1
|
Probst P, Hüttner FJ, Klaiber U, Knebel P, Ulrich A, Büchler MW, Diener MK. Stapler versus scalpel resection followed by handsewn closure of the pancreatic remnant for distal pancreatectomy. Cochrane Database Syst Rev 2025; 6:CD008688. [PMID: 40492489 DOI: 10.1002/14651858.cd008688.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/12/2025]
Abstract
BACKGROUND Resections of the pancreatic body and tail reaching to the left of the superior mesenteric vein are defined as distal pancreatectomy. Most distal pancreatectomies are elective treatments for chronic pancreatitis, benign or malignant diseases, and they have high morbidity rates of up to 40%. Pancreatic fistula formation is the main source of postoperative morbidity, and is associated with numerous further complications. Researchers have proposed several surgical resection and closure techniques of the pancreatic remnant in an attempt to reduce these complications. The two most common techniques are scalpel resection followed by handsewn closure of the pancreatic remnant and stapler resection and closure. OBJECTIVES To assess the effects of stapler resection and closure compared to scalpel resection followed by handsewn closure of the pancreatic remnant in people undergoing distal pancreatectomy. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase from database inception to October 2023, and the ISGPS Evidence Map of Pancreatic Surgery to 9 April 2025. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing stapler versus scalpel resection followed by handsewn closure of the pancreatic remnant for open distal pancreatectomy (irrespective of language or publication status). DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and performed data extraction. Our outcomes of interest were postoperative mortality and morbidity, especially postoperative pancreatic fistula. Taking into account the clinical heterogeneity between trials (e.g. different endpoint definitions), we analysed data using a random-effects model in RevMan, calculating risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI). We used GRADE to assess the certainty of evidence. MAIN RESULTS In three trials, a total of 515 participants underwent distal pancreatic resection and were randomised to closure of the pancreatic remnant either with stapler (n = 259) or scalpel resection followed by handsewn closure (n = 256). One study was a single-centre pilot RCT, and two studies were multicentre RCTs. The single-centre pilot RCT evaluated 69 participants in five intervention arms (stapler, handsewn, fibrin glue, mesh, and pancreaticojejunostomy), although we only assessed the stapler and handsewn closure groups (14 and 15 participants, respectively). The two multicentre RCTs had two interventional arms: stapler (n = 177 and 68) and handsewn closure (n = 175 and 66). Stapler may have similar effects on postoperative mortality compared to scalpel resection followed by handsewn closure, although the CI is wide (4 deaths per 1000 compared with 8 per 1000; RR 0.49, 95% CI 0.05 to 5.40; 3 RCTs; 515 participants; low-certainty evidence). Stapler likely results in little to no difference in postoperative pancreatic fistula according to the International Study Group of Pancreatic Surgery (ISGPS) definition compared to scalpel resection followed by handsewn closure (26% versus 29%; RR 1.11, 95% CI 0.84 to 1.47; 2 RCTs; 486 participants; moderate-certainty evidence). Stapler likely results in little to no difference in overall postoperative morbidity compared to scalpel resection followed by handsewn closure (63% versus 59%; RR 1.06, 95% CI 0.87 to 1.30; 2 RCTs; 486 participants; moderate-certainty evidence). We downgraded the certainty of evidence for all outcomes by one level due to potential selection bias alone or in combination with performance and detection bias, and for postoperative mortality by a further level for imprecision. AUTHORS' CONCLUSIONS The evidence is mainly based on the results of two multicentre RCTs. There is no ongoing RCT on this topic. We did not find evidence to indicate that either stapler or scalpel resection followed by handsewn closure of the pancreatic remnant for distal pancreatectomy is superior in terms of postoperative pancreatic fistula, overall postoperative mortality, or operation time. Currently, the choice of closure is left to the preference of the individual surgeon and the anatomical characteristics of the patient. Future trials stratifying for pancreatic texture (soft versus hard) could add valuable information to inform surgical approaches when considering different pancreatic textures. Future trials assessing novel methods of stump closure should compare them either with stapler or handsewn closure as a control group to ensure comparability of results.
