Relaparotomy for a pancreatic fistula after a pancreaticoduodenectomy: a comparison of different surgical strategies

Pancreatic duct occlusion with polychloroprene-based glue for the management of postoperative pancreatic fistula after pancreatoduodenectomy-an outdated approach?

Background

Managing postoperative pancreatic fistula (POPF) presents a formidable challenge after pancreatoduodenectomy. Some centers consider pancreatic duct occlusion (PDO) in reoperations following pancreatoduodenectomy as a pancreas-preserving procedure, aiming to control a severe POPF. The aim of the current study was to evaluate the short- and long-term outcomes of employing PDO for the management of the pancreatic stump during relaparotomy for POPF subsequent to pancreatoduodenectomy.

Methods

Retrospective review of consecutive patients at Oslo University Hospital undergoing pancreatoduodenectomy and PDO during relaparotomy. Pancreatic stump management during relaparotomy consisted of occlusion of the main pancreatic duct with polychloroprene Faxan-Latex, after resecting the dehiscent jejunal loop previously constituting the pancreaticojejunostomy.

Results

Between July 2005 and September 2015, 826 pancreatoduodenectomies were performed. Overall reoperation rate was 13.2% (n = 109). POPF grade B/C developed in 113 (13.7%) patients. PDO during relaparotomy was performed in 17 (2.1%) patients, whereas completion pancreatectomy was performed in 22 (2.7%) patients. Thirteen (76%) of the 17 patients had a persistent POPF after PDO, and the time from PDO until removal of the last abdominal drain was median 35 days. Of the PDO patients, 13 (76%) patients required further drainage procedures (n = 12) or an additional reoperation (n = 1). In-hospital mortality occurred in one patient (5.9%). Five (29%) patients developed new-onset diabetes mellitus, and 16 (94%) patients acquired exocrine pancreatic insufficiency.

Conclusions

PDO is a safe and feasible approach for managing severe POPF during reoperation following pancreatoduodenectomy. A significant proportion of patients experience persistent POPF post-procedure, necessitating supplementary drainage interventions. The findings suggest that it is advisable to explore alternative pancreas-preserving methods before opting for PDO in the management of POPF subsequent to pancreatoduodenectomy.

The incidence and risk factors of marginal ulcers in the short and medium term in symptomatic post-pancreaticoduodenectomy patients ---- single-center experience

BACKGROUND

Marginal ulcer (MU) is one of the postoperative complications of pancreaticoduodenectomy (PD), which needs particular attention in postoperative treatments.

METHODS

The data of 190 patients who underwent PD and follow-up gastroscopic review due to upper GI symptoms within two years were retrospectively analyzed. The incidence of MU and risk factors were analyzed based on personal history, surgical procedure, past medical history, postoperative complications, and other relevant indicators.

RESULTS

The proportion of MU in patients who underwent endoscopic follow-up for upper gastrointestinal symptoms in the postoperative period in this cohort was 10.5% (20/190). Advanced age (69y vs. 59y, P ​= ​0.012), alcohol consumption (20% vs. 8.2%, P ​= ​0.03), and cigarette smoking (35% vs. 14.7%, P ​= ​0.022) were associated with an increased incidence of MU. Longer surgery time (276.5min vs. 240min, P ​= ​0.049), postoperative bleeding (10% vs. 1.8%, P ​= ​0.030), and failure to take antacid regularly postoperatively (75% vs. 97.1%, P ​= ​0.000) would increase the risk of MU; taking antacid regularly was an independent protective factor for postoperative anastomotic ulceration (OR: 0.091, CI: 0.022-0.383, P ​= ​0.001).

CONCLUSION

Advanced age, alcohol consumption, smoking, longer operation time, or postoperative extraluminal hemorrhage are associated with MU. Regular use of antacids is an independent protective factor against the development of MU.

Completion Pancreatectomy. Indications and Outcomes: A Systematic Review

BACKGROUND/OBJECTIVE (S)

Completion pancreatectomy (C.P.) is one acceptable treatment of choice in clinical scenarios such as management of post-pancreatectomy complications and recurrence in the pancreatic remnant. Studies referring to completion pancreatectomy as a distinct operation are limited, without emphasizing at the operation itself, rather reporting completion pancreatectomy as a possible option for treatment of various diseases. The identification of indications of CP in various pathologies and the clinical outcomes are therefore mandatory.

METHODS

A systematic literature search was performed in the Pubmed and Scopus Databases (February 2020),guided by the PRISMA protocol, for all studies reporting CP as a surgical procedure with reference at indications for performing it combined with postoperative morbidity and/or mortality.

RESULTS

Out of 1647 studies, 32 studies from 10 countries with 2775 patients in total, of whom 561 (20.2%) CPs met the inclusion criteria and were included in the analysis. Inclusion year ranged from 1964 to 2018 and were published from 1992 until 2019. 17 studies with a total number of 249 CPs were performed for post-pancreatectomy complications. Mortality rate was 44.5% (111 out of 249). Morbidity rate was (72.6%). 12 studies with 225 CPs were performed for isolated local recurrence after initial resection with a morbidity rate of 21.5% and 0% mortality rate in the early postoperative period. Two studies with a total number of 12 patients reported CP as a treatment option for recurrent neuroendocrine neoplasms. The mortality in those studies was 8% (1/12) and the mean morbidity rate was 58.3% (7/12). Finally, CP for refractory chronic pancreatitis was presented in one study with morbidity and mortality rates of 19% and 0%, respectively.

CONCLUSION

Completion pancreatectomy is a distinct treatment option for various pathologies. Morbidity and mortality rates depend on the indications of performing CP, the status performance of the patients and whether the operation is performed electively or urgently.

