The Effect of Preoperative Biliary Drainage with or without Pancreatic Stenting on Complications after Pancreatoduodenectomy: A Retrospective Cohort Study

Optimizing pancreatic enucleation for benign tumors: the role of pre-placed pancreatic duct stents-a retrospective cohort study

OBJECTIVE

To investigate the effectiveness of pre-placed pancreatic duct stents on improving outcomes of pancreatic enucleation for benign tumors, a procedure often discouraged by postoperative complications, such as pancreatic fistulae.

METHODS

This single-center retrospective cohort study analyzed 148 patients with benign tumors located in the head, neck, and body of the pancreas between February 2021 and February 2024. Thirty-four patients received stent placement by endoscopic retrograde cholangiopancreatography 1-2 days before surgery, while 114 did not. Propensity score matching resulted in two groups: stent (n = 30) and non-stent (n = 60). Outcomes compared included enucleation success rate, incidence of pancreatic fistulae, hospital stay, procedural costs, pancreatic function deficiency, and quality of life.

RESULTS

Pre-placement of stents significantly increased enucleation success rate (86.7% vs. 28.3%, p = 1.763 × 10-7), facilitated more laparoscopic surgeries (86.7% vs. 41.7%, p = 4.9 × 10-5), and shortened hospital stays (median 7.5 days vs. 11 days, p = 0.001). The stent group also showed a lower incidence of pancreatic exocrine dysfunction (10.3% vs. 35.7%, p = 0.016) and higher quality of life scores (91.2 ± 5.8 vs. 85.5 ± 13.6, p = 0.019). No significant differences were observed in postoperative complications or overall costs. Additionally, the distance between tumor and main pancreatic duct was shorter in the stent group (4.2 ± 2.2 mm vs. 6.2 ± 2.5 mm, p = 0.008).

CONCLUSION

Pre-placement of pancreatic duct stents significantly enhances enucleation success rate, reduces hospital stays, preserves pancreatic function, and improves quality of life. These findings advocate the use of pre-placed stents in enucleation procedures. Further prospective studies are warranted to validate these outcomes.

Timing for a surgically safe and oncologically prompt pancreatoduodenectomy after preoperative biliary drainage in patients with bile duct cancer

BACKGROUND

Preoperative biliary drainage (PBD) is commonly performed in patients with bile duct cancer (BDC). However, data regarding the timing of pancreatoduodenectomy (PD) after PBD are insufficient. This study aimed to investigate the optimal timing for surgically and oncologically safe PD after PBD.

METHODS

Data of patients who underwent PD for BDC between 2018 and 2020 were reviewed. Risk factor analysis was performed to determine clinical associations of PBD with surgical and survival outcomes. Dose-response curves were plotted to indicate the effect of the time interval between PBD and PD on each outcome.

RESULTS

A total of 109 patients underwent PBD before surgery. In multivariable analysis, PD after 20 days of PBD was significantly associated with improved survival after adjusting for other risk factors (hazard ratio 0.119, 95% confidence interval 0.028-0.5000; P = 0.004). Dose-response graphs showed that rates of postoperative complications and survival were lower when PD was performed around 20 days after PBD.

CONCLUSION

In BDC patients, the rate of postoperative complications was lower with fair survival outcomes when PD was performed around 20 days after PBD. A large-scale, prospective study is needed to investigate surgical and oncological effects of PBD in BDC patients.

Enhanced Recovery After Surgery (ERAS) in Pancreatic Surgery: The Surgeon's Point of View

Pancreatic surgery is complex and associated with higher rates of morbidity and mortality compared to other abdominal surgeries. Over the past decade, the introduction of new technologies, such as minimally invasive approaches, improvements in multimodal treatments, advancements in anesthesia and perioperative care, and better management of complications, have collectively improved patient outcomes after pancreatic surgery. In particular, the adoption of Enhanced Recovery After Surgery (ERAS) recommendations has reduced hospital stays and improved recovery times, as well as post-operative outcomes. The aim of this narrative review is to highlight the surgeon's perspective on the ERAS program for pancreatic surgery, with a focus on its potential advantages for perioperative functional recovery outcomes.