Collapse
Affiliation(s)
- Pascal Probst
- Department of Surgery, Cantonal Hospital Thurgau, Frauenfeld, Switzerland
| | - Felix J Hüttner
- Department of General, Visceral and Thoracic Surgery, Klinikum Nuremberg, Nuremberg, Germany
| | - Ulla Klaiber
- Department of General and Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Phillip Knebel
- Department of General, Visceral and Transplant Surgery, University of Heidelberg, Heidelberg, Germany
| | - Alexis Ulrich
- Department of General, Visceral, Thoracic and Vascular Surgery, Lukas Hospital Neuss , Neuss, Germany
| | - Markus W Büchler
- Botton-Champalimaus Pancreatic Cancer Center, Champalimaud Foundation, Lisbon, Portugal
| | - Markus K Diener
- Department of General, Visceral and Thoracic Surgery, Klinikum Nuremberg, Nuremberg, Germany
| |
Collapse
|
2
|
de Oliveira Silva Nascimento A, Silva ODC, Duarte BN, de Carvalho Baptista Barbosa I, Bajou CMO, Taba JV, Pipek LZ, Iuamoto LR, Hsing WT, Carneiro-D'Albuquerque LA, Andraus W, Meyer A. Suture versus stapler in distal pancreatectomy and its impact on postoperative pancreatic fistula. Sci Rep 2025; 15:6052. [PMID: 39972194 PMCID: PMC11840080 DOI: 10.1038/s41598-025-90617-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Accepted: 02/14/2025] [Indexed: 02/21/2025] Open
Abstract
Postoperative pancreatic fistula is a critical complication after distal pancreatectomy. The aim of this systematic review is to assess new reports on the main pancreatic stump closure techniques (stapler and hand-sewn suture) in distal pancreatectomy, to define their influence on postoperative pancreatic fistula rates. A literature review was performed following PRISMA guidelines (PROSPERO: CRD42023408181). The survey was conducted in Medline (via PubMed) and EMBASE. Clinical trials and cohorts were included if they assessed pancreatic fistula rates after distal pancreatectomy, and excluded if they used a fistula rating system other than the ISGPF one. The risk of bias was assessed using the Study Quality Assessment Tools | NHLBI, NIH. A meta-analysis was presented as forest-plots. Eleven articles were included, representing 1498 patients. No significant difference was found between Suture and Bare stapler (95% CI 0.91-1.68) or Bare stapler and Reinforced stapler for A-graded fistula rates (95% CI 0.78-1.28) and B-graded fistula rates (I-squared = 0.0%, p = 0.784). Most articles showed unclear risk of detection bias. This meta-analysis found no difference in fistula rates between stump closure techniques. This choice should be made by surgeons' and hospital administration's preferences.
Collapse
Affiliation(s)
| | | | | | | | | | - João Victor Taba
- Faculty of Medicine FMUSP, University of São Paulo, São Paulo, SP, Brazil
| | - Leonardo Zumerkorn Pipek
- Department of Neurology, Hospital das Clínicas HCFMUSP, Faculty of Medicine FMUSP, University of São Paulo, São Paulo, Brazil
| | - Leandro Ryuchi Iuamoto
- Center of Acupuncture, Department of Orthopaedics and Traumatology, University of São Paulo, São Paulo, SP, Brazil
| | - Wu Tu Hsing
- Center of Acupuncture, Department of Orthopaedics and Traumatology, University of São Paulo, São Paulo, SP, Brazil
| | - Luiz Augusto Carneiro-D'Albuquerque
- Department of Gastroenterology, Hospital das Clínicas HCFMUSP, Faculty of Medicine FMUSP, University of São Paulo, Avenida Dr. Arnaldo, 455 - Cerqueira César, São Paulo, SP, 01246-903, Brazil
| | - Wellington Andraus
- Department of Gastroenterology, Hospital das Clínicas HCFMUSP, Faculty of Medicine FMUSP, University of São Paulo, Avenida Dr. Arnaldo, 455 - Cerqueira César, São Paulo, SP, 01246-903, Brazil
| | - Alberto Meyer
- Department of Gastroenterology, Hospital das Clínicas HCFMUSP, Faculty of Medicine FMUSP, University of São Paulo, Avenida Dr. Arnaldo, 455 - Cerqueira César, São Paulo, SP, 01246-903, Brazil.
