was used to minimize the risk of bias. RESULTS Overall, 264 patients with POH were stratified in the GM (59 patients) and CTR (104 patients) cohorts, which showed balanced baseline characteristics after matching. No difference in postoperative complications was observed between the groups (all p > 0.05), except for PPAP occurrence, which was significantly higher in the GM group (37% vs. 22%, p = 0.037). A total of 45 patients (28%) evolved to PPAP. Comparing PPAP patients in the GM and CTR groups, no significant differences in POPF, relaparotomy, and mortality (all p > 0.09) were found. No difference in intravenous crystalloid administration was found in patients with PPAP, whether or not they developed major complications or pancreatic fistula (p > 0.05) CONCLUSION: Protease inhibitor seems ineffective in preventing a PPAP after PD once a POH has occurred. Further studies are needed to achieve benchmarks for treating PPAP and identify mitigation strategies to prevent the evolution of POH into additional morbidity.
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Affiliation(s)
- Elisa Bannone
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy; Department of General Surgery, Poliambulanza Foundation Hospital, Brescia, Italy. https://twitter.com/PancreasVerona
| | - Alessandra Pulvirenti
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Pier Giuseppe Vacca
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alessio Marchetti
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alice Cattelani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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11
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Liu GH, Tan XY, Li JX, Zhong GH, Zhai JW, Li MY. A modified Blumgart anastomosis with a simple and practicable procedure after laparoscopic pancreaticoduodenectomy: our center's experience. BMC Surg 2023; 23:349. [PMID: 37974183 PMCID: PMC10655365 DOI: 10.1186/s12893-023-02221-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 10/06/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Laparoscopic pancreaticoduodenectomy(LPD) has become the goal of lots of minimally invasive surgical centers in recent years. Postoperative pancreatic fistula(POPF) is still the barrier to attaining the above goal. Thus, improving anastomosis techniques to reduce the rate of POPF has been a hotspot of surgery. Blumgart pancreaticojejunostomy is considered one of the best anastomosis procedures, with low rates of POPF. However, the original Blumgart pancreaticojejunostomy method is not easy for laparoscopic operation. In consequence, we modified a Blumgart pancreaticojejunostomy technique with a simple and practicable procedure and applied to LPD. METHODS We collected and retrospectively analyzed the perioperative clinical data of patients who underwent modified Blumgart anastomosis from February 2017 to September 2022. The above patients included 53 cases in open pancreaticojejunostomy(OPD) and 58 cases in LPD. After propensity score matching, 44 cases were included for comparison in each group. RESULTS After propensity score matching, the average time for pancreaticojejunostomy was about 30 min in the LPD group. The Clinically relevant POPF(CR-POPF) rate was 9.1%. The length of postoperative hospitalization was 13.1 days. Compared with the OPD group, The CR-POPF rate in the LPD group are not significant differences. But the postoperative length of hospital stay was significantly shorter in the LPD group. Besides, there were no other severely postoperative complications between two groups. CONCLUSION The modified Blumgart anastomosis technique applied to LPD in our Center not only has simple and convenient properties but also low rate of CR-POPF. And this method may be a good choice for surgeons to begin to carry out LPD.
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Affiliation(s)
- Guo-Hua Liu
- Department of Hepatobiliary Surgery, Affiliated Hospital, Guangdong Medical University, Zhanjiang, Guangdong, 524000, China
| | - Xiao-Yu Tan
- Department of Hepatobiliary Surgery, Affiliated Hospital, Guangdong Medical University, Zhanjiang, Guangdong, 524000, China
| | - Jia-Xing Li
- Department of Hepatobiliary Surgery, Affiliated Hospital, Guangdong Medical University, Zhanjiang, Guangdong, 524000, China
| | - Guo-Hui Zhong
- Department of Hepatobiliary Surgery, Affiliated Hospital, Guangdong Medical University, Zhanjiang, Guangdong, 524000, China
| | - Jing-Wei Zhai
- Department of Hepatobiliary Surgery, Affiliated Hospital, Guangdong Medical University, Zhanjiang, Guangdong, 524000, China
| | - Ming-Yi Li
- Department of Hepatobiliary Surgery, Affiliated Hospital, Guangdong Medical University, Zhanjiang, Guangdong, 524000, China.
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12
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Marchegiani G, Perri G, Reich F, Procida G, Bannone E, Salvia R, Bassi C. Blood loss predicts pancreas-specific complications only in high-risk patients: results of a prospective and systematic blood loss estimation during pancreatoduodenectomy. Br J Surg 2023; 110:1632-1636. [PMID: 37406083 DOI: 10.1093/bjs/znad207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/04/2023] [Accepted: 06/13/2023] [Indexed: 07/07/2023]
Affiliation(s)
- Giovanni Marchegiani
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
- Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padua, Padua, Italy
| | - Giampaolo Perri
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Federico Reich
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Giuseppa Procida
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Elisa Bannone
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
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13
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Swartling O, Evans M, Larsson P, Perri G, Yarbakht D, Al-Kamil H, Gilg S, Holmberg M, Sparrelid E, Ghorbani P. Preoperative chronic kidney disease and complications after pancreatoduodenectomy: a retrospective cohort study. ANZ J Surg 2023; 93:2492-2498. [PMID: 37654154 DOI: 10.1111/ans.18677] [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] [Received: 12/14/2022] [Revised: 08/01/2023] [Accepted: 08/17/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Chronic kidney disease is a prevalent condition in surgical patients. Possible associations with increased postoperative morbidity and mortality have not been clearly demonstrated in patients undergoing pancreatoduodenectomy. The aim of this study was to assess the risk of postoperative complications in patients with reduced kidney function undergoing pancreatoduodenectomy. METHODS All patients undergoing pancreatoduodenectomy at Karolinska University Hospital between 2008 and 2019 were retrospectively included. The variable of interest was chronic kidney disease, based on preoperative estimated glomerular filtration rate measurements. Unadjusted and adjusted logistic regression analyses were performed for standardized postoperative complications. RESULTS A total of 971 patients were included in the study, of whom 92 (10%) had an estimated glomerular filtration rate < 60 mL/min/1.73m2 , equivalent to chronic kidney disease Stage 3a or worse. Patients with chronic kidney disease had a higher odds of longer hospital stay (adjusted odds ratio 1.58, 95% confidence interval 1.00-2.50) and postoperative weight increase (adjusted odds ratio 2.02, 1.14-3.56). A 10 unit increase of preoperative estimated glomerular filtration rate was associated to lower odds of intensive care unit admission (adjusted odds ratio 0.81, 0.69-0.95), delayed gastric emptying (adjusted odds ratio 0.90, 0.81-0.99), and post-operative pancreatic fistula (adjusted odds ratio 0.83, 0.74-0.94). CONCLUSION Patients undergoing pancreatoduodenectomy with decreased preoperative kidney function are more likely to experience major postoperative complications, and also postoperative weight increase. Preoperative kidney function assessment is important in risk stratification before pancreatoduodenectomies.
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Affiliation(s)
- Oskar Swartling
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Marie Evans
- Renal Unit, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Patrik Larsson
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Giampaolo Perri
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Danial Yarbakht
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Hussein Al-Kamil
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Stefan Gilg
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Marcus Holmberg
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Ernesto Sparrelid
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Poya Ghorbani
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Division of Surgery, Department of Clinical Sciences, Interventions and Technology, Karolinska Institutet, Stockholm, Sweden
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14
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Mintziras I, Wächter S, Manoharan J, Albers MB, Kanngiesser V, Maurer E, Bartsch DK. Serum amylase on postoperative day 1 is superior to serum lipase in predicting clinically relevant pancreatic fistula after partial pancreaticoduodenectomy. Langenbecks Arch Surg 2023; 408:359. [PMID: 37714999 DOI: 10.1007/s00423-023-03090-1] [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] [Received: 04/27/2023] [Accepted: 08/29/2023] [Indexed: 09/17/2023]
Abstract
PURPOSE To compare the predictive value of serum amylase and lipase regarding the occurrence of clinically relevant postoperative pancreatic fistula (cr-POPF) after partial pancreaticoduodenectomy (PD). METHODS Data from 228 consecutive patients undergoing PD were obtained from a prospective database. Serum amylase and lipase were measured on postoperative days (PODs) 0-2. Receiver-operating characteristics analysis was performed and cutoff values were tested using logistic regression. RESULTS Serum amylase had a larger area under the curve (AUC) on POD1 (AUC 0.89, p <0.001) than serum lipase. For serum amylase POD 1, a cutoff value of 70 U/l showed sensitivity and specificity of 100% and 70% for the diagnosis of cr-POPF. Serum amylase POD 1 > 70 U/l (OR 9.815, 95% CI 3.683-26.152, p < 0.001), drain amylase POD 1 > 300 U/l (OR 2.777, 95% CI 1.071-7.197, p= 0.036), and a small (≤ 3mm) pancreatic duct diameter (OR 3.705, 95% CI 1.426-9.627, p= 0.007) were significant predictors of cr-POPF in the multivariable analysis. Patients were divided into three risk groups based on serum amylase POD 1 and pancreatic duct diameter. This model had a good performance in discriminating cr-POPF (AUC 0.846, 95% CI 0.793-0.898). The sensitivity, specificity, and negative predictive value for the combination of serum amylase POD 1 <70 U/l and pancreatic duct diameter >3 mm were 100%, 70%, and 100%. CONCLUSION Serum amylase POD 1 was superior to serum lipase in predicting cr-POPF after PD. The proposed risk prediction model had a sensitivity and negative predictive value of 100%, allowing for early identification of cr-POPF.
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Affiliation(s)
- Ioannis Mintziras
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps-University Marburg, Baldingerstrasse, 35043, Marburg, Germany.
| | - Sabine Wächter
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps-University Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - Jerena Manoharan
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps-University Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - Max Benjamin Albers
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps-University Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - Veit Kanngiesser
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps-University Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - Elisabeth Maurer
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps-University Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - Detlef K Bartsch
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps-University Marburg, Baldingerstrasse, 35043, Marburg, Germany
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15
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Robertson FP, Spiers HVM, Lim WB, Loveday B, Roberts K, Pandanaboyana S. Intraoperative pancreas stump perfusion assessment during pancreaticoduodenectomy: A systematic scoping review. World J Gastrointest Surg 2023; 15:1799-1807. [PMID: 37701689 PMCID: PMC10494594 DOI: 10.4240/wjgs.v15.i8.1799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/23/2023] [Accepted: 06/11/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Post-operative pancreatic fistula (POPF) is the primary cause of morbidity following pancreaticoduodenectomy. Rates of POPF have remained high despite well known risk factors. The theory that hypoperfusion of the pancreatic stump leads to anastomotic failure has recently gained interest. AIM To define the published literature with regards to intraoperative pancreas perfusion assessment and its correlation with POPF. METHODS A systematic search of available literature was performed in November 2022. Data extracted included study characteristics, method of assessment of pancreas stump perfusion, POPF and other post-pancreatic surgery specific complications. RESULTS Five eligible studies comprised two prospective non-randomised studies and three case reports, total 156 patients. Four studies used indocyanine green fluorescence angiography to assess the pancreatic stump, with the remaining study assessing pancreas perfusion by visual inspection of arterial bleeding of the pancreatic stump. There was significant heterogeneity in the definition of POPF. Studies had a combined POPF rate of 12%; intraoperative perfusion assessment revealed hypoperfusion was present in 39% of patients who developed POPF. The rate of POPF was 11% in patients with no evidence of hypoperfusion and 13% in those with evidence of hypoperfusion, suggesting that not all hypoperfusion gives rise to POPF and further analysis is required to analyse if there is a clinically relevant cut off. Significant variance in practice was seen in the pancreatic stump management once hypoperfusion was identified. CONCLUSION The current published evidence around pancreas perfusion during pancreaticoduodenectomy is of poor quality. It does not support a causative link between hypoperfusion and POPF. Further well-designed prospective studies are required to investigate this.
