Peri-operative outcomes for pancreatoduodenectomy in India: a multi-centric study

Extended distal pancreatectomy in pancreatic cancer: is it justified? A systematic review of literature

Background: Extended distal pancreatectomy (EDP) is being increasingly performed for pancreatic cancers with suspected invasion into the adjacent organs. However, the perioperative safety and oncological efficacy of this procedure merit further elucidation. Methods: Major databases were searched for studies evaluating EDP, and a meta-analysis was performed using fixed- or random-effects models. Results: Fifteen studies were included in the analysis. EDP was found to be associated with significantly greater incidence of postoperative pancreatic fistula overall and with major complications, re-explorations, mortality and readmissions. However, on pooled analysis of 3- and 5-year survival, EDP was found to be noninferior to standard distal pancreatectomy. Conclusion: EDP is feasible and may offer equivalent survival in highly selected patients but carries a higher risk of perioperative morbidity and mortality.

"Impact of Preoperative Biliary Drainage in Patients Undergoing Pancreaticoduodenectomy" - a Prospective Comparative Study from a Tertiary Care Centre in India

Preoperative biliary drainage (PBD) was primarily introduced to reduce perioperative complications following hepato-pancreato-biliary surgeries. There is no proper consensus on the routine use of PBD before pancreaticoduodenectomy (PD). This is a prospective observational study of patients who underwent PD between July 2013 and December 2014. The study group was divided into two groups based on whether a preoperative biliary drainage was performed or not. The intraoperative and postoperative complications were compared among the two groups. A total of 59 patients, predominantly males (64.4%) with a median age of 58 years, were included in study. All except 5 (8.5%) had undergone PD for periampullary malignancy. Thirty-eight patients (64.4%) underwent an upfront PD and the remaining 21 (35.5%) had undergone PBD. Cholangitis was the indication for PBD in all patients. The mean operative time (307.89 ± 52.51 min vs. 314.29 ± 36.273; p value = 0.62) and postoperative complications like delayed gastric emptying (63.2% vs. 61.9%; p value-0.924), postoperative pancreatic fistula (21.1% vs. 33.3%; p value 0.3), post-pancreaticoduodenectomy haemorrhage (5.3% vs. 9.5%; p value-0.611) and mean in-hospital stay were comparable among two groups. Even though the incidence of positive intraoperative bile cultures is significantly higher among the stented group (95.2% vs. 26.3%; p value = 0.0), no significant difference in surgical site infections (47.6% vs. 28.9%; p value 0.152) was noted. The overall mortality was 1.7% (1/59; grade C PPH). This study showed no significant difference in the postoperative complications following PBD despite increase in bile culture positivity. However, notable differences in the spectrum of microbial growths between stented and non-stented groups were observed.

Young-Onset Pancreatobiliary Cancers—Whereto from Here?

This Invited Editorial towards the Special Issue on Hepatobiliary and Pancreatic Surgery highlights the global problem of young-onset cancers. The paucity of data on young-onset pancreatobiliary cancers is presented in the context of its relevance to India (and its large component of adults in the at-risk age group for these cancers). In the face of limited information on the underlying cause of young-onset cancers, the author draws attention to evidence from colorectal cancer. The readers are encouraged to develop collaborative efforts in India to address answers to much needed questions on the management of young-onset pancreatobiliary cancers, some of which are listed in this Editorial.

Postoperative pancreatic fistulas after pancreaticoduodenectomy for malignancy: A Northeast Indian tertiary cancer center study

Background and Aim

Postoperative pancreatic fistula (POPF) is an important cause of major morbidity and mortality after pancreaticoduodenectomy. We intend to estimate the incidence and study the risk factors and outcomes of patients who developed this dreaded complication.

Methods

This is a retrospective observational study. We included all patients who underwent pancreaticoduodenectomy at a specialized surgical unit of a single tertiary care cancer center in Northeast India. The period of study was from 23 April 2012 to 27 December 2019. The 2016 update on the definition of POPF by the International Study Group for Pancreatic Fistula was used to define the complication. Chi‐square test and Fischer's exact test were applied to categorical variables. t‐test was used to quantify mean difference among continuous variables. P value <0.05 was considered statistically significant at 95% confidence interval.