| |
Collapse
|
3
|
Kjeseth T, Hagen RE, Edwin B, Lai X, Røsok BI, Tholfsen T, Sahakyan MA, Kleive D. Impact of pancreas transection site on incidence of pancreatic fistula after distal pancreatectomy: a propensity score matched study. HPB (Oxford) 2024; 26:1164-1171. [PMID: 38839509 DOI: 10.1016/j.hpb.2024.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 04/24/2024] [Accepted: 05/20/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Distal pancreatectomy (DP) is performed for lesions in the body and tail of the pancreas. The morbidity profile is considerable, mainly due to clinically relevant postoperative pancreatic fistula (CR-POPF). This study aims to investigate potential differences in CR-POPF related to transection site. METHODS An observational cohort study from a prospectively maintained database was performed. Subtotal distal pancreatectomy (SDP) was defined as transection over the superior mesenteric vein, and DP was defined as transection lateral to this point. Propensity score matching (PSM) in 1:1 fashion was applied based on demographical and perioperative variables. RESULTS Six hundred and six patients were included in the analysis (1997-2020). Four hundred twenty (69.3%) underwent DP, while 186 (30.7%) underwent SDP. The rate of CR-POPF was 19.3% after DP and 20.4% after SDP (p = 0.74). SDP was associated with older age (63.1 vs 60.1 years, p = 0.016), higher occurrence of ductal adenocarcinoma (37.1 vs 17.6%, p = 0.001) and more frequent use of neoadjuvant chemotherapy (3.8 vs 0.7%, p = 0.012). After PSM, 155 patients were left in each group. The difference in CR-POPF between DP and SDP remained statistically non-significant (20.6 vs 18.7%, p = 0.67). CONCLUSION This study found no difference in CR-POPF related to transection site during distal pancreatectomy.
Collapse
Affiliation(s)
- Trond Kjeseth
- Department of HPB Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway.
| | - Rolf E Hagen
- Department of HPB Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Bjørn Edwin
- Department of HPB Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway; The Intervention Centre, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
| | - Xiaoran Lai
- Oslo Centre for Biostatistics and Epidemiology, University of Oslo, Oslo, Norway
| | - Bård I Røsok
- Department of HPB Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Tore Tholfsen
- Department of HPB Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Mushegh A Sahakyan
- Department of HPB Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway; The Intervention Centre, Oslo University Hospital, Oslo, Norway; Department of Surgery N1, Yerevan State Medical University after M. Heratsi, Yerevan, Armenia
| | - Dyre Kleive
- Department of HPB Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| |
Collapse
|
4
|
Hajibandeh S, Hajibandeh S, Hablus MA, Bari H, Pathanki AM, Ali M, Ahmad J, Marangoni G, Khan S, Lam FT. Meta-analysis and trial sequential analysis of pancreatic stump closure using a hand-sewn or stapler technique in distal pancreatectomy. Ann Hepatobiliary Pancreat Surg 2024; 28:302-314. [PMID: 38522846 PMCID: PMC11341886 DOI: 10.14701/ahbps.24-015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/20/2024] [Accepted: 02/20/2024] [Indexed: 03/26/2024] Open
Abstract
This study aimed to compare outcomes of hand-sewn and stapler closure techniques of pancreatic stump in patients undergoing distal pancreatectomy (DP). Impact of stapler closure reinforcement using mesh on outcomes was also evaluated. Literature search was carried out using multiple data sources to identify studies that compared hand-sewn and stapler closure techniques in management of pancreatic stump following DP. Odds ratio (OR) was determined for clinically relevant postoperative pancreatic fistula (POPF) via random-effects modelling. Subsequently, trial sequential analysis was performed. Thirty-two studies with a total of 4,022 patients undergoing DP with hand-sewn (n = 1,184) or stapler (n = 2,838) closure technique of pancreatic stump were analyzed. Hand-sewn closure significantly increased the risk of clinically relevant POPF compared to stapler closure (OR: 1.56, p = 0.02). When stapler closure was considered, staple line reinforcement significantly reduced formation of such POPF (OR: 0.54, p = 0.002). When only randomized controlled trials were considered, there was no significant difference in clinically relevant POPF between hand-sewn and stapler closure techniques (OR: 1.20, p = 0.64) or between reinforced and standard stapler closure techniques (OR: 0.50, p = 0.08). When observational studies were considered, hand-sewn closure was associated with a significantly higher rate of clinically relevant POPF compared to stapler closure (OR: 1.59, p = 0.03). Moreover, when stapler closure was considered, staple line reinforcement significantly reduced formation of such POPF (OR: 0.55, p = 0.02). Trial sequential analysis detected risk of type 2 error. In conclusion, reinforced stapler closure in DP may reduce risk of clinically relevant POPF compared to hand-sewn closure or stapler closure without reinforcement. Future randomized research is needed to provide stronger evidence.