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Affiliation(s)
- Francis P Robertson
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne NE7 7DN, United Kingdom
| | - Harry V M Spiers
- Department of HPB Surgery, Addenbrookes Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Wei Boon Lim
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne NE7 7DN, United Kingdom
| | - Benjamin Loveday
- Department of General Surgery, Royal Melbourne Hospital, Melbourne VIC 3050, Australia
| | - Keith Roberts
- Department of HPB Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham BG15 2GW, United Kingdom
| | - Sanjay Pandanaboyana
- Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne NE7 7DN, United Kingdom
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16
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Marcus H, Nikolaos K, Patrik L, Oskar S, Stefan L, Stefan G, Ernesto S, Poya G. Post-pancreatectomy Acute Pancreatitis in Distal Pancreatectomies - a Rare Bird According to the New Definition. J Gastrointest Surg 2023; 27:1640-1649. [PMID: 37308735 PMCID: PMC10412659 DOI: 10.1007/s11605-023-05721-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 05/20/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Post-pancreatectomy acute pancreatitis (PPAP) is a recently identified clinical condition characterized by sustained elevated serum amylase levels for at least 48 h post-operatively, consistent radiological findings, and relevant clinical features. The purpose of this study was to determine the frequency of PPAP after DP, to investigate the rate of major complications in patients with sustained or transiently elevated serum amylase activity, and to explore the usability of CT as a prerequisite for the diagnosis of PPAP. METHODS This retrospective single-center observational study included consecutive patients 18 years or older who underwent DP at Karolinska University Hospital between 2008 and 2020. The two serum amylase levels on post-operative days (POD) 1 and 2 were correlated with post-operative major complications by logistic regression analyses. RESULTS Of the 403 patients who underwent DP, 14% (n = 58) had sustained elevated serum amylase levels according to PPAP criteria, and 31% (n = 126) had transiently elevated serum amylase levels on either POD1 or POD2. Of the patients with sustained elevated levels, 45% (n = 26) developed major complications, but less than 2% (n = 1) showed imaging findings consistent with acute pancreatitis. Of the 126 patients who exhibited only transiently elevated serum amylase on either POD1 or POD2, 38% (n = 48) developed major complications. The frequency of PPAP was 0.25% (n = 1). CONCLUSION These findings indicate that PPAP after DP is rare and that computed tomography has limited usability for diagnosing PPAP. The findings also suggest that transiently elevated serum amylase may be an early indicator of acute pancreatitis, especially when peaked.
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Affiliation(s)
- Holmberg Marcus
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden.
- Department of Surgery, Capio St Görans Hospital, Stockholm, Sweden.
| | - Kartalis Nikolaos
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Larsson Patrik
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Swartling Oskar
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Division of Clinical Epidemiology, Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Linder Stefan
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Gilg Stefan
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Sparrelid Ernesto
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Ghorbani Poya
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden
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17
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Peltoniemi P, Lehto I, Pere P, Mustonen H, Lehtimäki T, Seppänen H. Goal-directed fluid management associates with fewer postoperative fluid collections in pancreatoduodenectomy patients. Pancreatology 2023; 23:456-464. [PMID: 37258370 DOI: 10.1016/j.pan.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 04/28/2023] [Accepted: 05/17/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND The association between perioperative fluid management and complications in pancreatoduodenectomy patients remains controversial. We explored the association between fluid management and radiological signs of complications. METHODS We examined pancreatoduodenectomy patients operated between July 2014 and December 2015 (n = 125) and between January 2017 and June 2018 (n = 124). The first cohort received intraoperative fluid management according to a goal-directed strategy and the second cohort was treated conventionally. We analyzed fluid administration, edema visible in computed tomography (CT) scans seven days postoperatively, and radiological signs of complications occurring up to 30 days. We performed multivariable logistic regression analyses to identify risk factors for fluid collections. RESULTS No statistically significant difference in postoperative edema via CT scans emerged between the fluid management groups. However, the intraperitoneal space expanded in patients with severe Clavien-Dindo complications compared with patients experiencing mild or no complications (19.1% (IQR 10.4-40.5) vs 2.5% (IQR -7.9-16.6), p = 0.004). Fluid collections were less frequent in the goal-directed group than in the conventional fluid management group (16.8% vs 34.7%, p = 0.001). Risk factors for fluid collections included main pancreatic duct size ≤3 mm, less intraoperative fluid volume accompanying conventional fluid management, a lower postoperative urine output, and postoperative congestive heart failure. The goal-directed group received more intraoperative fluids than the conventional fluid management group and postoperative urine output was higher in the goal-directed group on postoperative days 1-3. CONCLUSIONS Optimization of intraoperative fluid management through target-controlled strategies and early diuresis were associated with a lower frequency of fluid collections in postoperative CT.
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Affiliation(s)
- Piia Peltoniemi
- Department of Perioperative, Intensive Care and Pain Medicine, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Inkeri Lehto
- Department of Radiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Pertti Pere
- Department of Perioperative, Intensive Care and Pain Medicine, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Harri Mustonen
- Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Gastroenterological Surgery, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; iCAN Digital Precision Cancer Medicine Flagship, University of Helsinki, Helsinki, Finland
| | | | - Hanna Seppänen
- Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Gastroenterological Surgery, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; iCAN Digital Precision Cancer Medicine Flagship, University of Helsinki, Helsinki, Finland
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18
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Loos M, König AK, von Winkler N, Mehrabi A, Berchtold C, Müller-Stich BP, Schneider M, Hoffmann K, Kulu Y, Feisst M, Hinz U, Lang M, Goeppert B, Albrecht T, Strobel O, Büchler MW, Hackert T. Completion Pancreatectomy After Pancreatoduodenectomy: Who Needs It? Ann Surg 2023; 278:e87-e93. [PMID: 35781509 PMCID: PMC10249602 DOI: 10.1097/sla.0000000000005494] [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: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to identify the indications for and report the outcomes of completion pancreatectomy (CPLP) in the postoperative course after pancreatoduodenectomy (PD). BACKGROUND CPLP may be considered or even inevitable for damage control after PD. METHODS A prospectively maintained database of all patients undergoing PD between 2001 and 2019 was searched for patients who underwent CPLP in the postoperative course after PD. Baseline characteristics, perioperative details, and outcomes of CPLP patients were analyzed and specific indications for CPLP were identified. RESULTS A total of 3953 consecutive patients underwent PD during the observation period. CPLP was performed in 120 patients (3%) after a median of 10 days following PD. The main indications for CPLP included postpancreatectomy acute necrotizing pancreatitis [n=47 (39%)] and postoperative pancreatic fistula complicated by hemorrhage [n=41 (34%)] or associated with uncontrollable leakage of the pancreatoenteric anastomosis [n=23 (19%)]. The overall 90-day mortality rate of all 3953 patients was 3.5% and 37% for patients undergoing CPLP. CONCLUSIONS Our finding that only very few patients (3%) need CPLP suggests that conservative, interventional, and organ-preserving surgical measures are the mainstay of complication management after PD. Postpancreatectomy acute necrotizing pancreatitis, uncontrollable postoperative pancreatic fistula, and fistula-associated hemorrhage are highly dangerous and represent the main indications for CPLP after PD.
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Affiliation(s)
- Martin Loos
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Anna-Katharina König
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Nikolai von Winkler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Christoph Berchtold
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Beat P. Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Schneider
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Katrin Hoffmann
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Yakup Kulu
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Manuel Feisst
- Institute of Medical Biometry, Heidelberg University, Heidelberg, Germany
| | - Ulf Hinz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Matthias Lang
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Benjamin Goeppert
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Albrecht
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Oliver Strobel
- Department of General Surgery, Vienna University Hospital, Vienna, Austria
| | - Markus W. Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
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Quero G, Fiorillo C, Massimiani G, Lucinato C, Menghi R, Longo F, Laterza V, Schena CA, De Sio D, Rosa F, Papa V, Tortorelli AP, Tondolo V, Alfieri S. The Impact of Post-Pancreatectomy Acute Pancreatitis (PPAP) on Long-Term Outcomes after Pancreaticoduodenectomy: A Single-Center Propensity-Score-Matched Analysis According to the International Study Group of Pancreatic Surgery (ISGPS) Definition. Cancers (Basel) 2023; 15:2691. [PMID: 37345028 DOI: 10.3390/cancers15102691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/02/2023] [Accepted: 05/07/2023] [Indexed: 06/23/2023] Open
Abstract
Post-pancreatectomy acute pancreatitis (PPAP) is a potentially life-threating complication. Although multiple authors demonstrated PPAP as a predisposing feature for a more detrimental clinical course, no evidence is currently present on its potential impact on long-term outcomes. The aim of this study is to evaluate how PPAP onset may influence overall (OS) and disease-free survival (DSF) after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC). Patients who underwent PD for PDAC from 2006 to 2021 were enrolled. PPAP was defined according to the International Study Group of Pancreatic Surgery (ISGPS) definition. Propensity score matching (PSM) was performed in order to reduce potential selection biases. After PSM, 32 patients out of 231 PDs who developed PPAP (PPAP group) were matched to 32 patients who did not present PPAP (no-PPAP group). PPAP patients more frequently presented major post-operative complications (p = 0.02) and post-operative pancreatic fistula (POPF) (p = 0.003). Median follow-up was 26.2 months, with no difference between the two groups (p = 0.79). A comparable rate of local or distant metastases was noted in the two cohorts (p = 0.2). Five-year OS was comparable between the two populations (39.3% and 35.7% for the no-PPAP and PPAP populations, respectively; p = 0.53). Conversely, despite not being statistically significant, a worse 5-year DFS was evidenced in the case of PPAP (23.2%) as compared to the absence of PPAP (37.4%) (p = 0.51). With the limitations due to the small sample size, PPAP may potentially relate to worse long-term outcomes in terms of DFS. However, further studies with wider study populations are still needed in order to better clarify the prognostic role of PPAP.
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Affiliation(s)
- Giuseppe Quero
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
- General Surgery Residency Program, Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Claudio Fiorillo
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
| | - Giuseppe Massimiani
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
| | - Chiara Lucinato
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
| | - Roberta Menghi
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
- General Surgery Residency Program, Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Fabio Longo
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
| | - Vito Laterza
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
| | - Carlo Alberto Schena
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
| | - Davide De Sio
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
| | - Fausto Rosa
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
- General Surgery Residency Program, Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Valerio Papa
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
- General Surgery Residency Program, Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Antonio Pio Tortorelli
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
| | - Vincenzo Tondolo
- General Surgery Unit, Fatebenefratelli Isola Tiberina-Gemelli Isola, Via di Ponte Quattro Capi, 39, 00186 Rome, Italy
| | - Sergio Alfieri
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168 Rome, Italy
- General Surgery Residency Program, Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168 Rome, Italy
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Wu Z, Zong K, Zhou B, Yin K, Zhang A, Li M. Incidence and risk factors of postoperative acute pancreatitis after pancreaticoduodenectomy: a systematic review and meta-analysis. Front Surg 2023; 10:1150053. [PMID: 37228763 PMCID: PMC10203505 DOI: 10.3389/fsurg.2023.1150053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/25/2023] [Indexed: 05/27/2023] Open
Abstract
Background Postoperative acute pancreatitis (POAP) is a specific complication after pancreatectomy. The acute inflammatory response of the residual pancreas may affect the healing of pancreatoenteric anastomoses, leading to postoperative pancreatic fistulas (POPFs), abdominal infections, and even progressive systemic reactions, conditions that negatively affect patients' prognoses and can cause death. However, to the best of our knowledge, no systematic reviews or meta-analytic studies have assessed the incidence and risk factors of POAP after pancreaticoduodenectomy (PD). Method We searched PubMed, Web of Science, Embase, and Cochrane Library databases for relevant literature describing the outcomes of POAP after PD until November 25, 2022, and we used the Newcastle-Ottawa Scale to assess the quality of the studies. Next, we pooled the incidence of POAP and the odds ratios (ORs) and 95% confidence intervals (CIs) of the risk factors using a random-effect meta-analysis. I2 tests were used to assess heterogeneity between the studies. Results We analyzed data from 7,164 patients after PD from 23 articles that met the inclusion criteria for this study. The subgroup results of the meta-analysis by different POAP diagnostic criteria showed that the incidences of POAP were 15% (95% CI, 5-38) in the International Study Group for Pancreatic Surgery group, 51% (95% CI, 42-60) in the Connor group, 7% (95% CI, 2-24) in the Atlanta group, and 5% (95% CI, 2-14) in the unclear group. Being a woman [OR (1.37, 95% CI, 1.06-1.77)] or having a soft pancreatic texture [OR (2.56, 95% CI, 1.70-3.86)] were risk factors of POAP after PD. Conclusion The results showed that POAP was common after PD, and its incidence varied widely according to different definitions. Large-scale reports are still needed, and surgeons should remain aware of this complication. Systematic Review Registration identifier: CRD42022375124.
