Surgical technique in distal pancreatectomy: a systematic review of randomized trials

Minimally invasive versus open distal pancreatectomy: a matched analysis using ACS-NSQIP

BACKGROUND

Minimally invasive distal pancreatectomy (MIDP) is gaining popularity due to improved perioperative outcomes over open distal pancreatectomy (ODP). The purpose of this study is to compare outcomes of MIDP and ODP using patients within a nationwide cohort.

METHODS

The American College of Surgeons' National Quality Improvement Program (2014-2018) was used to evaluate incidence of post-operative pancreatic fistula (POPF) as well as 30-day composite major morbidity for patients undergoing MIDP vs. ODP. Matching was performed with a Mahalanobis-distance model for demographic characteristics, preoperative risk factors, and benign versus malignant pathology. Outcomes were assessed via weighted multiple logistic regression.

RESULTS

A total of 3940 patients underwent distal pancreatectomy (1978 MIDP, 1962 ODP). After matching, 2985 patients were included (1978 MIDP, 1007 ODP). The rates of major morbidity (8.65% MIDP vs. 9.76% ODP, p = 0.37) were similar between groups. The MIDP group was found to have significantly decreased length of stay (5.6 vs. 7 days, p ≤ 0.001), but greater rates (12.54% MIDP vs. 9.35% ODP, p = 0.02) of post-operative fistula.

CONCLUSIONS

When matched for baseline patient characteristics, MIDP was associated with shorter length of hospitalization with similar rates of morbidity compared to ODP. However, MIDP was associated with significantly increased rates of POPF. Further studies are needed to investigate this difference in POPF rate, and determine how to optimize MIDP surgical technique to reduce this risk.

Pancreatic surgery is a safe teaching model for tutoring residents in the setting of a high-volume academic hospital: a retrospective analysis of surgical and pathological outcomes

BACKGROUND

Academic hospitals must train future surgeons, but whether residents could negatively affect the outcomes of major procedures is a matter of concern. The aim of this study is to assess if pancreatic surgery is a safe teaching model.

METHODS

Outcomes of 1230 major pancreatic resections performed at a high-volume pancreatic teaching hospital between 2015 and 2018 were compared according to the first surgeon type, attending vs resident.

RESULTS

Residents performed a selection of 132 (16%) pancreaticoduodenectomies (PD) and 46 (11%) distal pancreatectomies (DP). For PD, pancreatic fistula (25% vs 0, p < 0.001), biliary fistula (7.1% vs 3.5%, p = 0.04) and operative time (400 vs 390 min, p < 0.001) were lower for residents but post-pancreatectomy hemorrhage was higher (20.5% vs 13% p = 0.024). For DP, pancreatic fistula rate was lower for residents (31.7% vs 17.5% p = 0.046). There was no difference in terms of lymph nodes retrieval both for PDs and DPs, while the R1 resections were more frequent among PDs performed by attending surgeons (31.5% vs 15.7%, p = 0.023).

CONCLUSION

The active participation of residents does not negatively affect outcomes of major pancreatic resections in a high-volume center. By means of case selection and continuous tutoring, pancreatic surgery represents a safe and valid teaching model.

Distal pancreatectomy outcomes: Perspectives from a community-based teaching institution

Backgrounds/Aims

Distal pancreatic resections are intricate operations with potential for significant morbidity; there is controversy surrounding the appropriate setting regarding surgeon/hospital volume. We report our distal pancreatectomy experience from a community-based teaching hospital.

Methods

This study includes all patients who underwent laparoscopic distal pancreatectomy (LDP) and open distal pancreatectomy (ODP) for benign and malignant lesions between June 2004 and October 2017. Both groups were compared for perioperative characteristics, parenchymal resection technique, and outcomes.