Collapse
Affiliation(s)
- Shahin Hajibandeh
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Shahab Hajibandeh
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital of Wales, Cardiff, UK
| | - Mohammed Abdallah Hablus
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
- Department of General Surgery, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Hassaan Bari
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Adithya Malolan Pathanki
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Majid Ali
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Jawad Ahmad
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Gabriele Marangoni
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Saboor Khan
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - For Tai Lam
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| |
Collapse
|
5
|
Molasy B, Zemła P, Mrowiec S, Czopek P, Kusnierz K. Comparative Analysis of Complications Following Distal Resections for Neuroendocrine Tumors and Adenocarcinoma: Unveiling the Differences. Med Sci Monit 2024; 30:e943307. [PMID: 39155478 PMCID: PMC11346325 DOI: 10.12659/msm.943307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 04/23/2024] [Indexed: 08/20/2024] Open
Abstract
BACKGROUND Adenocarcinomas and pancreatic neuroendocrine tumors (pNETs) display some similarities and differences. The aim of this study was to compare preoperative data and morphological parameters, and to assess postoperative complications after resection. MATERIAL AND METHODS Data of 162 patients who underwent distal pancreatic resection for neuroendocrine or adenocarcinoma tumor were retrospectively analyzed. After applying inclusion and exclusion criteria, 131 patients were included in the study. The preoperative data analyzed included age, sex, and ASA-PS (American Society of Anesthesiologists Physical Status) grade. The diameter of the pancreatic duct and the texture of the pancreas were analyzed. Postoperative data included grading (G1-G3), the presence of PanIN (pancreatic intraepithelial neoplasia), infiltration of structures, and postoperative complications. RESULTS Patients with adenocarcinoma were statistically older and had a higher ASA-PS class than patients with NET (P<0.001). Statistically significantly more patients with adenocarcinoma had a histopathological diagnosis of G3 (p<0.001). In patients with adenocarcinomas infiltration of structures occurred more frequently. Pancreatic duct diameter ≥3 mm was more common in patients with adenocarcinoma (P=0.045). Clinically significant pancreatic fistulas were more frequent in patients with neuroendocrine tumors (P=0.044). CONCLUSIONS Adenocarcinomas in the pancreatic body and tail are more aggressive, they cause more frequent infiltration of structures, and more often metastasize to lymph nodes compared to NETs. NETs tend to have softer pancreatic texture and higher incidence of clinically significant pancreatic fistulas, but postoperative complications of Clavien-Dindo grade ≥III occur at a similar rate in both groups.