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Quero G, Massimiani G, Lucinato C, Fiorillo C, Menghi R, Laterza V, Schena CA, De Sio D, Rosa F, Papa V, Tortorelli AP, Tondolo V, Alfieri S. Acute pancreatitis after pancreatoduodenectomy: clinical outcomes and predictive factors analysis according to the International Study Group of Pancreatic Surgery definition. HPB (Oxford) 2023; 25:363-373. [PMID: 36764909 DOI: 10.1016/j.hpb.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/21/2022] [Accepted: 01/06/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND Post-pancreatectomy acute pancreatitis (PPAP) is an increasingly described complication after pancreatic resection. No uniform definition criteria were present in the literature until the recent proposal of the International Study Group of Pancreatic Surgery (ISGPS). Aim of this study is to evaluate the clinical significance of the novel ISGPS definition of PPAP. METHODS Patients who underwent pancreatoduodenectomy (PD) between 2006 and 2022 were enrolled. PPAP was defined and graded according to the ISGPS criteria. RESULTS Among 520 PDs, 120 (23%)patients developed post-operative hyperamylasemia (POH), while PPAP occurred in 63(12.1%) cases. PPAP occurrence related to a higher rate of more severe complications (48-76.1%vs118-25.8%; p < 0.0001), delayed gastric emptying (DGE) (27-42.9%vd114-24.9%; p = 0.003) and post-operative pancreatic fistula (POPF) (57-90.5%vs186-40.8%; p < 0.0001). When stratified for PPAP severity, grade B and C patients more frequently developed major complications (p < 0.0001), POPF (p < 0.0001), DGE (p = 0.02) and post-operative hemorrhage (p < 0.0001) as compared to POH. At the multivariable analysis, soft pancreatic texture (p = 0.01)and a Wirsung diameter ≤3 mm (p = 0.01) were recognized as prognostic factors for PPAP onset, while a pancreatic duct ≤3 mm was the only feature significantly influencing a more severe course of PPAP (p = 0.01). CONCLUSION The ISGPS classification is confirmed as a valuable method for a uniform definition and clinical course evaluation. Further studies in a prospective manner are still needed for a further confirmation.
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Affiliation(s)
- Giuseppe Quero
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168, Rome, Italy
| | - Giuseppe Massimiani
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy.
| | - Chiara Lucinato
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Claudio Fiorillo
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Roberta Menghi
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168, Rome, Italy
| | - Vito Laterza
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Carlo A Schena
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Davide De Sio
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Fausto Rosa
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168, Rome, Italy
| | - Valerio Papa
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168, Rome, Italy
| | - Antonio P Tortorelli
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Vincenzo Tondolo
- General Surgery Unit, Fatebenefratelli Isola Tiberina - Gemelli Isola, Via di Ponte Quattro Capi, 39, 00186, Roma, Italy
| | - Sergio Alfieri
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168, Rome, Italy
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22
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A Simple Classification of Pancreatic Duct Size and Texture Predicts Postoperative Pancreatic Fistula: A classification of the International Study Group of Pancreatic Surgery. Ann Surg 2023; 277:e597-e608. [PMID: 33914473 PMCID: PMC9891297 DOI: 10.1097/sla.0000000000004855] [Citation(s) in RCA: 63] [Impact Index Per Article: 63.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The aim of this study was to develop a classification system for pancreas-associated risk factors in pancreatoduodenectomy (PD). SUMMARY BACKGROUND DATA Postoperative pancreatic fistula (POPF) is the most relevant PD-associated complication. A simple standardized surgical reporting system based on pancreas-associated risk factors is lacking. METHODS A systematic literature search was conducted to identify studies investigating clinically relevant (CR) POPF (CR-POPF) and pancreas-associated risk factors after PD. A meta-analysis of CR-POPF rate for texture of the pancreas (soft vs not-soft) and main pancreatic duct (MPD) diameter was performed using the Mantel-Haenszel method. Based on the results, the International Study Group of Pancreatic Surgery (ISGPS) proposes the following classification: A, not-soft (hard) texture and MPD >3 mm; B, not-soft (hard) texture and MPD ≤3 mm; C, soft texture and MPD >3 mm; D, soft texture and MPD ≤3 mm. The classification was evaluated in a multi-institutional, international cohort. RESULTS Of the 2917 articles identified, 108 studies were included in the analyses. Soft pancreatic texture was significantly associated with the development of CR-POPF [odds ratio (OR) 4.24, 95% confidence interval (CI) 3.67-4.89, P < 0.01) following PD. Similarly, MPD diameter ≤3 mm significantly increased CR-POPF risk compared with >3 mm diameter MPDs (OR 3.66, 95% CI 2.62-5.12, P < 0.01). The proposed 4-stage system was confirmed in an independent cohort of 5533 patients with CR-POPF rates of 3.5%, 6.2%, 16.6%, and 23.2% for type A-D, respectively ( P < 0.001). CONCLUSION For future pancreatic surgical outcomes studies, the ISGPS recommends reporting these risk factors according to the proposed classification system for better comparability of results.
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Radulova-Mauersberger O, Oehme F, Missel L, Kahlert C, Welsch T, Weitz J, Distler M. Analysis of predictors for postoperative complications after pancreatectomy--what is new after establishing the definition of postpancreatectomy acute pancreatitis (PPAP)? Langenbecks Arch Surg 2023; 408:79. [PMID: 36746822 PMCID: PMC9902317 DOI: 10.1007/s00423-023-02814-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 01/17/2023] [Indexed: 02/08/2023]
Abstract
PURPOSE We aimed to analyze the predictive value of hyperamylasemia after pancreatectomy for morbidity and for the decision to perform rescue completion pancreatectomy (CP) in a retrospective cohort study. METHODS Data were extracted from a retrospective clinical database. Postoperative hyperamylasemia (POH) and postoperative hyperlipasemia (POHL) were defined by values greater than those accepted as the upper limit at our institution on postoperative day 1 (POD1). The endpoints of the study were the association of POH with postoperative morbidity and the possible predictors for postpancreatectomy acute pancreatitis (PPAP) and severe complications such as the necessity for rescue CP. RESULTS We analyzed 437 patients who underwent pancreaticoduodenectomy over a period of 7 years. Among them, 219 (52.3%) patients had POH and 200 (47.7%) had normal postoperative amylase (non-POH) levels. A soft pancreatic texture (odds ratio [OR] 3.86) and POH on POD1 (OR 8.2) were independent predictors of postoperative pancreatic fistula (POPF), and POH on POD1 (OR 6.38) was an independent predictor of rescue CP. The clinically relevant POPF (49.5% vs. 11.4%, p < 0.001), intraabdominal abscess (38.3% vs. 15.3%, p < 0.001), postoperative hemorrhage (22.8% vs. 5.1%, p < 0.001), major complications (Clavien-Dindo classification > 2) (52.5% vs. 25.6%, p < 0.001), and CP (13% vs. 1.8%, p < 0.001) occurred significantly more often in the POH group than in the non-POH group. CONCLUSION Although POH on POD1 occurs frequently, in addition to other risk factors, it has a predictive value for the development of postoperative morbidity associated with PPAP and CP.
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Affiliation(s)
- O Radulova-Mauersberger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrass 74, 01307, Dresden, Germany
| | - F Oehme
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrass 74, 01307, Dresden, Germany
| | - L Missel
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrass 74, 01307, Dresden, Germany
| | - C Kahlert
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrass 74, 01307, Dresden, Germany
| | - T Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrass 74, 01307, Dresden, Germany
| | - J Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrass 74, 01307, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrass 74, 01307, Dresden, Germany.
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany.
- German Cancer Research Center (DKFZ), Heidelberg, Germany.
- Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
- Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany.
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Post-Pancreatectomy Acute Pancreatitis-The New Criteria Fail to Recognize Significant Presentations. J Gastrointest Surg 2023; 27:363-372. [PMID: 36449249 PMCID: PMC9974691 DOI: 10.1007/s11605-022-05533-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 11/13/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Post-pancreatectomy acute pancreatitis (PPAP) is a newly described clinical entity defined as elevated serum amylase sustained ≥ 48 h postoperatively, radiological findings consistent with acute pancreatitis, and associated clinically relevant features. This study aimed to investigate the incidence of PPAP and the rate of major complications after pancreatoduodenectomy (PD) in patients with only transiently elevated serum amylase. METHODS A retrospective single-center observational study was conducted including consecutive patients ≥ 18 years of age undergoing PD at Karolinska University Hospital, between 2008 and 2020. Serum amylase on postoperative day (POD) 1 and 2 and records from computer tomography were analyzed and correlated with postoperative major complications by logistic regressions. RESULTS Of some 1078 patients that underwent PD, 284 exhibited sustained elevated serum amylase (according to PPAP criteria) and 183 transiently elevated serum amylase on either POD1 or POD2. Of the patients with sustained elevated levels, 43% (n = 123) developed major complications, but only 6.3% (n = 18) showed findings consistent with acute pancreatitis on imaging. Of the 183 cases that exhibited only transiently elevated serum amylase on either POD1 or POD2, 32% (n = 58) developed major complications. CONCLUSION Sustained hyperamylasemia was observed in 26% of patients after PD, and an additional 17% of patients had a transient elevation of serum amylase postoperatively. Acute pancreatitis after PD may be underdiagnosed, partly by overlooking transiently elevated serum amylase and partly by requiring imaging that potentially fails to recognize mild but complication-prone acute pancreatitis.
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Early and Sustained Elevation in Serum Pancreatic Amylase Activity: A Novel Predictor of Morbidity After Pancreatic Surgery. Ann Surg 2023; 277:e126-e135. [PMID: 33938491 DOI: 10.1097/sla.0000000000004921] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To characterize early postoperative serum pancreatic amylase (spAMY) trends after pancreatic resections. SUMMARY BACKGROUND DATA A postoperative spAMY elevation is a common finding but uncertainties remain about its meaning and prognostic implications. METHODS Analysis of patients who consecutively underwent pancreatectomy from 2016 to 2019. spAMY activity was assessed from postoperative day (POD) 0 to 3. Different patterns of spAMY have been identified based on the spAMY standard range (10-52 U/l). RESULTS Three patterns were identified: (#1) spAMY values always < the lower limit of normal/within the reference range /a single increase in spAMY > upper limit of normal at any POD; (#2) Sustained increase in spAMY activity on POD 0 + 1; (#3) Sustained increase in spAMY activity including POD 1 + 2. Shifting through spAMY patterns was associated with increase morbidity (21% in #1 to 68% in #3 at POD 7; log rank < 0.001). Almost all severe complications (at least Clavien-Dindo ≥3) occurred in patients with pattern #3 (15% vs 3% vs 5% in #1 and #2 at POD 7, P = 0.006), without difference considering >3-times or >the spAMY normal limit ( P = 0.85). POPF (9% in #1 vs 48% in #3, P < 0.001) progressively increased across patterns. Pre-operative diabetes (OR 0.19), neoadjuvant therapy (OR 0.22), pancreatic texture (OR 8.8), duct size (OR 0.78), and final histology (OR 2.2) were independent predictors of pattern #3. CONCLUSIONS A sustained increase in spAMY activity including POD 1 + 2 (#3) represents an early postoperative predictor of overall and severe early morbidity. An early and dynamic evaluation of spAMY could crucially impact the subsequent clinical course with relevant prognostic implications.
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Peltoniemi P, Pere P, Mustonen H, Seppänen H. Optimal Perioperative Fluid Therapy Associates with Fewer Complications After Pancreaticoduodenectomy. J Gastrointest Surg 2023; 27:67-77. [PMID: 36131201 PMCID: PMC9876870 DOI: 10.1007/s11605-022-05453-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 08/26/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Optimal fluid management in pancreaticoduodenectomy patients remains contested. We aimed to examine the association between perioperative fluid administration and postoperative complications. METHODS We studied 168 pancreaticoduodenectomy patients operated in 2015 (n = 93) or 2017 (n = 75) at Helsinki University Hospital. In 2015, patients received intraoperative fluids following a goal-directed approach and, in 2017, according to anesthesiologist's clinical practice (conventional fluid management). We analyzed the differences in perioperative fluid administration between the groups, specifically examining the occurrence of severe complications (Clavien-Dindo ≥ III), pancreatic fistulas, cardiovascular complications, and the length of hospital stay. RESULTS The goal-directed group received more intraoperative fluids than the conventional fluid management group (12.0 ml/kg/h vs. 8.3 ml/kg/h, p < 0.001). Urine output (770 ml vs. 575 ml, p = 0.004) and intraoperative fluid balance (9.4 ml/kg/h vs. 6.3 ml/kg/h, p < 0.001) were higher in the goal-directed group than in the conventional fluid management group. Severe surgical complications (19.4% vs. 38.7%, p = 0.009) as well as clinically relevant pancreatic fistulas (1.1% vs. 10.7%, p = 0.011) occurred more frequently in patients receiving conventional fluid management. Moreover, the conventional fluid management group experienced longer hospital stays (9.0 vs. 11.5 days, p = 0.02). Lower intraoperative fluid volume accompanying conventional fluid management was associated with a higher risk of severe postoperative complications compared with higher volume in the goal-directed group (odds ratio 2.58 (95% confidence interval 1.04-6.42), p = 0.041). CONCLUSIONS The goal-directed group experienced severe complications less frequently. Our findings indicate that optimizing the intraoperative fluid administration benefits patients, while adopting a too-restrictive approach represents an inferior choice.
