Combined prognostic nutritional index ratio and serum amylase level during the early postoperative period predicts pancreatic fistula following pancreaticoduodenectomy

Risk Factors For Progression From Biochemical Leak to Clinically Relevant Postoperative Pancreatic Fistula After Pancreaticoduodenectomy. The Key of the Lock: Prognostic Nutritional Index

Background/Aims

Postoperative pancreatic fistula (POPF), which is considered the most frightening complication after pancreatic oduodenectomy (PD), continues to be a serious problem even in experienced centers. In the present study, we aimed to determine the risk factors that increase the progression from biochemical leak (BL) to clinically relevant postoperative pancreatic fistula (CR-POPF) after PD.

Materials and Methods

We retrospectively analyzed the data of 152 patients who underwent PD. A total of 71 patients who developed POPF were included in the study and divided into two groups: 52 patients remained in the BL stage and 19 patients progressed from BL to CR-POPF. The groups were compared in terms of preoperative data, perioperative findings, and postoperative results. Risk factors for progression from BL to CR-POPF were analyzed.

Results

Preoperative prognostic nutritional index (PNI) was significantly lower in the CR-POPF group compared to the BL group (35.6 (30.1-47.9) vs 41.6 (33.5-58), P < .001). Receiver operating characteristic (ROC) curve analysis showed that the best cutoff of preoperative PNI value for predicting this progression was 38 (AUC = 0.835; 95% CI, 0.717-0.953; P = .001). While the progression rate was 58.3% in the group with PNI < 38, it was 10.6% with PNI ≥ 38. In univariate and multivariate analysis, preoperative PNI value was the only independent risk factor for progression from BL to CR-POPF after PD (OR, 15.428; 95% CI, 3.714-64.085; P < .01).

Conclusion

Preoperative PNI value is an important parameter predicting the progression from BL to CR-POPF after PD.

Impact of Early Enteral Nutrition on Delayed Gastric Emptying and Nutritional Status After Pancreaticoduodenectomy

BACKGROUND

Although early enteral nutrition (EEN) is an accepted practice after pancreaticoduodenectomy (PD), the impact of EEN on postoperative complications or nutritional status remains unclear. We aimed to investigate the impact of EEN on delayed gastric emptying (DGE) and nutritional status after PD.

METHODS

A total of 143 patients underwent PD between January 2012 and September 2020. We excluded patients who underwent a two-stage pancreatojejunostomy, in whom the enteral tube was accidentally pulled out, or with insufficient information in their medical records. The incidence of postoperative complications was compared between patients who received EEN (EEN group, n = 21) and those who did not (control group, n = 21) after propensity score matching. Univariate and multivariate analyses were performed to identify the risk factors affecting the incidence of these complications. Nutritional status was assessed at postoperative months 1, 3, and 6.

RESULTS

The incidence of grade B/C DGE in the EEN group was significantly lower than that in the control group (4.8% vs. 28.6%, p = 0.03). There was no significant difference in overall morbidity, incidence of any other postoperative complications, or all-grade DGE. In multivariate analysis, EEN was associated with a reduction in the incidence of grade B/C DGE (p < 0.01). In the analysis of nutritional status, EEN was significantly associated with better nutritional status at postoperative month 1.

CONCLUSION

EEN can lead to a lower clinically relevant DGE rate and better nutritional status in the early postoperative period in patients undergoing PD.

Preoperative and intraoperative risk factors of postoperative pancreatic fistula after pancreaticoduodenectomy – systematic review and meta-analysis

Introduction: Postoperative pancreatic fistula (POPF) is a potentially life-threatening complication after pancreaticoduodenectomy (PD). It is observed when the amylase activity in the drain fluid exceeds three times the normal upper value. Grades B and C of POPF are considered as clinically relevant. Fistula might originate due to failure of healing of a pancreatic anastomosis or from raw pancreatic surface. Materials and methods: 18 retrospective and prospective studies published between 2015 and 2020 were included in this meta-analysis. Total number of patients was 5836. To investigate potential risk factors associated with the occurrence of POPF, odds ratios (OR) with 95% confidence intervals (CI) were calculated. To compare discontinuous data, mean differences (MD) were calculated. Results: 13 factors were divided into preoperative and intraoperative groups. Male sex, higher BMI, soft pancreatic texture and small pancreatic duct were considered as significant risk factors while vascular resection lowered the risk of development pancreatic fistula. Discussion: It is considered that the development of POPF is associated with intrapancreatic fat. More severe infiltration with fat tissue is responsible for soft texture of the gland, while higher BMI is one of the risk factors of increased pancreatic fat. On the contrary, diabetes is associated with fibrotic pancreas which could lower the risk of developing POPF.