Collapse
Affiliation(s)
- Bartosz Molasy
- Student Scientific Society, Department of Gastrointestinal Surgery, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
- Department of General Surgery, St. Alexander Hospital, Kielce, Poland
| | - Patryk Zemła
- Student Scientific Society, Department of Gastrointestinal Surgery, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| | - Sławomir Mrowiec
- Department of Gastrointestinal Surgery, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| | - Piotr Czopek
- Department of Gastrointestinal Surgery, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| | - Katarzyna Kusnierz
- Department of Gastrointestinal Surgery, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| |
Collapse
|
6
|
Fingerhut A, Uranues S, Dziri C, Ma J, Vernerey D, Kurihara H, Stiegler P. Interaction analysis of subgroup effects in randomized trials: the essential methodological points. Sci Rep 2024; 14:12619. [PMID: 38824173 PMCID: PMC11144206 DOI: 10.1038/s41598-024-62896-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 05/22/2024] [Indexed: 06/03/2024] Open
Abstract
Subgroup analysis aims to identify subgroups (usually defined by baseline/demographic characteristics), who would (or not) benefit from an intervention under specific conditions. Often performed post hoc (not pre-specified in the protocol), subgroup analyses are prone to elevated type I error due to multiple testing, inadequate power, and inappropriate statistical interpretation. Aside from the well-known Bonferroni correction, subgroup treatment interaction tests can provide useful information to support the hypothesis. Using data from a previously published randomized trial where a p value of 0.015 was found for the comparison between standard and Hemopatch® groups in (the subgroup of) 135 patients who had hand-sewn pancreatic stump closure we first sought to determine whether there was interaction between the number and proportion of the dependent event of interest (POPF) among the subgroup population (patients with hand-sewn stump closure and use of Hemopatch®), Next, we calculated the relative excess risk due to interaction (RERI) and the "attributable proportion" (AP). The p value of the interaction was p = 0.034, the RERI was - 0.77 (p = 0.0204) (the probability of POPF was 0.77 because of the interaction), the RERI was 13% (patients are 13% less likely to sustain POPF because of the interaction), and the AP was - 0.616 (61.6% of patients who did not develop POPF did so because of the interaction). Although no causality can be implied, Hemopatch® may potentially decrease the POPF after distal pancreatectomy when the stump is closed hand-sewn. The hypothesis generated by our subgroup analysis requires confirmation by a specific, randomized trial, including only patients undergoing hand-sewn closure of the pancreatic stump after distal pancreatectomy.Trial registration: INS-621000-0760.
Collapse
Affiliation(s)
- Abraham Fingerhut
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, People's Republic of China.
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria.
| | - Selman Uranues
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Chadly Dziri
- Medical School of Tunis, Tunis University El Manar, Tunis, Tunisia
- Honoris Medical Simulation Center, Tunis, Tunisia
| | - Junjun Ma
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, People's Republic of China
| | - Dewi Vernerey
- Methodology and Quality of Life Unit, INSERM Unit. 1098, University of Besancon, Besancon, France
| | - Hayato Kurihara
- Emergency Surgery Unit, IRCCS - Ca' Granda - Policlinico Hospital, Via Francesco Sforza, 20122, Milan, Italy
| | - Philip Stiegler
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria
| |
Collapse
|
7
|
Funamizu N, Uraoka M, Numata Y, Koizumi M, Ogawa K, Ikeda Y, Takada Y. Refractory postoperative pancreatic fistula following laparoscopic distal pancreatectomy for pancreatic cancer caused by incomplete pancreas divisum: a case report. Clin J Gastroenterol 2024; 17:587-591. [PMID: 38460085 DOI: 10.1007/s12328-024-01942-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 02/19/2024] [Indexed: 03/11/2024]
Abstract
Pancreas divisum (PD) represents a prevalent congenital pancreatic variant, typically arising from the failure of fusion between the ventral and dorsal pancreatic ducts. This condition is frequently associated with recurrent pancreatitis. We herein present a case involving an incomplete PD diagnosis following the identification of a refractory postoperative pancreatic fistula (POPF) after laparoscopic distal pancreatectomy (DP) for pancreatic cancer. A 74-year-old female patient, who had undergone laparoscopic DP for pancreatic cancer, developed a POPF accompanied by intraabdominal bleeding, necessitating urgent intervention radiology to avert life-threatening complications. Following this, intraabdominal drainage was performed through an intraoperative drainage root. Subsequent fistulography and endoscopic retrograde pancreatography unveiled the presence of an incomplete PD for the first time. Consequently, a stent was placed in the Santorini duct. However, the volume of pancreatic juice from the intraabdominal drainage tube exhibited no reduction. Despite repeated attempts to access the pancreatic duct via a guidewire through the drainage tube, these endeavors proved futile. Paradoxically, the removal of the external drainage tube led to a recurrence of intraabdominal abscess formation. Consequently, reinsertion of the drainage tube became imperative. Consideration was given to draining the abscess under endoscopic ultrasonography and performing pancreatic duct drainage. However, due to the diminution of the abscess cavity through the external fistula drainage procedure, coupled with the absence of pancreatic duct dilation and its tortuous course, it was deemed a formidable challenge. the patient necessitated a lifestyle adaptation with a permanently placed percutaneous drainage tube.