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Affiliation(s)
- Piia Peltoniemi
- grid.7737.40000 0004 0410 2071Department of Perioperative, Intensive Care and Pain Medicine, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland ,grid.7737.40000 0004 0410 2071Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pertti Pere
- grid.7737.40000 0004 0410 2071Department of Perioperative, Intensive Care and Pain Medicine, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Harri Mustonen
- grid.7737.40000 0004 0410 2071Department of Gastroenterological Surgery, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland ,grid.7737.40000 0004 0410 2071Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hanna Seppänen
- grid.7737.40000 0004 0410 2071Department of Gastroenterological Surgery, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland ,grid.7737.40000 0004 0410 2071Translational Cancer Medicine Research Program, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Rössler F, Kümmerli C, Hügli S, Jonas JP, Hübel K, Oberkofler CE, Müller PC, de Rougemont O. Effect of donor pancreas extraction time on pancreas transplantation-a Swiss tertiary center experience. Clin Transplant 2023; 37:e14846. [PMID: 36322914 DOI: 10.1111/ctr.14846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 10/24/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
Abstract
We aimed to assess the effect of donor pancreas extraction time (ET) on postoperative complications and graft function after pancreas transplantation (PT). We analyzed all consecutive donor pancreas procurements for the simultaneous pancreas and kidney transplantation (SPK) and the associated PT in a Swiss transplant center over a 20-year period. Pancreas ET was defined as the time from cold flush to static storage of the pancreas on ice. The primary endpoint was the effect of extraction time on surgical complications. Secondary endpoints comprised the effect of ET on graft function (insulin-free survival) and graft pancreatitis. Of 115 procured pancreas grafts the median donor pancreas ET was 65 min (IQR: 48-78 min). In multivariable analysis, ET did not negatively affect major complications (OR 1.41 [95% CI: .59-3.36]; p = .438) and insulin-free survival (HR 1.42 [95% CI: .55-3.63]; p = .459). The median CIT was 522 (441-608) min. CIT was associated with major complications (OR 2.51 [95% CI: 1.11-5.68]; p = .027), but without impact on insulin-free survival (HR 1.94 [95% CI: .84-4.48]; p = .119). Patients with and without graft pancreatitis had no statistically significant differences in ET and CIT (p = .164 and p = .47, respectively). In multivariable analysis, Amylase levels > 270 U/L on postoperative day 1 were significantly associated with major complications (OR 3.61 [95% CI: 1.06-12.32]; p = .040). Our results suggest that although no effect of ET on complications and graft function after PT was found, shorter CIT and less graft pancreatitis can have a positive impact on surgical complications. Results could possibly be influenced by the exceptional quality of the pancreas donors, with short travel distances and preservation times in Switzerland.
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Affiliation(s)
- Fabian Rössler
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Christoph Kümmerli
- Clarunis, University Centre for Gastrointestinal and Liver Diseases, University Hospital Basel, Basel, Switzerland
| | - Sandro Hügli
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Jan P Jonas
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Kerstin Hübel
- Department of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Christian E Oberkofler
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland.,Vivèvis AG - Visceral, Tumor And Robotic Surgery Clinic Hirslanden Zürich, Zürich, Switzerland
| | - Philip C Müller
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Olivier de Rougemont
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
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Kokkinakis S, Kritsotakis EI, Maliotis N, Karageorgiou I, Chrysos E, Lasithiotakis K. Complications of modern pancreaticoduodenectomy: A systematic review and meta-analysis. Hepatobiliary Pancreat Dis Int 2022; 21:527-537. [PMID: 35513962 DOI: 10.1016/j.hbpd.2022.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 04/13/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND In the past decades, the perioperative management of patients undergoing pancreaticoduodenectomy (PD) has undergone major changes worldwide. This review aimed to systematically determine the burden of complications of PD performed in the last 10 years. DATA SOURCES A systematic review was conducted in PubMed for randomized controlled trials and observational studies reporting postoperative complications in at least 100 PDs from January 2010 to April 2020. Risk of bias was assessed using the Cochrane RoB2 tool for randomized studies and the methodological index for non-randomized studies (MINORS). Pooled complication rates were estimated using random-effects meta-analysis. Heterogeneity was investigated by subgroup analysis and meta-regression. RESULTS A total of 20 randomized and 49 observational studies reporting 63 229 PDs were reviewed. Mean MINORS score showed a high risk of bias in non-randomized studies, while one quarter of the randomized studies were assessed to have high risk of bias. Pooled incidences of 30-day mortality, overall complications and serious complications were 1.7% (95% CI: 0.9%-2.9%; I2 = 95.4%), 54.7% (95% CI: 46.4%-62.8%; I2 = 99.4%) and 25.5% (95% CI: 21.8%-29.4%; I2= 92.9%), respectively. Clinically-relevant postoperative pancreatic fistula risk was 14.3% (95% CI: 12.4%-16.3%; I2 = 92.0%) and mean length of stay was 14.8 days (95% CI: 13.6-16.1; I2 = 99.3%). Meta-regression partially attributed the observed heterogeneity to the country of origin of the study, the study design and the American Society of Anesthesiologists class. CONCLUSIONS Pooled complication rates estimated in this study may be used to counsel patients scheduled to undergo a PD and to set benchmarks against which centers can audit their practice. However, cautious interpretation is necessary due to substantial heterogeneity.
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Affiliation(s)
- Stamatios Kokkinakis
- Department of General Surgery, University General Hospital of Heraklion, Heraklion, Crete 71110, Greece
| | - Evangelos I Kritsotakis
- Laboratory of Biostatistics, Division of Social Medicine, School of Medicine, University of Crete, Heraklion, Crete 71110, Greece
| | - Neofytos Maliotis
- Department of General Surgery, University General Hospital of Heraklion, Heraklion, Crete 71110, Greece
| | - Ioannis Karageorgiou
- Department of General Surgery, University General Hospital of Heraklion, Heraklion, Crete 71110, Greece
| | - Emmanuel Chrysos
- Department of General Surgery, University General Hospital of Heraklion, Heraklion, Crete 71110, Greece
| | - Konstantinos Lasithiotakis
- Department of General Surgery, University General Hospital of Heraklion, Heraklion, Crete 71110, Greece.
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Jacquemin M, Mokart D, Faucher M, Ewald J, Tourret M, Brun C, Tezier M, Mallet D, Nguyen Duong L, Cambon S, Pouliquen C, Ettori F, Sannini A, Gonzalez F, Bisbal M, Chow-Chine L, Servan L, de Guibert JM, Boher JM, Turrini O, Garnier J. LATE POSTPANCREATICODUODENECTOMY HEMORRHAGE: INCIDENCE, RISK FACTORS, MANAGEMENT AND OUTCOME. Shock 2022; 58:374-383. [PMID: 36445230 DOI: 10.1097/shk.0000000000001999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
ABSTRACT Background:Postpancreaticoduodenectomy (PD) hemorrhage (PPH) is a life-threatening complication after PD. The main objective of this study was to evaluate incidence and factors associated with late PPH as well as the management strategy and outcomes. Methods: Between May 2017 and March 2020, clinical data from 192 patients undergoing PD were collected prospectively in the CHIRPAN Database (NCT02871336) and retrospectively analyzed. In our institution, all patients scheduled for a PD are routinely admitted for monitoring and management in intensive/intermediate care unit (ICU/IMC). Results: The incidence of late PPH was 17% (32 of 192), whereas the 90-day mortality rate of late PPH was 19% (6 of 32). Late PPH was associated with 90-day mortality (P = 0.001). Using multivariate analysis, independent risk factors for late PPH were postoperative sepsis (P = 0.036), and on day 3, creatinine (P = 0.025), drain fluid amylase concentration (P = 0.023), lipase concentration (P < 0.001), and C-reactive protein (CRP) concentration (P < 0.001). We developed two predictive scores for PPH occurrence, the PANCRHEMO scores. Score 1 was associated with 68.8% sensitivity, 85.6% specificity, 48.8% predictive positive value, 93.2% negative predictive value, and an area under the receiver operating characteristic curves of 0.841. Score 2 was associated with 81.2% sensitivity, 76.9% specificity, 41.3% predictive positive value, 95.3% negative predictive value, and an area under the receiver operating characteristic curve of 0.859. Conclusions: Routine ICU/IMC monitoring might contribute to a better management of these complications. Some predicting factors such as postoperative sepsis and biological markers on day 3 should help physicians to determine patients requiring a prolonged ICU/IMC monitoring.
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Affiliation(s)
- Mathieu Jacquemin
- Département d'Anesthésie-Réanimation, Institut Paoli Calmette, France
| | - Djamel Mokart
- Département d'Anesthésie-Réanimation, Institut Paoli Calmette, France
| | - Marion Faucher
- Département d'Anesthésie-Réanimation, Institut Paoli Calmette, France
| | - Jacques Ewald
- Département de Chirurgie Oncologique, Institut Paoli Calmette, France
| | - Maxime Tourret
- Département d'Anesthésie-Réanimation, Institut Paoli Calmette, France
| | - Clément Brun
- Département d'Anesthésie-Réanimation, Institut Paoli Calmette, France
| | - Marie Tezier
- Département d'Anesthésie-Réanimation, Institut Paoli Calmette, France
| | - Damien Mallet
- Département d'Anesthésie-Réanimation, Institut Paoli Calmette, France
| | - Lam Nguyen Duong
- Département d'Anesthésie-Réanimation, Institut Paoli Calmette, France
| | - Sylvie Cambon
- Département d'Anesthésie-Réanimation, Institut Paoli Calmette, France
| | - Camille Pouliquen
- Département d'Anesthésie-Réanimation, Institut Paoli Calmette, France
| | - Florence Ettori
- Département d'Anesthésie-Réanimation, Institut Paoli Calmette, France
| | - Antoine Sannini
- Département d'Anesthésie-Réanimation, Institut Paoli Calmette, France
| | - Frédéric Gonzalez
- Département d'Anesthésie-Réanimation, Institut Paoli Calmette, France
| | - Magali Bisbal
- Département d'Anesthésie-Réanimation, Institut Paoli Calmette, France
| | | | - Luca Servan
- Département d'Anesthésie-Réanimation, Institut Paoli Calmette, France
| | | | - Jean Marie Boher
- Unité de Biostatistique et de Méthodologie, Institut Paoli Calmette, France
| | - Olivier Turrini
- Département de Chirurgie Oncologique, Institut Paoli Calmette, France
| | - Jonathan Garnier
- Département de Chirurgie Oncologique, Institut Paoli Calmette, France
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Raza SS, Nutu A, Powell-Brett S, Marchetti A, Perri G, Carvalheiro Boteon A, Hodson J, Chatzizacharias N, Dasari BV, Isaac J, Abradelo M, Marudanayagam R, Mirza DF, Roberts JK, Marchegiani G, Salvia R, Sutcliffe RP. Early postoperative risk stratification in patients with pancreatic fistula after pancreaticoduodenectomy. Surgery 2022. [PMID: 37530481 DOI: 10.1016/j.surg.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Early stratification of postoperative pancreatic fistula according to severity and/or need for invasive intervention may improve outcomes after pancreaticoduodenectomy. This study aimed to identify the early postoperative variables that may predict postoperative pancreatic fistula severity. METHODS All patients diagnosed with biochemical leak and clinically relevant-postoperative pancreatic fistula based on drain fluid amylase >300 U/L on the fifth postoperative day after pancreaticoduodenectomy were identified from a consecutive cohort from Birmingham, UK. Demographics, intraoperative parameters, and postoperative laboratory results on postoperative days 1 through 7 were retrospectively extracted. Independent predictors of clinically relevant-postoperative pancreatic fistula were identified using multivariable binary logistic regression and converted into a risk score, which was applied to an external cohort from Verona, Italy. RESULTS The Birmingham cohort had 187 patients diagnosed with postoperative pancreatic fistula (biochemical leak: 99, clinically relevant: 88). In clinically relevant-postoperative pancreatic fistula patients, the leak became clinically relevant at a median of 9 days (interquartile range: 6-13) after pancreaticoduodenectomy. Male sex (P = .002), drain fluid amylase-postoperative day 3 (P < .001), c-reactive protein postoperative day 3 (P < .001), and albumin-postoperative day 3 (P = .028) were found to be significant predictors of clinically relevant-postoperative pancreatic fistula on multivariable analysis. The multivariable model was converted into a risk score with an area under the receiver operating characteristic curve of 0.78 (standard error: 0.038). This score significantly predicted the need for invasive intervention (postoperative pancreatic fistula grades B3 and C) in the Verona cohort (n = 121; area under the receiver operating characteristic curve: 0.68; standard error = 0.06; P = .006) but did not predict clinically relevant-postoperative pancreatic fistula when grades B1 and B2 were included (area under the receiver operating characteristic curve 0.52; standard error = 0.07; P = .802). CONCLUSION We developed a novel risk score based on early postoperative laboratory values that can accurately predict higher grades of clinically relevant-postoperative pancreatic fistula requiring invasive intervention. Early identification of severe postoperative pancreatic fistula may allow earlier intervention.