Results

138 patients underwent distal pancreatectomy during this time. The distribution of LDP and ODP was 68 and 70 respectively. Operative time (146 vs. 174 min), blood loss (139 vs. 395 ml) and mean length of stay (4.8 vs. 8.0 days) were significantly lower in the laparoscopic group. The 30-day Clavien Grade 2/3 morbidity rate was 13.7% (19/138) and the incidence of Grade B/C pancreatic fistula was 6.5% (9/138), with no difference between ODP and LDP. 30-day mortality was 0.7% (1/138). 61/138 resections had a malignancy on final pathology. ODP mean tumor diameter was greater (6.4 cm vs. 2.9 cm), but there was no significant difference in the mean number of harvested nodes (8.6 vs. 7.4). The cost of hospitalization, including readmissions and surgery was significantly lower for LDP ($7558 vs. $11610).

Conclusions

This series of distal pancreatectomies indicates a shorter hospital stay, less operative blood loss and reduced cost in the LDP group, and comparable morbidity and oncologic outcomes between LDP and ODP. It highlights the feasibility and safety of these complex surgeries in a community setting.

Risk factors for postoperative pancreatic fistula after laparoscopic distal pancreatectomy using stapler closure technique from one single surgeon

Laparoscopic distal pancreatectomy (LDP) is a safe and reliable treatment for tumors in the body and tail of the pancreas. Postoperative pancreatic fistula (POPF) is a common complication of pancreatic surgery. Despite improvement in mortality, the rate of POPF still remains high and unsolved. To identify risk factors for POPF after laparoscopic distal pancreatectomy, clinicopathological variables on 120 patients who underwent LDP with stapler closure were retrospectively analyzed. Univariate and multivariate analyses were performed to identify risk factors for POPF. The rate of overall and clinically significant POPF was 30.8% and13.3%, respectively. Higher BMI (≥25kg/m²) (p-value = 0.025) and longer operative time (p-value = 0.021) were associated with overall POPF but not clinically significant POPF. Soft parenchymal texture was significantly associated with both overall (p-value = 0.012) and clinically significant POPF (p-value = 0.000). In multivariable analyses, parenchymal texture (OR, 2.933, P-value = 0.011) and operative time (OR, 1.008, P-value = 0.022) were risk factors for overall POPF. Parenchymal texture was an independent predictive factor for clinically significant POPF (OR, 7.400, P-value = 0.001).

Risk factors and preventive strategies for post-operative pancreatic fistula after pancreatic surgery: a comprehensive review

BACKGROUND

Pancreas surgery has developed into a fairly safe procedure in terms of mortality, but is still hampered by considerable morbidity. Among the most frequent and dreaded complications are the development of a post-operative pancreatic fistula (POPF). The prediction and prevention of POPF remains an area of debate with several questions yet to be firmly addressed with solid answers.

METHODS

A systematic review of systematic reviews/meta-analyses and randomized trials in the English literature (PubMed/MEDLINE, Cochrane library, EMBASE) covering January 2005 to December 2015 on risk factors and preventive strategies for POPF.

RESULTS

A total of 49 systematic reviews and meta-analyses over the past decade discussed patient, surgeon, pancreatic disease and intraoperative related factors of POPF. Non-modifiable factors (age, BMI, comorbidity) and pathology (histotype, gland texture, duct size) that indicates surgery are associated with POPF risk. Consideration of anastomotic technique and use of somatostatin-analogs may slightly modify the risk of fistula. Sealant products appear to have no effect. Perioperative bleeding and transfusion enhance risk, but is modifiable by focus on technique and training. Drains may not prevent fistulae, but may help in early detection. Early drain-amylase may aid in detection. Predictive scores lack uniform validation, but may have a role in patient information if reliable pre-operative risk factors can be obtained.

CONCLUSIONS

Development of POPF occurs through several demonstrated risk factors. Anastomotic technique and use of somatostatin-analogs may slightly decrease risk. Drains may aid in early detection of leaks, but do not prevent POPF.

Effectiveness of Tachosil(®) in the prevention of postoperative pancreatic fistula after distal pancreatectomy: a systematic review and meta-analysis

PURPOSE

Postoperative pancreatic fistula (POPF) is a frequent and clinically relevant problem after distal pancreatectomy. A variety of methods have been tested in the attempt to prevent POPF, most of them without convincing results.