Collapse
Affiliation(s)
- Naotake Funamizu
- Department of Hepatobiliary Pancreatic Surgery, Ehime University Graduate School of Medicine, 454 Shitsugawa, Toon, Ehime, 791-0295, Japan.
| | - Mio Uraoka
- Department of Hepatobiliary Pancreatic Surgery, Ehime University Graduate School of Medicine, 454 Shitsugawa, Toon, Ehime, 791-0295, Japan
| | - Yuki Numata
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Mitsuhito Koizumi
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Kohei Ogawa
- Department of Hepatobiliary Pancreatic Surgery, Ehime University Graduate School of Medicine, 454 Shitsugawa, Toon, Ehime, 791-0295, Japan
| | - Yoshio Ikeda
- Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Yasutsugu Takada
- Department of Hepatobiliary Pancreatic Surgery, Ehime University Graduate School of Medicine, 454 Shitsugawa, Toon, Ehime, 791-0295, Japan
| |
Collapse
|
8
|
Walber JK, Antony P, Strothmann H, Kalkum E, Renzulli P, Hauswirth F, Probst P, Muller MK. Effect of artificial or autologous coverage of the pancreatic remnant or anastomosis on postoperative pancreatic fistulas after partial pancreatectomy: meta-analysis of randomized clinical trials. BJS Open 2024; 8:zrae059. [PMID: 38814751 PMCID: PMC11138960 DOI: 10.1093/bjsopen/zrae059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 04/10/2024] [Accepted: 04/20/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Postoperative pancreatic fistulas remain a driver of major complications after partial pancreatectomy. It is unclear whether coverage of the anastomosis or pancreatic remnant can reduce the incidence of postoperative pancreatic fistulas. The aim of this study was to evaluate the effect of autologous or artificial coverage of the pancreatic remnant or anastomosis on outcomes after partial pancreatectomy. METHODS A systematic literature search was performed using MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL) up to March 2024. All RCTs analysing a coverage method in patients undergoing partial pancreatoduodenectomy or distal pancreatectomy were included. The primary outcome was postoperative pancreatic fistula development. Subgroup analyses for pancreatoduodenectomy or distal pancreatectomy and artificial or autologous coverage were conducted. RESULTS A total of 18 RCTs with 2326 patients were included. In the overall analysis, coverage decreased the incidence of postoperative pancreatic fistulas by 29% (OR 0.71, 95% c.i. 0.54 to 0.93, P < 0.01). This decrease was also seen in the 12 RCTs covering the remnant after distal pancreatectomy (OR 0.69, 95% c.i. 0.51 to 0.94, P < 0.02) and the 4 RCTs applying autologous coverage after pancreatoduodenectomy and distal pancreatectomy (OR 0.53, 95% c.i. 0.29 to 0.96, P < 0.04). Other subgroup analyses (artificial coverage or pancreatoduodenectomy) showed no statistically significant differences. The secondary endpoints of mortality, reoperations, and re-interventions were each affected positively by the use of coverage techniques. The certainty of evidence was very low to moderate. CONCLUSION The implementation of coverage, whether artificial or autologous, is beneficial after partial pancreatectomy, especially in patients undergoing distal pancreatectomy with autologous coverage.