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Mintziras I, Stollenwerk L, Uhl W, Niescery J, Belyaev O, Luu AM, Munding J, Tannapfel A, Künzli B, Herzog T. Pancreatic Apoplexy: Fulminant Necrotizing Pancreatitis Leading to Completion Pancreatectomy Within 3 Days After Partial Pancreaticoduodenectomy. Pancreas 2022; 51:1128-1132. [PMID: 37078935 DOI: 10.1097/mpa.0000000000002149] [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: 04/21/2023]
Abstract
OBJECTIVES Patient characteristics with postoperative acute necrotizing pancreatitis and completion pancreatectomy (CP) after pancreaticoduodenectomy (PD) remain unclear. METHODS Data from all patients who underwent a PD with need for CP (January 2011-December 2019) at a German University Hospital were analyzed regarding the indications and timing of CP, laboratory and histopathological findings, and overall outcome. RESULTS Six hundred twelve patients underwent PD, 33 (5.4%) of them needed a CP. Indications were grade C pancreatic fistula with or without biliary leak (46% and 12%), biliary leak (6%), and hemorrhage due to pancreatic fistula (36%). Eight patients (24%) underwent CP within 3 days after PD. These fulminant courses ("pancreatic apoplexy") were accompanied by significantly higher levels of lactate dehydrogenase, C-reactive protein, serum amylase, serum lipase, drain amylase, and drain lipase compared with patients with CP after the third day. Pancreatic apoplexy was histologically associated with higher rates of pancreatic necrosis (P = 0.044) and hemorrhage (P = 0.001). A trend toward higher mortality was observed (75% vs 36%, P = 0.058). CONCLUSIONS Pancreatic apoplexy, defined as fulminant necrotizing pancreatitis after PD leading to CP within 3 days, is associated with characteristic laboratory and histopathological findings and a trend to higher mortality.
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Affiliation(s)
| | | | - Waldemar Uhl
- From the Departments of General and Visceral Surgery
| | | | - Orlin Belyaev
- From the Departments of General and Visceral Surgery
| | | | - Johanna Munding
- Institute of Pathology, Ruhr University Bochum, Bochum, Germany
| | | | - Beat Künzli
- Department of Visceral Surgery, Kantonsspital Graubünden, Chur, Switzerland
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Wei JP, Tai S, Su ZL. One-half layer pancreaticojejunostomy with the rear wall of the pancreas reinforced: A valuable anastomosis technique. World J Clin Cases 2022; 10:9276-9284. [PMID: 36159416 PMCID: PMC9477674 DOI: 10.12998/wjcc.v10.i26.9276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 03/26/2022] [Accepted: 08/05/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is one of the most common and serious complications after pancreaticoduodenectomy (PD). To effectively reduce the incidence of POPF, we designed a new type of pancreaticojejunostomy (PJ), which was termed one-half layer PJ with the rear wall of the pancreas reinforced.
AIM To explore the clinical application value of this new technique.
METHODS We compared 62 patients who had undergone PD by either the traditional duct-to-mucosa anastomoses or the new one-half layer PJ with the rear wall of the pancreas reinforced method at our hospital from May 2015 to September 2019. All 62 patients were operated by the same surgeon experienced in both procedures. We retrospectively analyzed patient characteristics, perioperative outcomes, and surgical results.
RESULTS There was no significant difference between the two groups in basic information except the postoperative hospital stays, 14.7 ± 5.4 d in the traditional duct-to-mucosa anastomoses group and 12.0 ± 4.2 d in the one-half layer PJ group (P = 0.042). In terms of postoperative complications, the one-half layer PJ group had a lower rate of POPF than the traditional group. The overall number of cases with POPF was 8 (24.2%) in the traditional group and 2 (6.9%) in the one-half layer group (P = 0.017). Additionally, the rate of grades B and C POPF was lower in the one-half layer group (3.4%) compared with that (12.1%) in the traditional group (P = 0.010). One patient died due to hemorrhage caused by severe pancreatic fistula in the traditional group.
CONCLUSION One-half layer PJ with the rear wall of the pancreas reinforced is a safe and feasible procedure that can successfully reduce the rate of POPF. It may be a promising technique for PJ after PD.
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Affiliation(s)
- Jin-Ping Wei
- Department of General Surgery, Beijing Chuiyangliu Hospital, Beijing 100022, China
| | - Sheng Tai
- Department of Hepatopancreatobiliary Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, Heilongjiang Province, China
| | - Zhi-Lei Su
- Department of Hepatopancreatobiliary Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, Heilongjiang Province, China
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Chen H, Wang W, Zou S, Wang X, Ying X, Cheng D, Weng Y, Deng X, Shen B. Serum lipase on postoperative day one is a strong predictor of clinically relevant pancreatic fistula after pancreaticoduodenectomy: A retrospective cohort. Pancreatology 2022; 22:810-816. [PMID: 35717304 DOI: 10.1016/j.pan.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 05/07/2022] [Accepted: 06/01/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Increased postoperative serum amylase has been recently reported to be associated with increased postoperative morbidity, but studies on postoperative serum lipase are limited. The aim of this study was to evaluate the value of postoperative serum lipase in predicting clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD). METHOD A retrospective analysis was performed on 212 patients who underwent PD from September 2018 and March 2021, focusing on the association between postoperative day (POD) 1 serum lipase and CR-POPF. RESULTS Overall, 108 (50.9%) patients had elevated serum lipase levels (>68 U/L) on POD 1. Patients with elevated serum lipase exhibited a significantly higher incidence of CR-POPF (37.0% vs. 6.7%, p < 0.001). Receiver operating characteristic (ROC) analyses showed improved diagnostic accuracy for POD 1 serum lipase compared with POD 1 serum amylase in predicting CR-POPF (AUC: 0.801 vs. 0.745, p = 0.029). Elevated serum lipase on POD 1 and elevated serum CRP on POD 3 were identified as independent predictors of CR-POPF. A simple early postoperative model, consisting of POD 1 serum lipase levels and POD 3 serum CRP levels, showed good discrimination (AUC 0.76, 95% CI 0.69-0.83) to identify the onset of CR-POPF. CONCLUSION Serum lipase on POD 1 outperformed serum amylase on POD 1 in predicting CR-POPF after PD. The combination of POD 1 serum lipase and POD 3 serum CRP provides a reliable predicting model for CR-POPF.
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Affiliation(s)
- Haoda Chen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weishen Wang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Siyi Zou
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinjing Wang
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiayang Ying
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dongfeng Cheng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuanchi Weng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Xiaxing Deng
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Baiyong Shen
- Department of General Surgery, Pancreatic Disease Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Brajcich BC, Platoff RM, Thompson VM, Hall B, Ko CY, Pitt HA. Hyperamylasemia grade versus drain fluid amylase: which better predicts pancreatectomy outcomes? HPB (Oxford) 2022; 24:1252-1260. [PMID: 35034836 DOI: 10.1016/j.hpb.2021.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 11/30/2021] [Accepted: 12/27/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The clinical importance of postoperative hyperamylasemia (POHA) grade is unknown. Our objectives were to evaluate the association of POHA grade with clinically relevant postoperative pancreatic fistula (CR-POPF) and compare its prognostic utility against postoperative day 1 drain fluid amylase (DFA-1). METHODS Patients who underwent pancreatectomy from January 2019 through March 2020 were identified in the ACS NSQIP pancreatectomy-targeted dataset. POHA grade was assigned using post-operative serum amylase and clinical sequelae. The primary outcome was CR-POPF within 30 days. The association of POHA grade with CR-POPF was assessed using multivariable logistic regression, and c-statistics were used to compare POHA grade versus DFA-1. RESULTS POHA occurred in 520 patients at 98 hospitals, including 261 (50.2%) with grade A, 234 (45.0%) with grade B, and 25 (4.8%) with grade C POHA. CR-POPFs were increased among patients with grade B (66.2%, OR 9.28 [5.84-14.73]) and C (68.0%, OR 10.50 [3.77-29.26]) versus grade A POHA (19.2%). POHA-inclusive models better predicted CR-POPF than those with DFA-1 alone (p < 0.002) and models with both predictors outperformed POHA alone (p = 0.039). CONCLUSION POHA grade represents a measure of post-pancreatectomy outcomes that predicts CR-POPF and outperforms DFA-1 but must be aligned with new international definitions.
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Affiliation(s)
- Brian C Brajcich
- American College of Surgeons, Chicago, IL, USA; Surgical Outcomes and Quality Improvement Center, Department of Surgery, Northwestern Medicine, Chicago, IL, USA
| | | | | | - Bruce Hall
- American College of Surgeons, Chicago, IL, USA; Department of Surgery, Washington University in Saint Louis School of Medicine, and BJC Healthcare, St Louis, MO USA
| | - Clifford Y Ko
- American College of Surgeons, Chicago, IL, USA; Department of Surgery, University of California Los Angeles School of Medicine, Los Angeles, CA, USA; The Healthcare Improvement Studies Institute, University of Cambridge, Cambridge, United Kingdom
| | - Henry A Pitt
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.
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35
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Wu S, Wu H, Xu G, Zhao Y, Xue F, Dong S, Han L, Wang Z, Wu Z. Risk Factors and Clinical Impacts of Post-Pancreatectomy Acute Pancreatitis After Pancreaticoduodenectomy: A Single-Center Retrospective Analysis of 298 Patients Based on the ISGPS Definition and Grading System. Front Surg 2022; 9:916486. [PMID: 35860201 PMCID: PMC9289243 DOI: 10.3389/fsurg.2022.916486] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
Background The definition and grading system of post-pancreatectomy acute pancreatitis (PPAP) has recently been proposed by ISGPS. This study aimed to put this definition and classification into practice and investigate the potential risk factors and clinical impacts of PPAP. Methods Demographic and perioperative data of consecutive patients who underwent pancreaticoduodenectomy (PD) from January 2019 to July 2021 were collected and analyzed retrospectively. The diagnostic criteria of PPAP published by ISGPS, consisting of biochemical, radiologic, and clinical parameters, were adopted. The risk factors were analyzed by univariate and multivariate analyses. Results A total of 298 patients were enrolled in this study, and the total incidence of PPAP was 52.4% (150 patients). Stratified by clinical impacts of PPAP, the incidences of grades B and C PPAP were 48.9% and 3.5%, respectively. PPAP after PD was significantly associated with pancreatic fistula and other unfavorable complications. Soft pancreatic texture (OR 3.0) and CRP ≥ 180 mg/L (OR 3.6) were the independent predictors of PPAP, AUC 0.613. Stratified by the grade of PPAP, soft pancreatic texture (OR 2.7) and CRP ≥ 180 mg/L (OR 3.4) were the independent predictors of grade B PPAP, and soft pancreatic texture (OR 19.3), operation duration >360 min (OR 13.8), and the pancreatic anastomosis by using conventional duct to mucosa methods (OR 10.4) were the independent predictors of grade C PPAP. PPAP complicated with pancreatic fistula significantly increased the severe complications and mortality compared to only PPAP occurrence. Conclusion PPAP was not an uncommon complication after PD and was associated with unfavorable clinical outcomes, especially since it was complicated with pancreatic fistula. Soft pancreatic texture and CRP ≥ 180 mg/L were the independent predictors of PPAP. Higher-volume multicenter and prospective studies are strongly needed.