Results

A total of 59 patients underwent pancreaticoduodenectomy during the study period with almost equal distribution among males and females (29 and 30 patients respectively). The mean age of the patients was 54.0 years (range 20–72). Grade A, B, and C pancreatic fistulas were seen in five (8.5%), three (5.1%), and two (3.4%) patients, respectively. Preoperative hyperbilirubinemia, pancreatic duct size ≤3 mm, hypoalbuminemia, preoperative biliary decompression, and prolonged duration of surgery were identified as risk factors for POPF. POPF also resulted in increased 90‐day mortality (20%).

Conclusion

POPF remains a potentially life‐threatening complication of pancreaticoduodenectomies. The knowledge and management of modifiable risk factors for this condition may help in mitigating this problem.

Perioperative outcome of Whipple's procedure with special attention to the impact of preoperative biliary drainage: a real-life scenario

The aim of the present study is to report the overall perioperative outcome of Whipple's procedure (WP) with particular attention to the impact of preoperative biliary drainage (PBD) on postoperative clinical outcome. All the patients who underwent WP at our institution between August 2007 and December 2019 were retrospectively reviewed. Impact of PBD and the stent-surgery interval on the postoperative clinical outcome of WP were analyzed. Of the total 404 patients, 254 (63%) were male. The median age at operation was 50 years. The overall morbidity was 57.7%. The most common complication was surgical site infection (SSI) (28.7%). POPF developed in 57 (14.1%) patients. Delayed gastric emptying, intra-abdominal collection, and postpancreatectomy hemorrhage developed in 82 (20%), 23 (5.7%), and 18 (4.5%) patients, respectively. PBD was performed in 175 (43%) patients. The median stent-surgery interval was 59 days. Postoperative overall complications and SSI were significantly more common in PBD patients. No significant difference in postoperative major complications or mortality was observed between PBD and no-PBD patients. Stent-surgery interval more than 6 weeks was not associated with increased postoperative complications or hospital stay. Similarly, PBD solely based on serum bilirubin ≥ 15 mg/dl has no beneficial effect on surgical outcome. The operative mortality was 4.2% (n = 17). The median postoperative hospital stay was 13 (7-68) days. PBD is associated with increased incidence of postoperative overall complications and SSI, but does not affect major complications or mortality. PBD-surgery interval greater than 6 weeks does not have a negative impact on postoperative clinical outcomes.

Pancreatic cancer in the Australian population: identifying opportunities for intervention

Pancreatic cancer is a disease associated with a poor overall survival. Advances in surgical techniques have helped improve outcomes of patients who are amenable to surgical resection. Sadly, surgery is amenable in only a small percentage of patients with the disease. Thus, there is a need to direct efforts at reducing the overall risk of pancreatic cancer or facilitating its early detection. The current review focused on collating all the literature published to date on pancreatic cancer in Australia with an aim to identify opportunities for intervention (at a state or national level) that are specific to Australia so as to help improve the outcome of patients with pancreatic cancer.

147 Pancreatoduodenectomies: a Single Center's Perspective into the Epidemiology and Surgical Outcomes of Periampullary and Pancreatic Cancers in South India

BACKGROUND

Pancreatoduodenectomy (PD) is the only curative procedure for resectable periampullary cancers. This study aims to survey the various outcome variables of the procedure at our institute, which is in the early process of evolving into a high-volume center for PDs.

METHODS

Data of patients, who underwent PDs, was collected retrospectively from January 2010 to December 2017 and prospectively from January 2018 to December 2019. Various preoperative, intraoperative, and histopathological parameters were compared with the outcome variables-morbidity and mortality rates.

RESULTS

A total of 147 patients underwent PDs over the last decade. From January 2010 to December 2014 (period A), 29 patients underwent PD, while 118 patients underwent PD from January 2015 to December 2019 (period B). Clinically relevant (CR) delayed gastric emptying (44.8% vs 23.7%), CR post-pancreatectomy hemorrhage (37.9% vs 18.6%), and blood loss (850 ml (400-5300 ml) vs 600 ml (150-2500 ml)) improved in period B with no improvement in CR postoperative pancreatic fistula (20.7% vs 28.8%). The rates of SSI (63.6%), pulmonary complications (29.9%), and mean postoperative stay (19.87 ± 11.59 days) were found to be higher than most of the major centers. Mortality rates decreased significantly from 27.6% in period A to 10.2% in period B (p = 0.029). Median overall survival was 30 months (95% CI 20.76-39.23 months) CONCLUSION: Over the last decade, there has been a significant improvement in the mortality rate, but morbidity remains high and must be looked into as the department enters the new decade as a young high-volume center.