Collapse
Affiliation(s)
- Jonas K Walber
- Department of Surgery, Cantonal Hospital Thurgau, Münsterlingen, Switzerland
| | - Pia Antony
- Department of Surgery, Cantonal Hospital Thurgau, Münsterlingen, Switzerland
| | - Hendrik Strothmann
- Department of Surgery, Cantonal Hospital Thurgau, Münsterlingen, Switzerland
| | - Eva Kalkum
- Study Centre of the German Society of Surgery (SDGC), University of Heidelberg, Heidelberg, Germany
| | - Pietro Renzulli
- Department of Surgery, Cantonal Hospital Thurgau, Münsterlingen, Switzerland
| | - Fabian Hauswirth
- Department of Surgery, Cantonal Hospital Thurgau, Münsterlingen, Switzerland
| | - Pascal Probst
- Department of Surgery, Cantonal Hospital Thurgau, Frauenfeld, Switzerland
| | - Markus K Muller
- Department of Surgery, Cantonal Hospital Thurgau, Münsterlingen, Switzerland
- Department of Surgery, Cantonal Hospital Thurgau, Frauenfeld, Switzerland
| |
Collapse
|
9
|
Hirashita T, Fujinaga A, Nagasawa Y, Orimoto H, Amano S, Kawamura M, Kawasaki T, Kawano Y, Masuda T, Endo Y, Inomata M. Efficacy of pancreaticojejunostomy of the pancreatic stump during distal or central pancreatectomy. Langenbecks Arch Surg 2024; 409:145. [PMID: 38687358 DOI: 10.1007/s00423-024-03335-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 04/23/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND A stapler is usually used for transection and closure of the pancreas in distal pancreatectomy (DP) or central pancreatectomy (CP). When the pancreas is transected to the right of the portal vein, it is difficult to use a stapler and clinically relevant postoperative pancreatic fistula (CR-POPF) frequently occurs. We report on the efficacy of pancreaticojejunostomy (PJ) of the pancreatic stump for patients in whom stapler use is difficult. METHODS Patients who underwent DP or CP were enrolled in this study. The pancreas was usually transected by a stapler, and ultrasonic coagulating shears (UCS) were used depending on the tumor situation. When using UCS, hand-sewn closure or PJ was performed for the pancreatic stump. The relationship between clinicopathological factors and the methods of pancreatic transection and closure were investigated. RESULTS In total, 164 patients underwent DP or CP, and the pancreas was transected with a stapler in 150 patients and UCS in 14 patients. The rate of CR-POPF was higher and the postoperative hospital stay was longer in the UCS group than in the stapler group. PJ of the pancreatic stump, which was performed for 7 patients, did not worsen intraoperative factors. CR-POPF was not seen in these 7 patients, which was significantly less than that with hand-sewn closure. CONCLUSIONS PJ of the pancreatic stump during DP or CP reduces CR-POPF compared with hand-sewn closure and may be useful especially when the pancreas is transected to the right of the portal vein.
Collapse
Affiliation(s)
- Teijiro Hirashita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan.
| | - Atsuro Fujinaga
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Yuiko Nagasawa
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Hiroki Orimoto
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Shota Amano
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Masahiro Kawamura
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Takahide Kawasaki
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Yoko Kawano
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Takashi Masuda
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Yuichi Endo
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Masafumi Inomata
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| |
Collapse
|
10
|
Chaouch MA, Dziri C, Uranues S, Fingerhut A. Pancreatic stump closure after distal pancreatectomy: Systematic review and meta-analysis of randomized clinical trials comparing non-autologous versus no reinforcement: Value of prediction intervals. Am J Surg 2024; 229:92-98. [PMID: 38184462 DOI: 10.1016/j.amjsurg.2023.12.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/17/2023] [Accepted: 12/30/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND This meta-analysis of randomized trials aimed to assess the benefits and harms of non-autologous versus no reinforcement of the pancreatic stump following distal pancreatectomy (DP). METHODS It was performed in accordance with PRISMA 2020 and AMSTAR 2 Guidelines. (registered in PROSPERO ID: EROCRD42021286863). RESULTS Nine relevant articles (between 2009 and 2021) were retrieved, comparing non-autologous reinforcement (757 patients) with non-reinforcement (740 patients) after PD. Pooled analysis showed a statistically significant lower rate of postoperative pancreatic fistula (POPF) in the reinforcement group (RR = 0.677; 95 % CI [0.479, 0.956], p = 0.027). The 95 % predictive interval (0.267-1.718) showed heterogeneity. Non-autologous reinforcement other than with "Tachosil®" was effective (subgroup analysis). No statistically significant differences were found between the two groups with regard to secondary outcomes. CONCLUSIONS This meta-analysis showed that covering the stump with non-autologous reinforcement other than Tachosil® had a preventive effect on the onset of POPF.