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Affiliation(s)
- Shuai Wu
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Hanxue Wu
- Department of Physiology and Pathophysiology, School of Basic Medicine, Xi’an Jiaotong University, Xi’an, China
| | - Guiping Xu
- Department of Radiology, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yaling Zhao
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Feng Xue
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Shunbin Dong
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Liang Han
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Zheng Wang
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Zheng Wu
- Department of Hepatobiliary Surgery, the First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- Correspondence: Zheng Wu
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Is routine CT scan after pancreaticoduodenectomy a useful tool in the early detection of complications? A single center retrospective analysis. Langenbecks Arch Surg 2022; 407:2801-2810. [PMID: 35752718 DOI: 10.1007/s00423-022-02599-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 06/20/2022] [Indexed: 10/17/2022]
Abstract
PURPOSE The clinical impact of routine CT imaging after pancreaticoduodenectomy (PD) has not been properly investigated. The aim of this study was to investigate the role of routine CT scan after PD for the detection of postoperative complications. METHODS Prospectively collected data of consecutive patients undergoing PD and receiving routine postoperative CT imaging were retrospectively analyzed. The primary endpoint was accuracy of CT imaging in identifying major complications. The secondary endpoint was identification of preoperative and intraoperative factors associated with severe complications. A subgroup analysis of CT scan accuracy in identifying severe complications in patients stratified by fistula risk score (FRS) and presence of early clinical alterations was also performed. RESULTS A total of 145 patients were included. Routine CT scan had low specificity (Sp = 0.36) and high sensitivity (Sn = 0.98) for predicting major complications, with an accuracy of 0.57. At multivariate logistic regression analysis, only fistula moderate-high FRS (p = 0.029) was independently associated with severe complications. In patients with negligible-low FRS, CT scan showed a Sp of 0.63 and a Sn of 1.0 with an accuracy of 0.69. In patients with moderate-high FRS, CT scan had a Sp of 0.19, a Sn of 0.97 and an accuracy of 0.5. In the 20 (14%) patients with negligible-low FRS and no clinical alterations, no deaths or readmissions occurred regardless of CT findings, while one severe complication occurred in the positive CT scan group. In all other groups, no deaths or readmissions occurred in case of negative CT, with only one severe complication in the moderate-high FRS group with clinical alterations. In case of positive CT, the rate of severe complications was 47% in case of negligible-low FRS and clinical alterations, 40% in case of moderate-high FRS with no clinical alterations, and 45% in case of moderate-high FRS and clinical alterations. CONCLUSIONS Routine postoperative CT scan after PD should not be performed in patients with negligible-low FRS and no clinical alterations. In all other patients, a negative CT scan appears to be highly accurate in identifying patients who will have an uneventful course and who could benefit from early discharge.
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Murakawa M, Kamioka Y, Kawahara S, Yamamoto N, Kobayashi S, Ueno M, Morimoto M, Tamagawa H, Ohshima T, Yukawa N, Rino Y, Masuda M, Morinaga S. Postoperative acute pancreatitis after pancreatic resection in patients with pancreatic ductal adenocarcinoma. Langenbecks Arch Surg 2022; 407:1525-1535. [PMID: 35217927 DOI: 10.1007/s00423-022-02481-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 02/21/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Postoperative pancreatic fistula (POPF) is one of the major critical complications after pancreatic resection. Recently, postoperative acute pancreatitis (POAP), a new concept for a pancreatic-specific complication following pancreatic resection, has been advocated, and its association with POPF has been reported. The present study examined the clinical features of POAP and identified the associations of POAP with POPF and other postoperative morbidities in pancreatic ductal adenocarcinoma (PDAC) patients undergoing pancreatic resection. METHODS A total of 312 consecutive patients who underwent pancreatic resection for PDAC at our institution from 2013 to 2019 were enrolled in this study. POAP was defined as an elevated serum amylase level above the upper limit normal on postoperative day (POD) 0 or 1, based on Connor's definition. The severity of POPF was assessed by the International Study Group on Pancreatic Surgery definition. RESULTS A total of 184 patients (58.9%) had POAP. POAP occurred in 58.5% of subtotal stomach-preserving pancreatoduodenectomy patients and 60% of distal pancreatectomy combined with splenectomy patients. The presence of POAP was significantly associated with the development of clinically relevant POPF, higher rates of severe morbidity, and a prolonged hospital stay after pancreatic resection. A multivariate analysis showed that the presence of POAP and elevated C-reactive protein levels on POD 3 were independent predictors of clinically relevant POPF after subtotal stomach-preserving pancreatoduodenectomy. CONCLUSIONS POAP is associated with the development of POPF, higher rates of severe morbidity, and a prolonged hospital stay after pancreatic resection and is an independent risk factor for clinically relevant POPF after pancreatoduodenectomy. POAP represents an important indicator for planning treatment strategies to prevent serious complications, including POPF.
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Affiliation(s)
- Masaaki Murakawa
- Department of Gastrointestinal Surgery, Kanagawa Cancer Center, 2-3-2 Nakao, Asahi-ward, Yokohama, 241-8515, Japan.
| | - Yuto Kamioka
- Department of Gastrointestinal Surgery, Kanagawa Cancer Center, 2-3-2 Nakao, Asahi-ward, Yokohama, 241-8515, Japan
| | - Shinnosuke Kawahara
- Department of Gastrointestinal Surgery, Kanagawa Cancer Center, 2-3-2 Nakao, Asahi-ward, Yokohama, 241-8515, Japan
| | - Naoto Yamamoto
- Department of Gastrointestinal Surgery, Kanagawa Cancer Center, 2-3-2 Nakao, Asahi-ward, Yokohama, 241-8515, Japan
| | - Satoshi Kobayashi
- Department of Hepatobiliary Pancreatic Oncology, Kanagawa Cancer Center, 2-3-2 Nakao, Asahi-ward, Yokohama, 241-8515, Japan
| | - Makoto Ueno
- Department of Hepatobiliary Pancreatic Oncology, Kanagawa Cancer Center, 2-3-2 Nakao, Asahi-ward, Yokohama, 241-8515, Japan
| | - Manabu Morimoto
- Department of Hepatobiliary Pancreatic Oncology, Kanagawa Cancer Center, 2-3-2 Nakao, Asahi-ward, Yokohama, 241-8515, Japan
| | - Hiroshi Tamagawa
- Department of Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Takashi Ohshima
- Department of Gastrointestinal Surgery, Kanagawa Cancer Center, 2-3-2 Nakao, Asahi-ward, Yokohama, 241-8515, Japan
| | - Norio Yukawa
- Department of Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Yasushi Rino
- Department of Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Munetaka Masuda
- Department of Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Soichiro Morinaga
- Department of Gastrointestinal Surgery, Kanagawa Cancer Center, 2-3-2 Nakao, Asahi-ward, Yokohama, 241-8515, Japan
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Ikenaga N, Nakata K, Fujita N, Abe T, Ideno N, Ishigami K, Nakamura M. Clinical significance of postpancreatectomy acute pancreatitis defined by the International Study Group for Pancreatic Surgery. Ann Gastroenterol Surg 2022; 6:842-850. [PMID: 36338587 PMCID: PMC9628230 DOI: 10.1002/ags3.12587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/21/2022] [Indexed: 11/10/2022] Open
Abstract
Aim The International Study Group for Pancreatic Surgery (ISGPS) developed a structured definition of postpancreatectomy acute pancreatitis (PPAP) in 2021. This study aimed to evaluate the clinical significance of PPAP as defined by the ISGPS criteria. Methods We evaluated the medical records and postoperative computed tomography (CT) findings of 247 patients who underwent pancreaticoduodenectomy. Postoperative hyperamylasemia (POH) was defined as an elevation in serum amylase levels over the upper baseline limit (≥133 U/L) on postoperative days 1 and 3. PPAP was defined as acute pancreatitis satisfying the following three requirements: POH, clinically relevant deterioration, and radiologic features consistent with acute pancreatitis. Results Postoperative hyperamylasemia and PPAP were prevalent in 9.7% (24/247) and 3.6% (9/247) of the patients, respectively. PPAP grade B occurred in eight patients, seven of whom experienced Clavien–Dindo grade IIIA complications, including postoperative pancreatic fistula (POPF) and extended periods of postoperative hospitalization. PPAP grade C occurred in one patient, who died from the exacerbation of underlying interstitial pneumonia following the POPF occurrence. Acute pancreatitis determined by CT was observed in 15.3% (38/247) of the patients who underwent pancreaticoduodenectomy and was strongly associated with severe morbidity (P < .0001) and longer postoperative hospitalization (P < .0001). POH preceded acute pancreatitis on CT in only 23.7% (9/38) of those cases, resulting in a low incidence rate of PPAP. Conclusion Post‐pancreatectomy acute pancreatitis is a major postoperative complication of pancreatic resection; however, based on the current ISGPS criteria, its prevalence is low. Defining PPAP promotes universal evaluation and understanding of this new concept.
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Affiliation(s)
- Naoki Ikenaga
- Departments of Surgery and Oncology, Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Kohei Nakata
- Departments of Surgery and Oncology, Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Nobuhiro Fujita
- Department of Clinical Radiology, Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Toshiya Abe
- Departments of Surgery and Oncology, Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Noboru Ideno
- Departments of Surgery and Oncology, Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Kousei Ishigami
- Department of Clinical Radiology, Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Masafumi Nakamura
- Departments of Surgery and Oncology, Graduate School of Medical Sciences Kyushu University Fukuoka Japan
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Di Gioia A, Giuliani T, Marchegiani G, Andrianello S, Bonamini D, Secchettin E, Esposito A, Bassi C, Salvia R. Pancreatoduodenectomy in obese patients: surgery for nonmalignant tumors might be deferred. HPB (Oxford) 2022; 24:885-892. [PMID: 34801400 DOI: 10.1016/j.hpb.2021.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/09/2021] [Accepted: 10/29/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Obesity has traditionally been considered a cause of increased surgical complexity and poor outcomes following pancreatoduodenectomy (PD). This study aimed at evaluating the role of obesity in terms of mortality and failure to rescue (FTR), with a particular focus on nonmalignant tumors. METHODS All patients undergoing elective PD over 10 consecutive years were analyzed. Patients were stratified according to their BMI and categorized into two groups. Predictors of mortality and FTR were assessed through logistic regression. RESULTS Out of 1865 patients included, 151 were obese (8.1%). Overall mortality and FTR were 3.1% and 14.1%, respectively. In obese patients, mortality was 6.0% and FTR 26.5%, significantly higher compared to nonobese (p < 0.05). In the multivariable analysis, obesity, age > 70 years, and ASA-PS score were independent predictors of mortality and FTR. Postoperative pancreatic fistula (35.8% vs. 25.8%), postpancreatectomy acute pancreatitis (24.5% vs. 12.5%), and chyle leak (6.0% vs. 3.2%) were more frequent among obese patients. In the subgroup of patients with nonmalignant tumors (n = 443), obesity was the only independent predictor of FTR. CONCLUSION PD performed in obese patients was associated with higher surgical morbidity and mortality. When dealing with nonmalignant tumors, deferring surgery in obese patients should be strongly considered.