Pancreatic cancer in Australia: is not it time we address the inequitable resource problem?

The present study reviewed the geographical variations in the delivery of pancreatic cancer therapy and whether this impacts overall survival. The evidence suggests a difference in the accessibility of pancreatic cancer care to patients in rural as compared with urban Australia. While centralization of pancreatic surgery is essential to deliver high quality care to patients, it may be interfering with the ease of access of this form of care to patients in regional areas. Access to chemotherapy in regional Australia is also limited. There is need for a concerted effort to improve the overall care and uptake of medical services to patients in metropolitan and remote Australia with the overarching aim of improving survival and meaningful quality of life.

Perioperative antimicrobial therapy in preventing infectious complications following pancreatoduodenectomy

BACKGROUND & OBJECTIVES

Infectious complications have been reported to occur in up to 45 per cent of patients, following pancreatoduodenectomy (PD). The incidence of perioperative infectious and overall complications is higher in patients undergoing preoperative invasive endoscopic procedures. The aim of the study was to compare the role of a carbapenem administered as three-once daily perioperative doses on infectious complications in patients at high risk for these complications versus those at low risk.

METHODS

A retrospective study with some secondary data collected from records was carried out on the data from a prospectively maintained surgical database of patients undergoing PD for pancreatic and periampullary lesions at a tertiary referral care centre, between June 2011 and May 2013. Patients were divided into two groups for comparison based on whether they underwent at least one preoperative endoscopic interventional procedure before PD (high-risk - intervention and low-risk - no intervention). All patients were administered three-once daily doses of ertapenem (1 g).

RESULTS

A total of 135 patients in two groups were comparable in terms of demographic and nutritional, surgical and histopathological factors. No significant difference between the two groups in terms of the overall morbidity (38.7 vs 35.7%), infectious complications (9.7 vs 4.8%), mortality (2.2 vs 2.4%) and mean post-operative hospital stay (9.2 vs 8.9 days) was observed.

INTERPRETATION & CONCLUSIONS

Perioperative three-day course of once-daily administered ertapenem resulted in a non-significant difference in infectious and overall complications in high-risk patients undergoing PD as compared to the low-risk group.

Maximum surgical blood order schedule for pancreatoduodenectomy: a long way from uniform applicability!

BACKGROUND

Unnecessary preoperative ordering of blood and blood products results in wastage of a valuable life-saving resource and poses a significant financial burden on healthcare systems.

AIM

To determine patient-specific factors associated with intra-operative transfusions, and if intra-operative blood transfusions impact postoperative morbidity.

PATIENTS & METHODS

Analysis of consecutive patients undergoing pancreatoduodenectomy (PD) for pancreatic tumors.

RESULTS

A total of 384 patients underwent a classical PD with an estimated median blood loss of 200 cc and percentage transfused being 9.6%. Pre-existing hypertension, synchronous vascular resection, end-to-side pancreaticojejunostomy and nodal disease burden significantly associated with the need for intra-operative transfusions. Intra-operative blood transfusion not associated with postoperative morbidity.

CONCLUSION

Optimization of MSBOS protocols for PD is required for more judicious use of blood products.

Pancreaticoduodenectomy for nonampullary duodenal lesions: indications and results

BACKGROUND

Pancreaticoduodenectomy (PD) is a complex procedure, associated with a definite risk of mortality and 30-50% risk of complications. For nonampullary duodenal lesions, PD can carry a higher morbidity as they are more commonly associated with a soft pancreas and narrow-calibre main pancreatic ducts. It is therefore paramount that the risks and benefits of surgery are considered carefully in this group of patients. A preoperative histological diagnosis for duodenal lesions is normally achieved by endoscopic biopsy. In this study, we aim to assess the outcome of PD in patients with nonampullary duodenal lesions and correlate the preoperative endoscopic histology work-up with the definitive postoperative pathology.

MATERIALS AND METHODS

We reviewed a prospectively collected PD database from January 2007 to December 2013. Demographic and clinical data were included. Preoperative endoscopic histology was compared with final specimen histology to assess concordance.