Surgical complications requiring late surgical revisions after pancreatoduodenectomy increase postoperative morbidity and mortality

BACKGROUND

Pancreatoduodenectomies are complex surgical procedures with considerable postoperative morbidity and mortality. Here, we describe complications and outcomes in patients requiring surgical revisions following pancreatoduodenectomy.

METHODS

A total of 1048 patients undergoing a pancreatoduodenectomy at our institution between 2002 and 2019 were analyzed retrospectively. All patients with surgical revisions were included. Revisions were divided into early and late using a cut-off of 5 days after the first surgery. Statistical significance was examined by using chi-square tests and Fisher's exact tests. Survival analysis was performed using Kaplan-Meier curves and log-rank tests.

RESULTS

A total of 150 patients with at least 1 surgical revision after pancreatoduodenectomy were included. Notably, 64 patients had a revision during the first 5 days and were classified as early revision. Compared with the 86 patients with late revisions, we found no differences concerning wound infections, delayed gastric emptying, or acute kidney failure. After late revisions, we found significantly more cases of sepsis (31.4% late versus 15.6% early, p = 0.020) and reintubation due to respiratory failure (33.7% versus 18.8%, p = 0.031). Postoperative mortality was significantly higher within the late revision group (23.2% versus 9.4%, p = 0.030).

CONCLUSION

Arising complications after pancreatoduodenectomy should be addressed as early as possible as patients requiring late surgical revisions frequently developed septic complications and multiorgan failure.

Completion Pancreatectomy After Pancreatoduodenectomy: Who Needs It?

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.

Management of postoperative pancreatic fistula after pancreaticoduodenectomy

A postoperative pancreatic fistula (POPF) is the main complication after cephalic pancreaticoduodenectomy (CPD). Unlike its prevention, the curative management of POPFs has long been poorly codified. This review seeks best practices for managing POPFs after CPD. The diagnosis of a POPF is based on two signs: (i) an amylase level in drained fluid more than 3 times the upper limit of the blood amylase level; and (ii) an abnormal clinical course. In the standardised definition of the International Study Group of Pancreatic Surgery, a purely biochemical fistula is no longer counted as a POPF and is treated by gradual withdrawal of the drain over at most 3 weeks. POPF risk can be scored using pre- and intraoperative clinical criteria, many of which are related to the quality of the pancreatic parenchyma and are common to several scoring systems. The prognostic value of these scores can be improved as early as Day 1 by amylase assays in blood and drained fluid. Recent literature, including in particular the Dutch randomised trial PORSCH, argues for early systematic detection of a POPF (periodic assays, CT-scan with injection indicated on standardised clinical and biological criteria plus an opinion from a pancreatic surgeon), for rapid minimally invasive treatment of collections (percutaneous drainage, antibiotic therapy indicated on standardised criteria) to forestall severe septic and/or haemorrhagic forms, and for the swift withdrawal of abdominal drains when the risk of a POPF is theoretically low and evolution is favourable. A haemorrhage occurring after Day 1 always requires CT angiography with arterial time and monitoring in intensive care. Minimally invasive treatment of a POPF (radiologically-guided percutaneous drainage or, more rarely, endoscopic drainage, arterial embolisation) should be preferred as first-line treatment. The addition of artificial nutrition (enteral via a nasogastric or nasojejunal tube, or parenteral) is most often useful. If minimally invasive treatment fails, then reintervention is indicated, preserving the remaining pancreas if possible, but the expected mortality is higher.

Surgical management of severe pancreatic fistula after pancreatoduodenectomy: a comparison of early versus late rescue pancreatectomy

Background

Rescue pancreatectomy for postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) is associated with high mortality. However, in-depth literature is scarce and hard to interpret. This study aimed to evaluate the indications, timing and perioperative outcomes of rescue pancreatectomy for severe POPF after PD.

Methods

Retrospective single-centre study from all consecutive patients (2008–2020) with POPF-C after PD (ISGPS 2016 definition). Major morbidity and mortality during hospitalization or within 90 days after index surgery were evaluated. Time from index surgery to rescue pancreatectomy was dichotomized in early and late (≤ 11 versus > 11 days).

Results

From 1076 PDs performed, POPF-B/C occurred in 190 patients (17.7%) of whom 53 patients (4.9%) with POPF-C were included. Mortality after early rescue pancreatectomy did not differ significantly compared to late rescue pancreatectomy (13.6% versus 35.3%; p = 0.142). Timing of a rescue pancreatectomy did not change significantly during the study period: 11 (IQR, 8–14) (2008–2012) versus 14 (IQR, 7–33) (2013–2016) versus 8 days (IQR, 6–11) (2017–2020) (p = 0.140). Over time, the mortality in patients with POPF grade C decreased from 43.5% in 2008–2012 to 31.6% in 2013–2016 up to 0% in 2017–2020 (p = 0.014). However, mortality rates after rescue pancreatectomy did not differ significantly: 31.3% (2008–2012) versus 28.6% (2013–2016) versus 0% (2017–2020) (p = 0.104).

Conclusions

Rescue pancreatectomy for severe POPF is associated with high mortality, but an earlier timing might favourably influence the mortality. Hypothetically, this could be of value for pre-existent vulnerable patients. These findings must be carefully interpreted considering the sample sizes and differences among subgroups by patient selection.

Conversion to pancreaticogastrostomy for salvage of disrupted pancreaticojejunostomy following pancreaticoduodenectomy

Purpose

This study aimed to report on a pancreas-preserving strategy consisting of the conversion to pancreaticogastrostomy (PG) for the salvage of disrupted pancreaticojejunostomy (PJ) following pancreaticoduodenectomy (PD).