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Affiliation(s)
- Anthony Di Gioia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Tommaso Giuliani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy.
| | - Stefano Andrianello
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Deborah Bonamini
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Erica Secchettin
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Alessandro Esposito
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, University of Verona Hospital Trust, Verona, Italy
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Bannone E, Marchegiani G, Perri G, Procida G, Vacca PG, Cattelani A, Salvia R, Bassi C. Postoperative serum hyperamylasemia (POH) predicts additional morbidity after pancreatoduodenectomy: It is not all about pancreatic fistula. Surgery 2022; 172:715-722. [PMID: 35636983 DOI: 10.1016/j.surg.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/16/2022] [Accepted: 04/07/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The association between postoperative serum hyperamylasaemia (POH) and morbidity has been hypothesized but rarely explored once occurring with or without (POH-exclusive) a combined postoperative pancreatic fistula (POPF). METHODS Analysis of patients who consecutively underwent pancreaticoduodenectomy from 2016 to 2020. POH was defined as serum amylase activity greater than the institutional upper limit of normal (52 U/L), persisting within the first 48 hours postoperatively (postoperative day [POD] 1 and 2). RESULTS Among 852 patients, 15.8% developed POH-exclusive. Compared with patients without POH or POPF (64.3%), they showed a significantly higher postoperative burden (Clavien-Dindo ≥II: 52.6% vs 30.8%) with increased rates of bacteraemia (12.6% vs 6%), pleural effusion (13.3% vs 5.3%), postpancreatectomy haemorrhage (13.3% vs 7.5%), postpancreatectomy acute pancreatitis (PPAP) (10.3% vs 0%), and organ site infections (18.5% vs 10.9%; all P < .05). A total of 13.8% experienced POH with POPF leading to the worse outcome. The combined occurrence of POH with POPF led to a shorter median time to morbidity (3 PODs, 95% confidence interval [CI] 2.2-3.7 vs 6 PODs, 95% CI 4.2-8; P < .001) than patients experiencing POPF-exclusive (5.9%). In all, 46.6% of POH patients developed POPF. Body mass index (BMI) (odds ratio [OR] 1.1), male sex (OR 2.1), increased drain fluid amylase on POD 1 (OR 1.001), and increased C-reactive protein (OR 1.01) were independent risk factors for POPF once POH has occurred. CONCLUSION POH has relevant postoperative clinical implications, independently from POPF occurrence. Developing POH with POPF leads to an earlier onset of higher postoperative burdens. Once POH is diagnosed, risk factors for additional POPF could identify patients who may benefit from additional surveillance, specific drains protocols, and preventive strategies.
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Affiliation(s)
- Elisa Bannone
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giampaolo Perri
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppa Procida
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Pier Giuseppe Vacca
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alice Cattelani
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
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Schuh F, Fink MA, Feisst M, Eckert C, Dörr-Harim C, Knebel P, Diener MK, Büchler MW, Mihaljevic AL, Probst P. Protocol of a prospective study investigating the association of PAncreatic parenchymal RISk factors with postoperative pancreatic fistula after partial pancreaticoduodenectomy (PARIS trial). BMJ Open 2022; 12:e054138. [PMID: 35418425 PMCID: PMC9013991 DOI: 10.1136/bmjopen-2021-054138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 03/10/2022] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Partial pancreatoduodenectomy (PD) is the treatment of choice for many malignant and benign diseases of the pancreatic head. Postoperative complication rates of up to 40% are regularly reported. One of the most common and potentially life-threatening complication is the postoperative pancreatic fistula (POPF). Parenchymal risk factors like main pancreatic duct diameter or texture of the pancreatic gland have already been identified in retrospective studies. The aim of this study is to evaluate the diagnostic value of parenchymal risk factors on POPF in a prospective manner. METHODS AND ANALYSIS All patients scheduled for elective PD at the Department of General, Visceral and Transplantation Surgery of the University of Heidelberg will be screened for eligibility. As diagnostic factors, diameter and texture of the pancreatic gland as well as radiological and histopathological features will be recorded. Furthermore, the new four class risk classification system by the International Study Group of Pancreatic Surgery (ISGPS) will be recorded. The postoperative course will be monitored prospectively. The primary endpoint will be the association of the main pancreatic duct size and the texture of the pancreatic gland on POPF according to the updated ISGPS definition. The diagnostic value of the above-mentioned factors for POPF will be evaluated in a univariable and multivariable analysis. ETHICS AND DISSEMINATION PARIS is a monocentric, prospective, diagnostic study to evaluate the association of parenchymal risk factors and the development of POPF approved by the Ethics Committee of the medical faculty of Heidelberg University (S-344/2019). Results will be available in 2022 and will be published at national and international meetings. With this knowledge, the intraoperative and perioperative decision-making process could be eased and improve the individual outcome of patient. TRIAL REGISTRATION NUMBER DRKS00017184.
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Affiliation(s)
- Fabian Schuh
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Matthias A Fink
- Department for Diagnostic and Interventional Radiology, Heidelberg University, Heidelberg, Germany
| | - Manuel Feisst
- Institute of Medical Biometry and Informatics, Heidelberg University, Heidelberg, Germany
| | - Christoph Eckert
- Institute of Pathology, Heidelberg University, Heidelberg, Germany
| | - Colette Dörr-Harim
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Phillip Knebel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - André L Mihaljevic
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Heidelberg, Germany
- Department of Surgery, Cantonal Hospital Thurgau, Frauenfeld, Switzerland
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Marchegiani G, Barreto SG, Bannone E, Sarr M, Vollmer CM, Connor S, Falconi M, Besselink MG, Salvia R, Wolfgang CL, Zyromski NJ, Yeo CJ, Adham M, Siriwardena AK, Takaori K, Hilal MA, Loos M, Probst P, Hackert T, Strobel O, Busch ORC, Lillemoe KD, Miao Y, Halloran CM, Werner J, Friess H, Izbicki JR, Bockhorn M, Vashist YK, Conlon K, Passas I, Gianotti L, Del Chiaro M, Schulick RD, Montorsi M, Oláh A, Fusai GK, Serrablo A, Zerbi A, Fingerhut A, Andersson R, Padbury R, Dervenis C, Neoptolemos JP, Bassi C, Büchler MW, Shrikhande SV. Postpancreatectomy Acute Pancreatitis (PPAP): Definition and Grading From the International Study Group for Pancreatic Surgery (ISGPS). Ann Surg 2022; 275:663-672. [PMID: 34596077 DOI: 10.1097/sla.0000000000005226] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The ISGPS aimed to develop a universally accepted definition for PPAP for standardized reporting and outcome comparison. BACKGROUND PPAP is an increasingly recognized complication after partial pancreatic resections, but its incidence and clinical impact, and even its existence are variable because an internationally accepted consensus definition and grading system are lacking. METHODS The ISGPS developed a consensus definition and grading of PPAP with its members after an evidence review and after a series of discussions and multiple revisions from April 2020 to May 2021. RESULTS We defined PPAP as an acute inflammatory condition of the pancreatic remnant beginning within the first 3 postoperative days after a partial pancreatic resection. The diagnosis requires (1) a sustained postoperative serum hyperamylasemia (POH) greater than the institutional upper limit of normal for at least the first 48 hours postoperatively, (2) associated with clinically relevant features, and (3) radiologic alterations consistent with PPAP. Three different PPAP grades were defined based on the clinical impact: (1) grade postoperative hyperamylasemia, biochemical changes only; (2) grade B, mild or moderate complications; and (3) grade C, severe life-threatening complications. DISCUSSIONS The present definition and grading scale of PPAP, based on biochemical, radiologic, and clinical criteria, are instrumental for a better understanding of PPAP and the spectrum of postoperative complications related to this emerging entity. The current terminology will serve as a reference point for standard assessment and lend itself to developing specific treatments and prevention strategies.
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Affiliation(s)
- Giovanni Marchegiani
- Department of Surgery, The Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Savio George Barreto
- Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Bedford Park, Adelaide, South Australia, Australia
| | - Elisa Bannone
- Department of Surgery, The Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Michael Sarr
- Mayo Clinic Department of General Surgery, Rochester, NY
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Saxon Connor
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, "Vita-Salute" University, Milan, Italy
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Roberto Salvia
- Department of Surgery, The Pancreas Institute, Verona University Hospital, Verona, Italy
| | | | - Nicholas J Zyromski
- Indiana University School of Medicine, Indiana University Health, Indianapolis, IN
| | - Charles J Yeo
- Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - Mustapha Adham
- Digestive Surgery Department, Lyon Civil Hospital, Lyon, France
| | | | - Kyoichi Takaori
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Martin Loos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Olivier R C Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Yi Miao
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, PR China
| | - Christopher M Halloran
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Jens Werner
- Department of General, Visceral, and Transplantation Surgery, Ludwig Maximilians-University, Munich, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Yogesh K Vashist
- Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland
| | - Kevin Conlon
- Department of Surgery, AGIA OLGA Hospital, Athens, Greece
| | - Ioannis Passas
- School of Medicine and Surgery, Milano - Bicocca University, and Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Luca Gianotti
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Marco Del Chiaro
- Department of Surgery, Humanitas University and Research Hospital IRCCS, Milan, Italy
| | | | - Marco Montorsi
- Department of HPB Surgery and Liver Transplant, Royal Free Hospital NHS Foundation Trust, London, UK
| | - Attila Oláh
- Department of Surgery, Miguel Servet University Hospital, Paseo Isabel la Catolica, Zaragoza, Spain
| | | | - Alejandro Serrablo
- Department of Surgery, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Alessandro Zerbi
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Abe Fingerhut
- Department of Gastrointestinal and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | | | - Robert Padbury
- Division of Surgery and Perioperative Medicine, Flinders Medical Centre, Bedford Park, Adelaide, South Australia, Australia
| | | | - John P Neoptolemos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Claudio Bassi
- Department of Surgery, The Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Shailesh V Shrikhande
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
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Gorin DS, Kriger AG, Galkin GV, Raevskaya MB. [Postoperative pancreatitis after pancreatoduodenectomy]. Khirurgiia (Mosk) 2022:11-16. [PMID: 35146994 DOI: 10.17116/hirurgia202202111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Retrospective assessment of the influence of postoperative pancreatitis in development of pancreatic fistula. MATERIAL AND METHODS The study included 173 patients after pancreatoduodenectomy performed between 2016 and 2019. Postoperative pancreatitis within the 1st postoperative day was verified considering blood amylase > 125 U/L. Patients with postoperative pancreatitis (n=36) were included in the main group, the control group consisted of 137 patients without pancreatitis. Postoperative pancreatic fistula was determined according to the ISGPS 2016 classification. Statistical analysis of the effect of postoperative pancreatitis on development of pancreatic fistula was carried out using relative risk and odds ratio with 95% confidence interval in both groups. RESULTS Postoperative pancreatitis occurred in 36 (20.8%) out of 173 patients after pancreatoduodenectomy. Pancreatic fistula occurred in 18 (50%) cases. Among 137 patients without postoperative pancreatitis, only 18 (13.1%) patients developed severe pancreatic fistula. Relative risk was 3.8 (95% CI 2.22-6.51, p<0.0001), odds ratio - 6.6 (95% CI 2.91-15.01, p<0.0001). CONCLUSION Postoperative pancreatitis significantly influences development of severe pancreatic fistula.
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Affiliation(s)
- D S Gorin
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - A G Kriger
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - G V Galkin
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - M B Raevskaya
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
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Analysis of Intraoperative Frozen Pancreatic Resection Margin and Prediction of Postoperative Pancreatic Fistula Risk During Pancreatoduodenectomy. J Am Coll Surg 2022; 234:928-937. [DOI: 10.1097/xcs.0000000000000142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Pecorelli N, Guarneri G, Palucci M, Gozzini L, Vallorani A, Crippa S, Partelli S, Falconi M. Early biochemical predictors of clinically relevant pancreatic fistula after distal pancreatectomy: a role for serum amylase and C-reactive protein. Surg Endosc 2022; 36:5431-5441. [PMID: 34988737 DOI: 10.1007/s00464-021-08883-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 11/16/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Recent evidence suggests that pancreatic inflammation plays a pivotal role in the occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy but few data are available for distal pancreatectomy (DP). The aim of this study was to evaluate the impact of early biochemical markers on the occurrence of CR-POPF after DP. METHODS Clinical and laboratory data for 432 consecutive DP patients were reviewed. Serum amylase was evaluated on postoperative day (POD) 1, and drain fluid amylase (DFA) and C-reactive protein (CRP) were evaluated on POD 2 and 3. Receiver operator characteristic (ROC) curves were performed for all biochemical markers and an area under the curve (AUC) was computed. Multivariable regression analyses to identify the factors associated with CR-POPF and severe postoperative morbidity (Clavien-Dindo grade ≥ 3) were performed. RESULTS At 90 days after surgery, CR-POPF occurred in 155 (36%) patients, severe complications in 66 (15%) patients. ROC curve analyses showed that DFA on POD2 had the largest AUC (0.753, p < 0.001), followed by serum amylase on POD 1 (0.651, p < 0.001), serum CRP on POD3 (0.644, p < 0.001), and CRP change between POD 2 and POD 3 (0.644, p < 0.001). Multivariable analysis identified male gender (OR 2.29, 95% CI 1.36-3.86; p = 0.002), DFA ≥ 1500 U/L on POD2 (OR 4.63, 95% CI 2.72-7.89; p < 0.001), serum amylase ≥ 100 U/L on POD 1 (OR 1.72, 95% CI 1.01-2.93; p = 0.046), and CRP increase by at least 25 mg/L on POD 3 compared to the previous day (OR 1.89, 95% CI 1.11-3.21; p = 0.019) as independent predictors of CR-POPF, yielding a valid regression model (AUC 0.765, 95% CI 0.714-0.816, p < 0.001). CONCLUSIONS Postoperative serum amylase and CRP trajectory represent useful early biochemical markers for CR-POPF in addition to DFA. Our findings suggest that these laboratory tests should be incorporated into clinical practice to aid postoperative patient and drain management.