RESULTS

Forty patients (55% women, mean age 69.4 years, range 45-83 years) underwent PD for duodenal lesions over a 7-year time period. The most common presenting symptom was epigastric pain (32.5%), followed by anaemia (20%). Overall, the complication rate was 55%, with the most frequent adverse event being pancreatic fistula in 13/40 (32.5%). The perioperative mortality was 2/40 (5%). Duodenal adenocarcinoma (65%) was the most common postoperative histological diagnosis. The mean tumour size was 36 mm (range 5-103 mm) and a median of 13 nodes were harvested. The median length of stay was 15 days (range 7-66 days). Overall, 12/40 patients (30%) had a preoperative diagnosis of high-grade dysplasia. The postoperative specimen in this subgroup of patients was reviewed carefully and only 3/12 (25%) patients had high-grade dysplasia in the resection specimen. In the remaining patients, 3/12 (25%) had adenocarcinoma in the resection specimen and 6/12 patients (50%) had low-grade dysplasia.

CONCLUSION

PD carries a high mortality and morbidity, especially for duodenal lesions. We recommend a careful endoscopic review after the index case with a high-definition optical evaluation of duodenal lesions. This, in addition to an experienced histological assessment of the index biopsy material, forms an essential prerequisite in aiding the multidisciplinary team in the decision-making process with respect to triage of these lesions to conservative management, surveillance, endoscopic resection or finally surgical resection.

The cost of Pancreatoduodenectomy - An analysis of clinical determinants

BACKGROUND

Health care spending is increasing the world over. Determining preventable or correctable factors may offer us valuable insights into developing strategies aimed at reducing costs and improving patient care. The aim of this study was to conduct an exploratory analysis of clinical factors influencing costs of Pancreatoduodenectomy (PD).

METHODS

The financial and clinical records of 173 consecutive patients who underwent PD at a tertiary care referral centre, between January 2013 and June 2015 were analysed.

RESULTS

Complications, by themselves, did not increase costs associated with PD unless they resulted in an increase in the duration of stay more than 11 days. Intraoperative blood transfusion (p-.098) and performance of an end-to-side PJ (p-.043) were independent factors significantly affecting costs. Synchronous venous resections significantly increased costs (p-.006) without affecting duration of stay. Advancing age, hypertension, neurological and respiratory disorders, preoperative endoscopic retrograde cholangiopancreatography (ERCP), performance of a feeding jejunostomy, and surgical complications eg PPH, POPF and DGE significantly increased the duration of stay sufficient enough to influence costs of PD.

CONCLUSIONS

It is not the merely the development, but severity of complications that significantly increase the cost of PD by increasing hospital stay. Strategies aimed at reducing intraoperative blood transfusion requirement as well as minimising the development of POPF can help reduce costs. Synchronous venous resections significantly increase costs independent of hospital stay. This study identified nine factors that may be included in the development of a preoperative nomogram that could be used in preoperative financial counselling of patients undergoing PD.

Use and results of consensus definitions in pancreatic surgery: a systematic review

BACKGROUND

Because of the lack of standardized definitions of complications in gastrointestinal operations, consensus definitions have been developed in recent years. The aim of the current study was to systematically review the available consensus definitions and to report their use, acceptance, and results.

METHODS

A systematic search of the literature was conducted of the Medline, Cochrane, and ISI Web of Science databases. All articles published until August 2011 and that applied the identified consensus definitions were considered. Inclusion criteria for quantitative analysis were studies with correct usage of the definition and 100 or more patients who were treated after the year 2000.

RESULTS

Seven consensus definitions were identified: postoperative pancreatic fistula, postpancreatectomy hemorrhage, delayed gastric emptying, posthepatectomy liver failure, bile leakage after hepatobiliary and pancreatic surgery, posthepatectomy hemorrhage, and anastomotic leakage after anterior resection of the rectum. Of 1,637 articles retrieved from the literature search, 59 articles that correctly applied the definitions met the inclusion criteria. Subanalyses were feasible for definitions after pancreatic surgery. According to the consensus definitions, the median complication rates of retrospective studies were 21.9% (postoperative pancreatic fistula, n = 11,244 patients), 5.9% (postpancreatectomy hemorrhage, n = 3,311 patients), and 22.8% (delayed gastric emptying, n = 4,553 patients) after pancreatic resections. The incidences were not substantially different in prospective trials. Validation was performed for all three definitions, demonstrating that the severity grades significantly correlated with the clinical course of the patients.