Methods

This single-center retrospective study included 188 patients who underwent PD between March 2000 and June 2021. Conversion to PG was performed by placing the pancreatic stump with an internal stent in the stomach through the posterior gastrostomy and suturing the wound in 2 layers through the anterior gastrostomy.

Results

A total of 181 patients underwent PJ, while 7 underwent PG. Of all patients, 6 had International Study Group on Pancreatic Fistula grade C postoperative pancreatic fistulae (POPF; 3.3%) and 23 had grade B POPF (12.7%). Two of the 6 grade C patients underwent completion pancreatectomy and died of liver failure after common hepatic artery embolization due to pseudoaneurysm. Conversion to PG was performed in 4, all of whom survived and experienced no long-term pancreatic fistulae, remnant pancreatic atrophy, or newly developed diabetes after a median follow-up period of 11.5 months.

Conclusion

Conversion to PG for the salvage of disrupted PJ following PD is safe and effective in selected patients that can lower mortality rates while maintaining pancreatic function.

A comparison of surgical approaches in the treatment of grade C postoperative pancreatic fistula: A retrospective study

Background

Postoperative pancreatic fistula is one of the most dreaded complications following pancreatic resections with Grade C the most severe. Several possible types of surgical intervention are available but to date, none of them have clearly shown superiority. This study aims to compare different surgical approaches.

Methods

A retrospective analysis of patients who underwent revision surgery for postoperative pancreatic fistula between 2008 and 2020 was performed. Three surgical approaches were compared: open drainage; a disconnection of the pancreaticojejunostomy; and salvage total pancreatectomy. The data of nine monitored parameters were collected. Selected parameters were statistically analyzed and compared.

Results

A total of 54 patients were included. Eighteen patients underwent open drainage, 28 had disconnections of the pancreaticojejunostomy and eight had salvage total pancreatectomy. Statistically significant differences were observed in the time of Intensive Care Unit stay, the number of surgical interventions, 90-day mortality, the number of administered blood transfers and treatment costs. Open drainage showed to be superior in each category. The difference in long-term survival also slightly favored simple drainage.

Conclusion

Open drainage procedure showed to be superior to other types of interventions in most of the monitored parameters. Disconnection of the pancreaticojejunostomy and a salvage total pancreatectomy had similar results, which correlated with the surgical burden of these interventions.

Surgical Management of Postoperative Grade C Pancreatic Fistula following Pancreatoduodenectomy

Background

The incidence of Grade C postoperative pancreatic fistula ranges from 2 to 11% depending on the type of pancreatic resection. This complication may frequently require early relaparotomy and the surgical approach remains technically challenging and is still associated with a high mortality. Infectious complications and post-operative hemorrhage are the two most common causes of reoperation.

Summary

The best management of grade C pancreatic fistulas remains controversial and ranges from conservative approaches up to completion pancreatectomy. The choice of the technique depends on the patient's conditions, intraoperative findings, and surgeon's discretion. A pancreas-preserving strategy appears to be attractive, including from simple to more complex procedures such as debridement and drainage, and external wirsungostomy. Completion pancreatectomy should be reserved for selected cases, including stable patients with severe infection complication or hemorrhage after pancreatic fistula who do not respond to pancreas-preserving procedures.

Key Messages

This review describes the current options for management of grade C pancreatic fistula after pancreatoduodenectomy with regard to indication, choice of procedure and outcomes of the different approaches.

Completion pancreatectomy or a pancreas-preserving procedure during relaparotomy for pancreatic fistula after pancreatoduodenectomy: a multicentre cohort study and meta-analysis

BACKGROUND

Despite the fact that primary percutaneous catheter drainage has become standard practice, some patients with pancreatic fistula after pancreatoduodenectomy ultimately undergo a relaparotomy. The aim of this study was to compare completion pancreatectomy with a pancreas-preserving procedure in patients undergoing relaparotomy for pancreatic fistula after pancreatoduodenectomy.

METHODS

This retrospective cohort study of nine institutions included patients who underwent relaparotomy for pancreatic fistula after pancreatoduodenectomy from 2005-2018. Furthermore, a systematic review and meta-analysis were performed according to the PRISMA guidelines.

RESULTS

From 4877 patients undergoing pancreatoduodenectomy, 786 (16 per cent) developed a pancreatic fistula grade B/C and 162 (3 per cent) underwent a relaparotomy for pancreatic fistula. Of these patients, 36 (22 per cent) underwent a completion pancreatectomy and 126 (78 per cent) a pancreas-preserving procedure. Mortality was higher after completion pancreatectomy (20 (56 per cent) versus 40 patients (32 per cent); P = 0.009), which remained after adjusting for sex, age, BMI, ASA score, previous reintervention, and organ failure in the 24 h before relaparotomy (adjusted odds ratio 2.55, 95 per cent c.i. 1.07 to 6.08). The proportion of additional reinterventions was not different between groups (23 (64 per cent) versus 84 patients (67 per cent); P = 0.756). The meta-analysis including 33 studies evaluating 745 patients, confirmed the association between completion pancreatectomy and mortality (Mantel-Haenszel random-effects model: odds ratio 1.99, 95 per cent c.i. 1.03 to 3.84).

CONCLUSION

Based on the current data, a pancreas-preserving procedure seems preferable to completion pancreatectomy in patients in whom a relaparotomy is deemed necessary for pancreatic fistula after pancreatoduodenectomy.

Standardized salvage completion pancreatectomy for grade C postoperative pancreatic fistula after pancreatoduodenectomy (with video)

BACKGROUND

Emergency completion pancreatectomy (CP) after pancreatoduodenectomy (PD) is a technically demanding procedure. We report our experiences with a four-step standardized technique used at our center since 2012.