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Affiliation(s)
- Nicolò Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milano, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Guarneri
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milano, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | | | | | | | - Stefano Crippa
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milano, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milano, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milano, Italy. .,Vita-Salute San Raffaele University, Milan, Italy.
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De Pastena M, Paiella S, Fontana M, Filippini C, Addari L, Giorgi A, Canton S, Zanusso G, Azzini AM, Bassi C, Tacconelli E, Salvia R. The clinical and economic impact of surgical site infections after distal pancreatectomy. Surgery 2022; 171:1652-1657. [PMID: 34972593 DOI: 10.1016/j.surg.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 10/20/2021] [Accepted: 11/11/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The present study aimed to evaluate surgical site infections' clinical and economic impact after distal pancreatectomy. METHODS The study was a prospective, monocentric, observational study, including all adult patients who underwent distal pancreatectomy. According to the American Centers for Disease Control and Prevention definition, the surgical site infection assessment was prospectively performed by trained personnel. The Accordion Severity Grading System was used to evaluate the clinical burden of surgical site infection. The hospitalization's total costs were calculated using the hospital expenditure report, excluding the intraoperative costs. RESULTS During the study period, 414 distal pancreatectomies were performed. The overall incidence of surgical site infection was 26% (106 patients). Surgical site infections were associated with a higher body mass index (P = .022, odds ratio 1.2), positive preoperative rectal swab for multidrug resistant bacteria (P = .010, odds ratio 4.2), and increased operative time (P = .037, odds ratio 1.1). Using the Accordion Severity Grading System, surgical site infections contributed significantly to the total clinical burden (25.5%) and prolonged hospitalization (P < .001). Furthermore, surgical site infection doubled the costs (12.915 vs 6.888 euros, P < .001). CONCLUSION Surgical site infection has a high clinical burden, negatively impacting the postoperative course. The costs and length of stay proportionally increased with the surgical site infection severity, doubling the hospitalization expenses.
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Affiliation(s)
- Matteo De Pastena
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Michele Fontana
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Chiara Filippini
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Laura Addari
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Alice Giorgi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Simona Canton
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Giovanni Zanusso
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Anna Maria Azzini
- Infectious Diseases Unit, Department of Diagnostic and Public Health, University of Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Evelina Tacconelli
- Infectious Diseases Unit, Department of Diagnostic and Public Health, University of Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy.
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Bonsdorff A, Helanterä I, Tarvainen T, Sirén J, Kokkola A, Sallinen V. OUP accepted manuscript. BJS Open 2022; 6:6573990. [PMID: 35470380 PMCID: PMC9039121 DOI: 10.1093/bjsopen/zrac012] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/27/2021] [Accepted: 01/19/2022] [Indexed: 11/21/2022] Open
Abstract
Background Recent studies have suggested postoperative acute pancreatitis (POAP) as a serious complication after pancreaticoduodenectomy (PD) and have speculated on its possible role in the pathogenesis of postoperative pancreatic fistula (POPF). This study aimed to assess the impact of POAP on post-PD outcomes and fistula risk score (FRS) performance in predicting POAP. Methods All PDs at Helsinki University Hospital between 2013 and 2020 were analysed. POAP was defined as a plasma amylase activity greater than the normal upper limit on postoperative day (POD) 1 and stratified as clinically relevant (CR)-POAP once C-reactive protein (CRP) reached or exceeded 180 mg/l, and non-CR-POAP once CRP was less than 180 mg/l on POD 2. The Comprehensive Complication Index (CCI) was used to assess total postoperative morbidity. Different FRSs were assessed using receiver operating characteristic curves. Results Of the 508 patients included, POAP occurred in 202 (39.8 per cent) patients, of whom 91 (17.9 per cent) had CR-POAP. The incidence of CR-POPF was 12.6 per cent (64 patients). Patients with non-CR-POAP had a similar morbidity to patients with no POAP (median CCI score 24.2 versus 22.6; P = 0.142), while CCI score was significantly higher (37.2) in patients with CR-POAP (P < 0.001). CR-POAP was associated with increased rates of CR-POPF, delayed gastric emptying, haemorrhage, and bile leak, while non-CR-POAP was associated only with CR-POPF. Ninety-day mortality was 1.6 per cent, 0.9 per cent, and 3.3 per cent in patients with no-POAP, non-CR-POAP, and CR-POAP, respectively. Updated alternative FRS showed the best performance in predicting CR-POAP (area under the curve 0.834). Conclusion CR-POAP was associated with a higher CCI score, suggesting CR-POAP as a distinct entity from non-CR-POAP. FRSs can be used to assess the risk of CR-POAP.
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Affiliation(s)
- Akseli Bonsdorff
- Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ilkka Helanterä
- Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Timo Tarvainen
- Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jukka Sirén
- Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Arto Kokkola
- Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ville Sallinen
- Gastroenterological Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Correspondence to: Ville Sallinen, Gastroenterological Surgery/Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00029 Helsinki, Finland (e-mail: )
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SSAT GI Surgery Debate: Hepatobiliary and Pancreas: Is Post-Pancreatectomy Acute Pancreatitis a Relevant Clinical Entity? J Gastrointest Surg 2022; 26:60-63. [PMID: 34741252 DOI: 10.1007/s11605-021-05194-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/23/2021] [Indexed: 01/31/2023]
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Zimmitti G, Coppola A, Ardito F, Meniconi R, Ettorre GM, Rosso E, Manzoni A, Colasanti M, Clemente G, Murazio M, Giuliante F. Outcomes comparison of Pancreato-Gastrostomy and Isolated Jejunal Loop Pancreato-Jejunostomy following Pancreato-Duodenectomy in patients with soft pancreas and at moderate-high risk for POPF: a retrospective multicenter experience-based analysis. Updates Surg 2021; 74:223-234. [PMID: 34761349 DOI: 10.1007/s13304-021-01203-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 11/01/2021] [Indexed: 10/19/2022]
Abstract
Following pancreatoduodenectomy (PD), the modality of pancreato-enteric continuity restoration may impact on postoperative pancreatic fistula (POPF) risk. The aim of this study is to compare, among patients with soft pancreas and at moderate/high risk for POPF, the outcomes of PD with Pancreato-Gastrostomy (PG), versus Isolated Jejunal Loop Pancreato-Jejunostomy (IJL-PJ). 193 patients with a Callery Fistula Risk Score (C-FRS) ≥ 3 operated at 3 HPB Units, two performing PG and one IJL-PJ as their preferred anastomotic technique following PD (2009-2019) were included in this study (PG = 123, IJL-PJ = 70). Primary outcomes were POPF, clinically relevant (cr-)postoperative pancreatic hemorrhage (cr-PPH), delayed gastric emptying (cr-DGE), and postoperative major complications and mortality. POPF, cr-PPH, and cr-DGE occurred in 21.8%, 17.6%, and 11.4% of patients, and did not differ significantly between PG (26%, 19.5%, and 10.6%, respectively) and IJL-PJ (17.1%, 14.3%, and 12.9%, respectively; all p > 0.05) patients. Major (Dindo ≥ 3) complication and mortality rates were 26.4% and 3.3%, respectively, and did not differ significantly between PG (29.3% and 3.8%) and IJL-PJ (21.4% and 2.9) patients (p > 0.05). A faster surgical drain and nasogastric tube removal matched a significantly shorter hospitalization among IJL-PJ patients (median LOS: 18 days versus 25 days among PG patients, p < 0.001). In conclusion, IJL-PJ and PG, when performed by surgeons specialized with the concerned anastomotic technique in patients with soft pancreas and moderate/high risk for POPF, have similar results in terms of perioperative mortality and postoperative complications both overall and specific for PD.
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Affiliation(s)
- Giuseppe Zimmitti
- Dipartimento Di Chirurgia Generale, Istituto Ospedaliero Fondazione Poliambulanza, via Bissolati n.57, Brescia, Italy
| | - Alessandro Coppola
- Dipartimento Di Chirurgia Generale Ed Epato-Biliare, Policlinico Universitario Agostino Gemelli, via della Pineta Sacchetti n.217, Roma, Italy
| | - Francesco Ardito
- Dipartimento Di Chirurgia Generale Ed Epato-Biliare, Policlinico Universitario Agostino Gemelli, via della Pineta Sacchetti n.217, Roma, Italy
| | - Roberto Meniconi
- Dipartimento Di Chirurgia Generale E Trapianti, Ospedale S. Camillo-Forlanini Spallanzani, via G. Folchi n.6a, Roma, Italy
| | - Giuseppe Maria Ettorre
- Dipartimento Di Chirurgia Generale E Trapianti, Ospedale S. Camillo-Forlanini Spallanzani, via G. Folchi n.6a, Roma, Italy
| | - Edoardo Rosso
- Dipartimento Di Chirurgia Generale, Istituto Ospedaliero Fondazione Poliambulanza, via Bissolati n.57, Brescia, Italy
| | - Alberto Manzoni
- Dipartimento Di Chirurgia Generale, Istituto Ospedaliero Fondazione Poliambulanza, via Bissolati n.57, Brescia, Italy
| | - Marco Colasanti
- Dipartimento Di Chirurgia Generale E Trapianti, Ospedale S. Camillo-Forlanini Spallanzani, via G. Folchi n.6a, Roma, Italy
| | - Gennaro Clemente
- Dipartimento Di Chirurgia Generale Ed Epato-Biliare, Policlinico Universitario Agostino Gemelli, via della Pineta Sacchetti n.217, Roma, Italy
| | - Marino Murazio
- Dipartimento Di Chirurgia Generale Ed Epato-Biliare, Policlinico Universitario Agostino Gemelli, via della Pineta Sacchetti n.217, Roma, Italy
| | - Felice Giuliante
- Dipartimento Di Chirurgia Generale Ed Epato-Biliare, Policlinico Universitario Agostino Gemelli, via della Pineta Sacchetti n.217, Roma, Italy.
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50
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Loos M, Strobel O, Mehrabi A, Mihaljevic AL, Ramouz A, Dietrich M, Müller-Stich BP, Diener MK, Schneider M, Berchtold C, Al-Saeedi M, Feisst M, Hinz U, Schwab C, von Winterfeld M, Mayer P, Giannakis A, Weigand MA, Hackert T, Büchler MW. Postoperative acute pancreatitis is a serious but rare complication after distal pancreatectomy. HPB (Oxford) 2021; 23:1339-1348. [PMID: 33546896 DOI: 10.1016/j.hpb.2021.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 12/16/2020] [Accepted: 01/05/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The clinical relevance of hyperamylasemia after distal pancreatectomy (DP) remains unclear and no internationally accepted definition of postoperative acute pancreatitis (POAP) exists. The aim of this study was to characterize POAP after DP and to assess the role of serum amylase (SA) in POAP. METHODS Outcomes of 641 patients who had undergone DP between 2015 and 2019 were analyzed. Postoperative SA was determined in all patients. POAP was defined based on contrast-enhanced computed tomography (CT) or intraoperative findings during relaparotomy. RESULTS An elevation of SA on postoperative day 1 (hyperamylasemiaPOD1) was found in 398 patients (62.1%). Twelve patients (1.87%) were identified with POAP. Ten patients demonstrated radiologic criteria for POAP and in two patients POAP was diagnosed during relaparotomy. Outcome of POAP patients was worse than that of patients with hyperamylasemiaPOD1 alone and that with normal SAPOD1 without POAP evidence (postoperative pancreatic fistula 50% vs 30.6% vs 18.5%; length of hospital stay 26 days vs 12 vs 11, respectively). The overall 90-day mortality of all 641 patients was 0.6%. CONCLUSION POAP is a serious but rare complication after DP. HyperamylasemiaPOD1 is of prognostic relevance after DP, but it seems not sufficient as a single parameter to diagnose POAP.
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Affiliation(s)
- Martin Loos
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - André L Mihaljevic
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Ali Ramouz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Maximilian Dietrich
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Beat P Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Schneider
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Christoph Berchtold
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Mohammed Al-Saeedi
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Manuel Feisst
- Institute of Medical Biometry and Informatics, Heidelberg University, Heidelberg, Germany
| | - Ulf Hinz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Constantin Schwab
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Philipp Mayer
- Department of Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany.
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