METHODS

A systematic literature search was conducted in PubMed, Embase and the Cochrane Library to identify clinical studies comparing pancreatic stump closure with the addition of Tachosil(®) to conventional stump closure. The identified studies were critically appraised, and meta-analyses were performed using a random-effects model. Dichotomous data were pooled using odds ratios, and weighted mean differences were calculated for continuous outcomes, together with the corresponding 95 % confidence intervals.

RESULTS

Four studies (two randomised controlled trials and two retrospective clinical studies) reporting data from 738 patients were included in the meta-analysis. Overall POPF, clinically-relevant POPF, mortality, reoperations, intraoperative blood loss and length of hospital stay did not differ significantly between conventional closure and additional covering of the pancreatic stump with Tachosil(®). A sensitivity analysis of only randomised controlled trials confirmed the results.

CONCLUSIONS

The application of Tachosil(®) to the pancreatic stump after distal pancreatectomy is a safe procedure but provides no relevant benefit in terms of POPF, mortality, reoperation rate, blood loss or length of hospital stay. Future research should concentrate on novel methods of pancreatic stump closure to prevent POPF after distal pancreatectomy.

Effectiveness of Tachosil(®) in the prevention of postoperative pancreatic fistula after distal pancreatectomy: a systematic review and meta-analysis

PURPOSE

Postoperative pancreatic fistula (POPF) is a frequent and clinically relevant problem after distal pancreatectomy. A variety of methods have been tested in the attempt to prevent POPF, most of them without convincing results.

METHODS

A systematic literature search was conducted in PubMed, Embase and the Cochrane Library to identify clinical studies comparing pancreatic stump closure with the addition of Tachosil(®) to conventional stump closure. The identified studies were critically appraised, and meta-analyses were performed using a random-effects model. Dichotomous data were pooled using odds ratios, and weighted mean differences were calculated for continuous outcomes, together with the corresponding 95 % confidence intervals.

RESULTS

Four studies (two randomised controlled trials and two retrospective clinical studies) reporting data from 738 patients were included in the meta-analysis. Overall POPF, clinically-relevant POPF, mortality, reoperations, intraoperative blood loss and length of hospital stay did not differ significantly between conventional closure and additional covering of the pancreatic stump with Tachosil(®). A sensitivity analysis of only randomised controlled trials confirmed the results.

CONCLUSIONS

The application of Tachosil(®) to the pancreatic stump after distal pancreatectomy is a safe procedure but provides no relevant benefit in terms of POPF, mortality, reoperation rate, blood loss or length of hospital stay. Future research should concentrate on novel methods of pancreatic stump closure to prevent POPF after distal pancreatectomy.

Impact of postoperative complications on clinical and economic consequences in pancreatic surgery

Purpose

Patients who develop complications consume a disproportionately large share of available resources in surgery; therefore the attention of healthcare funders focuses on the economic impact of complications. The main objective of this work was to assess the clinical and economic impact of postoperative complications in pancreatic surgery, and furthermore to assess risk factors for increased costs.

Methods

In all, 161 consecutive patients underwent pancreatic resection. The costs of the treatment were determined and analyzed.

Results

The overall morbidity rate was 53.4%, and the in-hospital mortality rate was 3.7%. The median of costs for all patients without complication was 3,963 Euro, whereas the median of costs for patients with at least one complication was significantly increased at 10,670 Euro (P < 0.001). In multivariate analysis American Society of Anesthesiologists ≥ 3 (P = 0.006), multivisceral resection (P < 0.001) and any complication (P < 0.001) were independently associated with increased costs.

Conclusion

Postoperative complications are associated with an increase in mortality, length of hospital stay, and hospital costs. The treatment costs increase with the severity of the postoperative complications. Those factors that are known to increase the treatment costs in pancreatic resection should be considered when planning patients for surgery.