METHODS

In the first step, the gastrojejunostomy is divided with a stapler to quickly access the pancreatic anastomosis and permit adequate exposure, especially in cases of active bleeding. Second, the bowel loops connected to the pancreatic anastomosis is divided in cases of pancreaticojejunostomy. Third, the pancreatectomy is completed with or without the splenic vessels and spleen conservation according to the local conditions. Finally, the fourth step reconstructs in a Roux-en-Y fashion and ensures drainage.

RESULTS

From January 2012 to December 2019, 450 patients underwent PD at our center. Reintervention for grade C postoperative pancreatic fistula was decided for 30 patients, and CP was performed in 21 patients. The mean intraoperative blood loss and operative duration were relatively low (600 ml and 240 min, respectively). During the perioperative period, three patients died from multiple organ failure, and two patients died intraoperatively from a cataclysmic hemorrhage originating from the superior mesenteric artery.

DISCUSSION

Our standardized procedure appears to be relatively safe, reproducible, and could be particularly useful for young surgeons.

Total pancreatectomy and pancreatic fistula: friend or foe?

Postoperative pancreatic fistula (POPF) still represents the major driver of surgical morbidity after pancreaticoduodenectomy. The purpose of this narrative review was to critically analyze current evidence supporting the use of total pancreatectomy (TP) to prevent the development of POPF in patients with high-risk pancreas, and to explore the role of completion total pancreatectomy (CP) in the management of severe POPF. Considering the encouraging perioperative outcomes, TP may represent a promising tool to avoid the morbidity related to an extremely high-risk pancreatic anastomosis in selected patients. Surgical management of severe POPF is only required in few critical scenarios. In this context, even if anecdotal, CP might play a role as last resort in expert hands.

Decision points in pancreatoduodenectomy: Insights from the contemporary experts on prevention, mitigation, and management of postoperative pancreatic fistula

BACKGROUND

Despite abundant, high-level scientific evidence, there is no consensus regarding the prevention, mitigation, and management of clinically relevant pancreatic fistula after pancreatoduodenectomy. The aim of the present investigation is three-fold: (1) to analyze the multiple decision-making points for pancreatico-enteric anastomotic creation and fistula mitigation and management after pancreatoduodenectomy, (2) to reveal the practice of contemporary experts, and (3) to indicate avenues for future research to reduce the burden of clinically relevant pancreatic fistula.

METHODS

A 109-item questionnaire was sent to a panel of international pancreatic surgery experts, recognized for their clinical and scientific authority. Their practice habits and thought processes regarding clinically relevant pancreatic fistula risk assessment, anastomotic construction, application of technical adjuncts, and mitigation strategies, as well as postoperative management, was explored. Sixteen clinical vignettes were presented to reveal their certain approaches to unique situations-both common and uncommon.

RESULTS

Sixty experts, with a cumulative 48,860 pancreatoduodenectomies, completed the questionnaire. Their median pancreatectomy/pancreatoduodenectomy case volume was 1,200 and 705 procedures, respectively, with a median career duration of 22 years and 200 indexed publications. Although pancreatico-jejunostomy reconstruction with transperitoneal drainage is the standard operative approach for most authorities, uncertainty emerges regarding the employment of objective risk stratification and adaptation of practice to risk. Concrete suggestions are offered to inform decision-making in intimidating circumstances. Early drain removal is frequently embraced, while a step-up approach is unanimously invoked to treat severe clinically relevant pancreatic fistula.

CONCLUSION

A comprehensive conceptual framework of 4 sequential phases of decision-making is proposed-risk assessment, anastomotic technique, mitigation strategy employment, and postoperative management. Basic science studies and outcome analyses are proposed for improvement.

Management of postoperative pancreatic fistula after pancreatoduodenectomy: Analysis of 600 cases of pancreatoduodenectomy patients over a 10-year period at a single institution

BACKGROUND

Although postoperative pancreatic fistula (POPF) is a common and critical complication of pancreatoduodenectomy (PD), effective strategies to prevent POPF have not yet been completely developed. Because appropriate management of POPF is important to reduce the mortality rate after PD, in this study we aimed to evaluate our approach for the management of POPF after PD, including the postoperative course.

METHODS

This retrospective study included 605 consecutive patients who underwent PD at our hospital between 2010 and 2020. All patients who developed POPF were first managed conservatively, with drainage tubes placed during surgery retained to manage POPF. In cases wherein conservative treatment was unsuccessful, open drainage, followed by continuous negative pressure and continuous irrigation, was used. For open drainage, the surgical wound was opened bluntly (approximate length, 5 cm) under local anesthesia, and the fluid was directly and completely drained.

RESULTS

The prevalence of POPF of grades B and C was 15.4% (n = 93) and 0.33% (n = 2), respectively. Of these patients, 1 required reoperation, 43 recovered with conservative management only, 47 required open drainage, and 4 required image-guided percutaneous drainage. Postoperative hemorrhage with a pseudoaneurysm was identified in 3 (0.66%) patients. The postoperative in-hospital mortality rate was low (n = 1, 0.16%). The rate of successful POPF management was 98.9%.

CONCLUSION

Based on our high success rate in POPF management, we consider open drainage to be a safe primary management method for POPF.

Risk factors for perforated marginal ulcers following pancreaticoduodenectomy and prospective analysis of marginal ulcer development

Background

Perforated marginal ulcers (PMUs) are a feared long-term complication following pancreaticoduodenectomy (PD), which always require relaparotomy compared to marginal ulcers.

Methods

First, we performed a retrospective chart review for all patients who underwent PD from 2007-2016 to identify incidence and risk factors associated with PMUs. Second, we analyzed follow up gastroscopies in all patients undergoing PD from 2007-2011 to identify the overall incidence of marginal ulcers.