CONCLUSION

The available consensus definitions were increasingly cited and facilitate scientific comparability and transparency if appropriately applied. The present data update the incidences of major pancreatic complications.

Multivariate logistic regression analysis for prediction of clinically relevant pancreatic fistula in the early phase after pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (PF) remains a major complication after pancreaticoduodenectomy (PD). We aimed to investigate the predictors of clinically relevant PF after PD.

METHODS

We retrospectively analyzed the predictive factors of relevant grade B/C PF using logistic regression analysis of 100 consecutive patients who underwent PD. PF was defined in accordance with the International Study Group on PF (ISGPF).

RESULTS

White blood cell count (WBC) of 73.6 × 10(2) /μl, C-reactive protein (CRP) of 9.3 mg/dl and amylase value in drains (d-amylase) of 647 U/I on postoperative day (POD) 4 were proposed as the cut-off values for predicting grade B/C PF with high accuracy by the receiver operating characteristic (ROC) curve. Multivariate logistic regression analysis revealed that the three factors as significant predictive factors and the predicted probability of detecting grade B/C PF was calculated by the following formula; P = 1/[1 + exp{-(2.033 × WBC+3.269 × CRP+2.698 × d-amylase-4.122)}]. P > 0.5 indicates the prospective incidence of the PF. When the cut-off values of the three significant predictors were substituted into the formula, P always showed above 0.5 if more than two predictors were above their cut-off values, indicating a high probability of grade B/C PF.

CONCLUSIONS

White blood cell count, CRP and d-amylase on POD4 were predictive factors for clinically relevant PF after PD. These findings indicate that our formula is useful for management of drain after PD.

Evolution of pancreatoduodenectomy in a tertiary cancer center in India: improved results from service reconfiguration

BACKGROUND

Pancreatic cancer incidence in India is low. Over the years, refinements in technique of pancreatoduodenectomy (PD) may have improved outcomes. No data is available from India, South-Central, or South West Asia to assess the impact of these refinements.

PURPOSE

To assess the impact of service reconfiguration and standardized protocols on outcomes of PD in a tertiary cancer center in India.

METHODS

Three specific time periods marking major shifts in practice and performance of PD were identified, viz. periods A (1992-2001; pancreaticogastrostomy predominantly performed), B (2003-July 2009; standardization of pancreaticojejunal anastomosis), and C (August 2009-December 2011; introduction of neoadjuvant chemo-radiotherapy and increased surgical volume).

RESULTS

500 PDs were performed with a morbidity and mortality rate of 33% and 5.4%, respectively. Over the three periods, volume of cases/year significantly increased from 16 to 60 (p < 0.0001). Overall incidence of post-operative pancreatic anastomotic leak/fistula (POPF), hemorrhage, delayed gastric emptying (DGE), and bile leak was 11%, 6%, 3.4%, and 3.2%, respectively. The overall morbidity rates, as well as, the above individual complications significantly reduced from period A to B (p < 0.01) with no statistical difference between periods B and C.

CONCLUSION

Evolution of practice and perioperative management of PD for pancreatic cancer at our center improved perioperative outcomes and helped sustain the improvements despite increasing surgical volume. By adopting standardized practices and gradually improving experience, countries with low incidence of pancreatic cancer and resource constraints can achieve outcomes comparable to high-incidence, developed nations.

SYNOPSIS

The manuscript represents the largest series on perioperative outcomes for pancreatoduodenectomy from South West and South-Central Asia - a region with a low incidence of pancreatic cancer and a disproportionate distribution of resources highlighting the impact of high volumes, standardization and service reconfiguration.

Surgery for pancreatic carcinoma: state of the art

Carcinoma of the pancreas remains a malignancy with a generally dismal outcome owing to the delayed presentation of the disease. To date, surgery affords the best outcomes when a complete resection can be achieved. Improvements in imaging, surgical techniques and adjuvant therapies are perceived advancements in the management of this cancer. This article reviews the latest evidence in terms of the diagnosis and management of pancreatic cancer.