Intra-abdominal drainage following pancreatic resection: A systematic review

AIM

To study all the aspects of drain management in pancreatic surgery.

METHODS

We conducted a systematic review according to the PRISMA guidelines. We searched the Cochrane Central Registry of Controlled Trials, EMBASE, Web of Science, and PubMed (MEDLINE) for relevant articles on drain management in pancreatic surgery. The reference lists of relevant studies were screened to retrieve any further studies. We included all articles that reported clinical studies on human subjects with elective pancreatic resection and that compared various strategies of intra-abdominal drain management, such as drain vs no drain, selective drain use, early vs late drain extraction, and the use of different types of drains.

RESULTS

A total of 19 studies concerned with drain management in pancreatic surgery involving 4194 patients were selected for this systematic review. We included studies analyzing the outcomes of pancreatic resection with and without intra-abdominal drains, studies comparing early vs late drain removal and studies analyzing different types of drains. The majority of the studies reporting equal or superior results for pancreatic resection without drains were retrospective and observational with significant selection bias. One recent randomized trial reported higher postoperative morbidity and mortality with routine omission of intra-abdominal drains. With respect to the timing of drain removal, all of the included studies reported superior results with early drain removal. Regarding the various types of drains, there is insufficient evidence to determine which type of drain is more suitable following pancreatic resection.

CONCLUSION

The prophylactic use of drains remains controversial. When drains are used, early removal is recommended. Further trials comparing types of drains are ongoing.

Technical Aspects of Laparoscopic Distal Pancreatectomy for Benign and Malignant Disease: Review of the Literature

Distal pancreatectomy is the standard curative treatment for symptomatic benign, premalignant, and malignant disease of the pancreatic body and tail. The most obvious benefits of a laparoscopic approach to distal pancreatectomy include earlier recovery and shorter hospital stay. Spleen-preserving distal pancreatectomy should be attempted in case of benign disease. Spleen preservation can be achieved preferably by preserving the splenic vessels (Kimura technique), but also by resecting the splenic vessels and maintaining vascularity through the short gastric vessels and left gastroepiploic artery (Warshaw technique). Several studies have suggested a higher rate of spleen preservation with laparoscopy. The radical antegrade modular pancreatosplenectomy has become mainstay for treating pancreatic cancer and can be performed laparoscopically as well. Evidence on the feasibility and safety of laparoscopic distal pancreatectomy for cancer is scarce. Despite the obvious advantages of laparoscopic surgery, postoperative morbidity remains relatively high, mainly because of the high incidence of pancreatic fistula. For decades, surgeons have tried to prevent these fistulas but to date no strategy has been confirmed to be effective in 2 consecutive randomized studies. Pragmatic multicenter studies focusing on technical aspects of laparoscopic distal pancreatectomy are lacking and should be encouraged.

Can the measurement of amylase in drain after distal pancreatectomy predict post-operative pancreatic fistula?

INTRODUCTION

The most frequent reason for performing a distal pancreatectomy is the presence of cystic or neuroendocrine tumors, in which the distal pancreatic stump is often soft and non fibrotic. This parenchymal consistence represents the main risk factor for post-operative pancreatic fistula. In order to identify the fistula and assessing its severity postoperative monitoring of amylase from intraperitoneal drains is important.

METHODS

From a retrospective multicentric database analysis were included 33 patients who underwent distal pancreatectomy for pancreatic neoplastic disease.

RESULTS

Postoperative pancreatic fistula occurred in four cases. One patient had a ductal adenocarcinoma, two presented with pancreatic endocrine neoplasms and the last one had an intraductal papillary mucinous neoplasia. Two patients underwent open, the other two laparoscopic distal pancreatectomy.

DISCUSSION

Postoperative pancreatic fistulas after distal pancreatectomy worsen the quality of life, prolong the post-operative stay and delay further adjuvant therapy. In patients who underwent distal pancreatectomy literature exposed some advantages deriving from the placement of abdominal drainages only in selected cases and from their early removal. Patients presenting a high risk of pancreatic fistula had higher amylase levels of drainage fluid in the first postoperative day.