Results

A total of 725 patients underwent PD in the retrospective study period. 17 patients (2.3%) suffered from PMU at a median postoperative time of 13 months. These patients were significantly younger (median age: 49 vs. 62 years; P=0.02) and suffered most often from chronic pancreatitis (P<0.001). Smoking and alcohol consumption were significantly more common (P=0.01 and P=0.023). An elevated level of carcinoembryonic antigen and chronic pancreatitis were identified as independent risk factors. Overall, 373 patients were enrolled for prospective analysis. Marginal ulcers occurred in 5-5.9% over a postoperative period of 5 years.

Conclusions

Continuous treatment with proton-pump inhibitors for at least 5 years, immediate smoking cessation and follow-up gastroscopies are obligate for patients undergoing PD to avoid marginal ulcers and PMUs.

Permanent Pancreatic Duct Occlusion With Neoprene-based Glue Injection After Pancreatoduodenectomy at High Risk of Pancreatic Fistula: A Prospective Clinical Study

The aim of this study was to assess safety and efficacy of pancreatic duct occlusion (PDO) with neoprene-based glue in selected patients undergoing pancreatoduodenectomy (PD) at high risk of postoperative pancreatic fistula (POPF).

Facing the surgeon's nightmare: Incidence and management of postoperative pancreatic fistulas grade C after pancreaticoduodenectomy based on the updated definition of the International Study Group of Pancreatic Surgery (ISGPS)

BACKGROUND

Postoperative pancreatic fistulas (POPF) grade C represent a rare but feared complication following pancreaticoduodenectomy (PD). They can contribute significantly to postoperative morbidity and mortality.

METHODS

We performed a retrospective chart review for all patients who had undergone pancreatic head resection between 2007 and 2016 to identify those who suffered from POPF grade C according to the updated definition of the International Study Group of Pancreatic Surgery (ISGPS).

RESULTS

A total of 722 patients underwent PD. Twenty-three patients (3.19%) developed a POPF grade C. Cardiovascular diseases, soft pancreatic texture and main pancreatic duct diameter were identified as risk factors (P < .05). Reoperation was necessary in all affected patients on postoperative day 12 ± 9 on average. Mortality was significantly associated with POPF grade C (P < .05) being present in 39.1% (9/23).

CONCLUSIONS

POPF grade C after PD remains a serious complication with a high level of morbidity and mortality. Surgical treatment is the sole curative therapy and thus the treatment of choice.

Surgical management of the grade C pancreatic fistula after pancreatoduodenectomy

BACKGROUND

Surgical management of severe pancreatic fistula after pancreatoduodenectomy remains challenging, and carries high mortality. The aim of this retrospective study was to compare different surgical techniques used at relaparotomy for pancreatic fistula after pancreatoduodenectomy, and to identify factors predictive of failure to rescue.

METHODS

A total of 43 patients after pancreatoduodenectomy developed a pancreatic fistula requiring relaparotomy. The perioperative data and outcomes were reviewed retrospectively.

RESULTS

Completion pancreatectomy, simple drainage of the pancreatic anastomosis and external wirsungostomy were performed in 17, 16, and 10 cases, respectively. The mortality rate for completion pancreatectomy was 47.1%, compared with 56.3% for simple drainage (p = 0.598) and 50.0% for external wirsungostomy (p = 0.883). Simple drainage was associated with a higher rate of further relaparotomies (56.3%) in comparison with completion pancreatectomy (23.5%, p = 0.055) and external wirsungostomy (0%, p = 0.003). A rescue resection of the pancreatic remnant after failed simple drainage resulted invariably in death. On multivariate analysis, the factors predictive of mortality after relaparotomy for pancreatic fistula were organ failure on the day of reoperation (p = 0.001) and need of further surgical reintervention (p = 0.007).

CONCLUSION

Timely reintervention and appropriate surgical technique are essential for reducing mortality after reoperation for pancreatic fistula after pancreatoduodenectomy.

Two forms of one complication: Late erosive and nonerosive postpancreatectomy hemorrhage following laparoscopic pancreaticoduodenectomy