The effect of preoperative biliary drainage on postoperative complications of pancreaticoduodenectomy: a triple center retrospective study

Background

Biliary obstruction which is a major complication of pancreas and periampullary tumors could result in cholangitis, coagulopathies, gastrointestinal symptoms, and impaired wound healing. Pancreaticoduodenectomy (PD) is still the standard approach for pancreas resection and imposes high risk of morbidity and mortality to patients. To reduce the high risk of PD and address the biliary obstruction, the use of preoperative biliary stenting was increased. However, available literature doubts its efficiency.

Methods

A total of 147 patients who underwent PD between September 2012, and February 2022, at three medical centers were identified. Patients were grouped based on biliary stent placement. Non-jaundiced patients with and without preoperative biliary drainage (PBD) were compared.

Results

The incidence of overall complications (34.2% versus 45.8%) and mortality (17.8% versus 24.3%) did not differ in the PBD group compared to the no PBD group. There was no difference in complications and mortality in non-jaundiced patients with and without PBD. Patients with drainage duration of > 30 days experienced more overall complications compared to patients with less than 30 days drainage duration (12 (50.0%) and three (15.8%) patients, respectively, p-value = 0.019).

Conclusions

PBD does not significantly increase the post-operative burden on patients who undergo PD. However, we cannot overlook the financial burden that PBD places on the patient and the healthcare system, as well as the difficulties related to endoscopic retrograde cholangiopancreatography (ERCP). Therefore, biliary stenting should not be routinely practiced in the absence of a valid indication, such as severe jaundice, pruritus, cholangitis, delayed surgery for neoadjuvant treatment, or referral to a tertiary facility.

Case report: Conversion therapy for advanced intrahepatic cholangiocarcinoma using PD-1 inhibitor plus S-1 and nab-paclitaxel

Intrahepatic cholangiocarcinoma (iCCA) is a highly malignant hepatobiliary tumor with a high rate of advanced disease at initial presentation. Conversion into resectable iCCA is important for improving the prognosis. Immunotherapy-based regimens are being increasingly used for treating advanced iCCA in recent years. However, the use of combined chemotherapy and immunotherapy for conversion has rarely been reported. The aim of this report was to present the outcomes of a 52-year-old female patient with IIIB iCCA. The patient was treated with a programmed cell death protein-1 inhibitor plus S-1 and nab-paclitaxel. The postoperative histopathological results indicated pathologic complete response after six cycles of systematic treatment. The patient is currently disease-free for one year.

A dynamic risk factor assessment for myocardial infarction and cardiac arrest in patients undergoing pancreatectomy

BACKGROUND

To identify pancreatectomy specific risk factors for myocardial infarction and cardiac arrest (MICA) and to assess whether addition of new information obtained during the hospitalization changes these risk factors.

METHODS

Analysis was performed on elective pancreatectomy data from the ACS-NSQIP database (2014-2019). Risk factors were grouped into pre-operative, intra-operative, and postoperative phases. Factors were selected using a bootstrap resampling procedure to determine MICA association. Independent significance was assessed by logistic regression.

RESULTS

In the first 30 days post-op, 650 of 39779 patients (1.88%) developed MICA. Some of the surgery specific, intra- and post-operative factors that were identified are: delayed gastric emptying (OR: 2.61; 95% CI: 2.12-3.21), total pancreatectomy (OR: 2.16; 95% CI: 1.29-3.42), pancreatic fistula (OR: 1.54; 95% CI: 1.25-1.90), post-operative transfusion (OR: 1.28; 95% CI: 1.03-1.58), and open approach (OR: 1.36; 95% CI: 1.05-1.77). Adding new variables improved statistical model performance and the c-statistic improved from 0.69 to 0.76 in the final analysis.

CONCLUSION

Surgery specific, intra-, and post-operative factors were associated with MICA. Addition of new information during the hospital course changed risk factors and the statistical prediction of MICA risk improved.