CONCLUSION

POPF is the most frequently complication after pancreatectomy. In our analysis DFA1>5000 can be considered as a predictive factor for pancreatic fistula. For this reason, the systematic measurement of amylase in drain fluid in first-postoperative day can be considered a good clinical practice.

DRAPA trial--closed-suction drains versus closed gravity drains in pancreatic surgery: study protocol for a randomized controlled trial

BACKGROUND

The morbidity of pancreatic resection remains high, with pancreatic fistula being the most common cause. The important question is whether any postoperative treatment adjustment may prevent the development of clinically significant postoperative pancreatic fistulae. Recent studies have shown that intraabdominal drains and manipulation using them are of great importance. Although authors of a few retrospective reports have described good results of pancreatic resection without the use of intraabdominal drains, a recent prospective randomized trial showed that routine elimination of drains in pancreaticoduodenectomy is associated with poor outcome. An important issue arises as to which type of drain is most suitable for pancreatic resection. Two types of surgical drains exist: open drains and closed drains. Open drains are considered obsolete nowadays because of frequent retrograde infection. Closed drains include two types: passive gravity drains and closed-suction drains. Closed-suction drains are more effective, as they remove fluid from the abdominal cavity under light pressure. However, some surgeons believe that closed-suction drains represent a potential hazard to patients and that negative pressure might increase the risk of pancreatic fistulae. Nobody has yet specifically dealt with the question of which kind of drainage is most appropriate in pancreatic surgery.

METHODS/DESIGN

The aim of the DRAins in PAncreatic surgery (DRAPA) trial is to compare the closed-suction drain versus the closed passive gravity drain in pancreatic resection. DRAPA is a dual-centre, prospective, randomized controlled trial. The primary endpoint is the rate of postoperative pancreatic fistula; the secondary endpoint is postoperative morbidity with follow-up of 3 months.

DISCUSSION

No study to date has compared different types of drains in pancreatic surgery. This study is designed to answer the question whether any particular type of drain might lower the rate of postoperative pancreatic fistula or other complications.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01988519. Registered 13 November 2013.

Perioperative management of distal pancreatectomy

Recent advances in surgical techniques and perioperative management have markedly reduced operative morbidity after distal pancreatectomy (DP). However, some questions remain regarding the protocol for the perioperative management of DP, in particular, with regard to the development of pancreatic fistula (PF). A review of DP was therefore conducted in order to standardize the management of patients for a favorable outcome. Overall, operative technique and perioperative management emerged as two critical factors contributing to favorable outcome in DP patients. As for the operative method, surgical and closure techniques exhibited differences in outcome. Laparoscopic DP generally yields more favorable perioperative outcomes compared to open DP, and is applicable for benign tumors and some ductal carcinomas of the pancreas. Robotic DP is also available for safe pancreatic surgery. En bloc celiac axis resection offers a high R0 resection rate and potentially allows for some local control in the case of advanced pancreatic cancer. Following resection, staple closure was not found to reduce the rate of PF when compared to hand-sewn closure. In addition, ultrasonic dissection devices, fibrin glue sealing, and staple closure with mesh reinforcement were shown to significantly reduce PF, although there was some bias in these studies. In perioperative management, both preoperative and postoperative treatment affected outcome. First, preoperative endoscopic pancreatic stenting may be an effective prophylactic measure against fistula development following DP in selected patients. Second, in postoperative management, a multifactorial approach including prophylactic antibiotics improved high surgical site infection rates following complex hepato-pancreato-biliary surgery. Furthermore, although conflicting results have been reported, somatostatin analogues should be administered selectively to patients considered to have a high risk for PF. Finally, careful drain management also facilitates a favorable outcome in patients with PF after DP. The results of the review indicate that laparoscopic DP coupled with perioperative management influences outcome in DP patients.