Postpancreatectomy hemorrhage (PPH) remains a rare but lethal complication following laparoscopic pancreaticoduodenectomy (LPD) in the modern era of advanced surgical techniques. The main reason for early PPH (within 24 hours following surgery) has been found to be a failure of hemostasis during the surgical procedure. The reasons for late PPH tend to be variate. Positive associations have been identified between late PPH and intraabdominal erosive factors such as postoperative pancreatic fistula, bile leakage, gastrointestinal fistula, and intraabdominal infection. Still, some patients suffer PPH who do not have these erosive factors. The severity of bleeding and clinical prognosis of erosive and nonerosive PPH following LPD is different.We analyzed the electronic clinical records of 33 consecutive patients undergoing LPD and experiencing one or more episodes of hemorrhage after postoperative day 1 in this study. All patients received an LPD with standard lymphadenectomy. The patient's hemorrhage-related information was extracted, such as interval from surgery to bleeding, presentation, bleeding site, severity, management, and clinical prognosis. Based on our clinical practice, we proposed a treatment strategy for these 2 forms of late PPH following LPD.Of these 33 patients, 8 patients (24.24%) developed nonerosive bleeding, and other 25 patients (75.76%) suffered from postoperative hemorrhage caused by various intraabdominal erosive factors. The median interval from the LPD surgery to postoperative hemorrhage for both groups was 11 days, and no significant differences were found (P = .387). For patients with erosive bleeding, most (60%) underwent their episodes of bleeding on postoperative days 5 to 14. For patients with nonerosive bleeding, most (75%) began postoperative hemorrhage 2 weeks after surgery, and 50% of these patients had bleeding between postoperative days 20 and 30. In the present study, 64% (16/25) of patients with erosive bleeding and 87.5% (7/8) of patients with nonerosive bleeding had internal bleeding. The fact that 90% (9/10) of all gastrointestinal bleeding patients had intraabdominal erosive factors indicated strong relationships between gastrointestinal hemorrhage and these erosive factors. The bleeding sites were detected in most patients, except for 4 patients who received conservative treatments. For patients with erosive bleeding, the most common bleeding site detected was the pancreatic remnant (43.48%); others included the hepatic artery (39.13%), splenic artery (13.04%), and left gastric artery (4.35%). For patients with nonerosive bleeding, the most common bleeding site was the hepatic artery (83.33%), and the 2nd most frequent site was the splenic artery (16.67%). No hemorrhage from pancreaticojejunal anastomosis occurred in the patients with nonerosive bleeding. Statistical significance was noted between these 2 groups in hemorrhage severity (P = .012), management strategies (P = .001), rebleeding occurrence (P = .031), and prognosis outcome (P = .010). The patients with intraabdominal erosive factors tended to have a higher risk of grade C bleeding (68.00%) than that of their nonerosive bleeding counterparts (12.50%). As for treatment strategy for postoperative bleeding, the favorable method to manage nonerosive bleeding was conservative and endovascular treatments if the patients' hemodynamics was stable. All these nonerosive bleeding patients survived. On the contrary, 22 patients (88.00%) in the erosive bleeding group had a 2nd surgical procedure, and the mortality was 56.00%. In this group, 2 patients received conservative therapy due to the demand of their family and expired. One patient underwent endovascular treatment and had another episode of hemorrhage, finally dying from multi-organ failure. No patients in the nonerosive bleeding group suffered from rebleeding after complete hemostasis, and 44.00% of patients with erosive bleeding underwent a 2nd episode of postoperative bleeding.Erosive and nonerosive PPH are 2 forms of this lethal complication following LPD. Their severity of bleeding, rebleeding rate, and treatment strategy are different. Patients with erosive factors tend to have a higher incidence of grade C bleeding, rebleeding, and mortality. Factors influencing treatment protocols for PPH include the existence of intraabdominal erosive factors, patient hemodynamics, possibility to detect the bleeding site during endovascular treatment, and surgeon's preference. The performance of endovascular treatment with stent repair for managing postoperative hemorrhage after LPD depends on the discovery of the bleeding site. Surgery should be reserved as an emergent and final choice to manage PPH.

Completion pancreatectomy in the acute management of pancreatic fistula after pancreaticoduodenectomy: a systematic review and qualitative synthesis of the literature

BACKGROUND

Pancreatic fistula remains a major complication after pancreaticoduodenectomy (PD). Re-operation is generally considered only after exhaustion of non-surgical options. A variety of pancreas-preserving operations have been proposed, but completion pancreatectomy (CP) stands out in locally complicated cases as a universal approach. This study aims to provide a qualitative synthesis of the peer-reviewed literature regarding emergency CP for post-PD pancreatic fistula.

METHODS

A systematic search of PubMed and EMBASE for all studies reporting clinical outcomes for CP in the acute treatment of pancreatic fistula following PD from January 1975 until May 2016.

RESULTS

Eleven patient-series with a total of 5566 PD and 151 (3%) emergency CP were included. Median time from PD to CP ranged from 6 to 17 days (7 studies), and mean operative time and blood loss - reported in only two studies - were 197 min and 2173 mL respectively. Re-laparotomy following CP was required in 35% of patients. Median hospital length-of-stay varied from 21 to 64 days, and postoperative mortality was 42%.

CONCLUSIONS

Emergency surgery for postoperative pancreatic fistula should only be considered after expert consultation. CP carries a high risk of mortality, and it is most commonly recommended for a selected subgroup of patients with locally complicated fistula.

Salvage Islet Auto Transplantation After Relaparatomy

BACKGROUND

To assess feasibility, safety, and metabolic outcome of islet auto transplantation (IAT) in patients undergoing completion pancreatectomy because of sepsis or bleeding after pancreatic surgery.

METHODS

From November 2008 to October 2016, approximately 22 patients were candidates to salvage IAT during emergency relaparotomy because of postpancreatectomy sepsis (n = 11) or bleeding (n = 11). Feasibility, efficacy, and safety of salvage IAT were compared with those documented in a cohort of 36 patients who were candidate to simultaneous IAT during nonemergency preemptive completion pancreatectomy through the pancreaticoduodenectomy.

RESULTS

The percentage of candidates that received the infusion of islets was significantly lower in salvage IAT than simultaneous IAT (59.1% vs 88.9%, P = 0.008), mainly because of a higher rate of inadequate islet preparations. Even if microbial contamination of islet preparation was significantly higher in candidates to salvage IAT than in those to simultaneous IAT (78.9% vs 20%, P < 0.001), there was no evidence of a higher rate of complications related to the procedure. Median follow-up was 5.45 ± 0.52 years. Four (36%) of 11 patients reached insulin independence, 6 patients (56%) had partial graft function, and 1 patient (9%) had primary graft nonfunction. At the last follow-up visit, median fasting C-peptide was 0.43 (0.19-0.93) ng/mL; median insulin requirement was 0.38 (0.04-0.5) U/kg per day, and median HbA1c was 6.6% (5.9%-8.1%). Overall mortality, in-hospital mortality, metabolic outcome, graft survival, and insulin-free survival after salvage IAT were not different from those documented after simultaneous IAT.

CONCLUSIONS

Our data demonstrate the feasibility, efficacy, and safety of salvage IAT after relaparotomy.

Management of Severe Pancreatic Fistula After Pancreatoduodenectomy

Importance

Postoperative pancreatic fistula is a potentially life-threatening complication after pancreatoduodenectomy. Evidence for best management is lacking.

Objective

To evaluate the clinical outcome of patients undergoing catheter drainage compared with relaparotomy as primary treatment for pancreatic fistula after pancreatoduodenectomy.

Design, Setting, and Participants

A multicenter, retrospective, propensity-matched cohort study was conducted in 9 centers of the Dutch Pancreatic Cancer Group from January 1, 2005, to September 30, 2013. From a cohort of 2196 consecutive patients who underwent pancreatoduodenectomy, 309 patients with severe pancreatic fistula were included. Propensity score matching (based on sex, age, comorbidity, disease severity, and previous reinterventions) was used to minimize selection bias. Data analysis was performed from January to July 2016.

Exposures

First intervention for pancreatic fistula: catheter drainage or relaparotomy.

Main Outcomes and Measures

Primary end point was in-hospital mortality; secondary end points included new-onset organ failure.

Results

Of the 309 patients included in the analysis, 209 (67.6%) were men, and mean (SD) age was 64.6 (10.1) years. Overall in-hospital mortality was 17.8% (55 patients): 227 patients (73.5%) underwent primary catheter drainage and 82 patients (26.5%) underwent primary relaparotomy. Primary catheter drainage was successful (ie, survival without relaparotomy) in 175 patients (77.1%). With propensity score matching, 64 patients undergoing primary relaparotomy were matched to 64 patients undergoing primary catheter drainage. Mortality was lower after catheter drainage (14.1% vs 35.9%; P = .007; risk ratio, 0.39; 95% CI, 0.20-0.76). The rate of new-onset single-organ failure (4.7% vs 20.3%; P = .007; risk ratio, 0.15; 95% CI, 0.03-0.60) and new-onset multiple-organ failure (15.6% vs 39.1%; P = .008; risk ratio, 0.40; 95% CI, 0.20-0.77) were also lower after primary catheter drainage.

Conclusions and Relevance

In this propensity-matched cohort, catheter drainage as first intervention for severe pancreatic fistula after pancreatoduodenectomy was associated with a better clinical outcome, including lower mortality, compared with primary relaparotomy.

Pancreatic stump closure after pancreatoduodenectomy in elderly patients: a retrospective clinical study

BACKGROUND

Pancreatic fistula (PF) after pancreatoduodenectomy (PD) represents the major source of morbidity. Derivative procedures are preferred by pancreatic surgeons, but the optimal management of remnant pancreatic stump remains controversial.

AIMS

The purpose of this retrospective study is to evaluate the efficacy and safety of pancreatic stump closure in selected elderly patients (>65 years).

METHODS

Clinical data of 44 PD undergone mechanical closure of the pancreatic stump performed between 2001 and 2014 in two department of general and oncologic surgery were retrospectively collected. Considering the age, patients were divided into two groups: 21 patients of less than 65 years (Group A) and 23 patients of more than 65 years (Group B).

RESULTS

A soft pancreatic parenchyma with a not-dilated duct (diameter <3 mm) was reported in all the 44 patients. A grade-A PF, which did not required further treatments, developed in 20 cases (45.4%; 13 in group A and 7 in group B; p < 0.05), grade-B in 5 patients (11.4%; 3 in group A and 2 in group B; statistically not significant) and a grade-C PF was observed only in one patient (2.2%; 1 in group A and 0 in group B).

DISCUSSION

In selected "high risk" elderly patients (>65 years) with soft pancreatic texture, the closure of the pancreatic stump can be a useful tool in the surgical armamentarium with the aim to reduce the incidence of age-related complications.

CONCLUSIONS

Prospective randomized controlled trial to better evaluate PF risk factors is needed.

Autologous Islet Transplantation in Patients Requiring Pancreatectomy: A Broader Spectrum of Indications Beyond Chronic Pancreatitis

Islet autotransplantation (IAT) is usually performed in patients undergoing pancreatic surgery for chronic pancreatitis. In the present series, IAT was offered also to patients undergoing pancreatic surgery for both nonmalignant and malignant diseases, having either completion pancreatectomy as treatment for severe pancreatic fistulas (n = 21) or extensive distal pancreatectomy for neoplasms of the pancreatic neck (n = 19) or pancreatoduodenectomy because of the high risk of pancreatic fistula (n = 32). Fifty-eight of 72 patients who were eligible to this broader spectrum of indication actually received IAT. There was no evidence of a higher-than-expected rate of major complications for pancreatectomy. Forty-five patients receiving IAT were still alive at the time of the last scheduled follow-up (1375 ± 365 days). Eighteen (95%) of 19 and 11 (28%) of 39 patients reached insulin independence after partial or total pancreatectomy, respectively. The metabolic results were dependent on the transplanted islet mass. Thirty-one of 58 patients had malignant diseases of the pancreas or periampullary region, and only three patients developed ex novo liver metastases after IAT (median follow-up 914 ± 382 days). Our data demonstrate the feasibility, efficacy, and safety of IAT for a broader spectrum of clinical indications beyond chronic pancreatitis.

Pancreatic fistula and postoperative pancreatitis after pancreatoduodenectomy for pancreatic cancer

The most serious complication after pancreatoduodenectomy (PD) is pancreatic fistula (PF) type C, either as a consequence or independently from postoperative pancreatitis (PP). Differentiating between these two types of complications is often very difficult, if not impossible. The most significant factor in early diagnosis of PP after PD is an abrupt change in clinical status. In our retrospective study we also observed significantly higher levels of serum concentrations of CRP and AMS comparing to PF without PP. Based on our findings, CT scan is not beneficial in the early diagnosis of PP. Meantime PF type C is indication to operative revision with mostly drainage procedure which is obviously not much technically demanding, there are no definite guidelines on how to proceed in PP. Therefore the surgeon's experience determines not only whether PP will be diagnosed early enough and will be differentiated from PF without PP, but also whether a completion pancreatectomy will be performed in indicated cases.

Diagnosis and management of postoperative pancreatic fistula

BACKGROUND

Postoperative pancreatic fistula (POPF) is the leading complication after partial pancreatic resection and is associated with increased length of hospital stay and resource utilization. The introduction of a common definition in 2005 by the International Study Group of Pancreatic Surgery (ISGPS), which has been since employed in the vast majority of reports, has allowed a reliable comparison of surgical results. Despite the systematic investigation of risk factors and of surgical techniques, the incidence of POPF did not change in recent years, whereas the associated mortality has decreased.

PURPOSE

The purposes of this review article were to summarize the current evidence on the diagnosis and management strategies of POPF and to provide a concise reference for the practicing surgeons and physicians.

CONCLUSION

The high incidence of POPF was accompanied by a shift from operative to non-operative management. However, the current management strategy is driven by the patient's condition and local expertise and is generally based on poor evidence. A randomized trial showed that enteral nutrition is superior to total parenteral nutrition, and pooled data of randomized trials failed to show any advantage of somatostatin analogs for accelerating fistula closure. The choice of percutaneous versus endoscopic drainage of peripancreatic collections remains arbitrary, and-when re-operation is needed-there are very few comparative data regarding local drainage with or without main pancreatic stenting as opposed to anastomotic revision or salvage re-anastomosis. The continuous development of specialist, high-volume units with appropriate resources and multidisciplinary experience in complication management might further improve the evidence and the outcomes.

Autologous islet transplantation in patients requiring pancreatectomy for neoplasm

Autologous islet cell transplantation is a procedure performed to prevent or reduce the severity of diabetes after pancreatic resection. Autologous islet cell transplantation is being used almost exclusively in patients undergoing pancreatectomy because of painful, chronic pancreatitis, or multiple recurrent episodes of pancreatitis that is not controlled by standard medical and surgical treatments. Here, we discuss the possibility of extending the clinical indications for this treatment on the basis of our experience in patients undergoing pancreatic surgery for both nonmalignant and malignant diseases, including patients undergoing completion pancreatectomy because of anastomosis leakage after pancreaticoduodenectomy and those with pancreatic anastomosis deemed at high risk for failure.

Pancreatic islet autotransplantation after completion pancreatectomy for pancreatic fistula after hemipancreatoduodenectomy for carcinoma

OBJECTIVE

Pancreatic islet autotransplantation (IAT) has a potential to prevent brittle diabetes in patients after total pancreatectomy. Because of the fear of tumor spread, IAT has rarely been used in case of malignancy. We report our experience with patients who underwent hemipancreatoduodenectomy for carcinoma and later completion pancreatectomy for pancreatic fistula with islet autotransplantation at our institution.

METHODS

From August 2007 to December 2012, 5 patients underwent IAT after completion pancreatectomy for pancreatic fistula after hemipancreatoduodenectomy for carcinoma. Islets were isolated from the pancreatic tail with the use of digestion with collagenase. Nonpurified islet suspension was infused into the portal vein during surgery.

RESULTS

The median number of islets transplanted was 175,000 islet equivalents (range, 70,000-365,000). One patient died after surgery for reasons unrelated to IAT. Another 3 patients had stable diabetes with partial graft function (fasting C-peptide levels 0.23, 0.41, and 0.61 nmol/L and HbA1c 4.8%, 4.6%, and 6.9% at 24, 24 and 9 months after IAT, respectively). The 1st patient, with pancreatic head carcinoma, was alive 28 months after IAT with lymph node and liver recurrence since 18 months after IAT. The 2nd patient, with gall bladder and distal bile duct carcinoma, died 47 months after IAT with tumor recurrence. The 3rd patient, with ampullary carcinoma, died 12 months after IAT with local recurrence and solitary liver metastasis. The last patient had been off insulin 9 months after IAT without tumor recurrence (fasting C-peptide, 0.89 nmol/L; HbA1c, 4.2%).

CONCLUSIONS

Autotransplantation of pancreatic islets isolated from the residual pancreatic tissue in patients who previously underwent hemipancreatoduodenectomy for cancer may provide stable glucose control and thus improve quality of life. In this small series we did not observe early development of multiple liver metastases caused by islet suspension contamination with malignant cells. Oncologic outcome of the patients was not worse than what would be expected without IAT.

Is there an alternative to centralization for pancreatic resection in New Zealand?

BACKGROUND

Internationally pancreatic surgery has become increasingly centralized; however, geographical and population distribution within New Zealand (NZ) limits the practicalities of such an approach. The aim of this study was to review the short-term outcomes of patients undergoing pancreatic surgery by a single hepato-pancreato-biliary trained surgeon in a centre that would meet the minimum criteria set by the NZ National Standards but not necessarily the definition of a high-volume surgeon/centre.

METHODS

A retrospective review of consecutive patients undergoing pancreatic resection within an enhanced recovery programme by a single surgeon between March 2005 and April 2013. Primary outcomes were 30-day morbidity and 90-day mortality.

RESULTS

A total of 156 patients who underwent a pancreatic resection were included. Eighty-two (53%) patients underwent a pancreaticoduodenectomy. Forty-seven (30%) underwent a left pancreatectomy. Overall, 30-day morbidity was 64% and overall 90-day mortality was 2.6%. Overall median length of stay was 11 (3-140) days.

CONCLUSIONS

Acceptable outcomes have been achieved for patients undergoing pancreatic resection within a centre that meets the criteria proposed by the NZ National Standards for treatment of pancreatic cancer.