Collapse
Affiliation(s)
- Mohamed Ali Chaouch
- Department of Visceral & Digestive Surgery -Monastir Medical School -Monastir University, Tunisia.
| | - Chadli Dziri
- Tunis University El Manar, Medical School of Tunis, Director of Honoris Medical Simulation Center, Tunis, Tunisia.
| | - Selman Uranues
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria.
| | - Abe Fingerhut
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria; Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, PR China.
| |
Collapse
|
11
|
Wysocki M, Borys M, Gałązka K, Stranek M, Budzyński A. Splenectomy and tumor size are risk factors for serious perioperative morbidity of laparoscopic distal pancreatectomies. POLISH JOURNAL OF SURGERY 2023; 96:6-12. [PMID: 38348977 DOI: 10.5604/01.3001.0053.9292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
<b><br>Introduction:</b> The determinants influencing the risk for complications of laparoscopic distal pancreatectomies (LDP) are not yet fully defined, thus we aimed to determine risk factors for serious perioperative morbidity after LDP with spleen preservation, LDP and radical antegrade modular pancreatosplenectomy for adenocarcinoma of the body and tail of the pancreas (RAMPS).</br> <b><br>Material and methods:</b> Retrospective cohort study of consecutive patients that underwent LDP between January 2019 and December 2022. The study group included cases of serious perioperative morbidity (III-V grades in Clavien-Dindo classification) during a 30-day period after operation. The control group consisted of patients without serious perioperative morbidity. As many as 142 patients were included in the study.</br> <b><br>Results:</b> Serious perioperative morbidity was found in 33 (23.24%) operated patients, while mortality in 3 cases (2.11%). Serious perioperative morbidity after LDP with spleen preservation was found in 9/68 (13.2%) patients (27.3% of the perioperative morbidity group). Thirteen out of 51 patients, i.e. 25.5%, after LDP with splenectomy were included in the perioperative morbidity group (39.4%). Serious perioperative morbidity after RAMPS was found in 11/23 (47.8%) patients (33.3% of the perioperative morbidity group). In multivariate logistic regression, the need for splenectomy during pancreatectomy (OR 3.66, 95%CI 1.20-11.18) and tumor above 28 millimeters in size (OR 3.01, 95%CI 1.19-9.59) were independent risk factors for serious perioperative morbidity.</br> <b><br>Conclusions:</b> The need for splenectomy during laparoscopic distal pancreatectomy and tumor size above 28 millimeters were independent risk factors for serious perioperative morbidity after laparoscopic distal pancreatectomies.</br>.
Collapse
Affiliation(s)
- Michal Wysocki
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital, Cracow, Poland
| | - Maciej Borys
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital, Cracow, Poland
| | - Krystyna Gałązka
- Department of Pathomorphology, Jagiellonian University Medical College, Cracow, Poland
| | - Maciej Stranek
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital, Cracow, Poland
| | - Andrzej Budzyński
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital, Cracow, Poland
| |
Collapse
|
12
|
Yamasaki Y, Kurahara H, Oi H, Hozaka Y, Idichi T, Kawasaki Y, Mataki Y, Ohtsuka T. Metal-free laparoscopic distal pancreatectomy using transpancreatic mattress suture with polyglycolic acid sheet and fibrin glue: A case report. Asian J Endosc Surg 2023; 16:770-773. [PMID: 37483158 DOI: 10.1111/ases.13229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 06/27/2023] [Indexed: 07/25/2023]
Abstract
Laparoscopic distal pancreatectomy (LDP) is the standard surgery for malignant and premalignant tumors of the pancreatic body and tail. A stapler is commonly used to close the pancreatic stump due to its simplicity; however, the use of a stapler is associated with the risk of metal allergy and postoperative pancreatic fistula, especially in thick pancreases. Here, we present a case of LDP without metal instruments, including staplers and clips, in a 54-year-old woman with a metal allergy and a thick pancreas. The pancreatic stump was closed using the transpancreatic mattress suture method with a polyglycolic acid sheet (PGA) and fibrin glue. The postoperative course was uneventful. Metal-free LDP is useful and can be adopted regardless of the patient's background, such as a metal allergy or pancreatic thickness.
Collapse
Affiliation(s)
- Yoichi Yamasaki
- Department of Digestive Surgery, and Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Hiroshi Kurahara
- Department of Digestive Surgery, and Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Hideyuki Oi
- Department of Digestive Surgery, and Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Yuto Hozaka
- Department of Digestive Surgery, and Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Tetsuya Idichi
- Department of Digestive Surgery, and Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Yota Kawasaki
- Department of Digestive Surgery, and Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Yuko Mataki
- Department of Digestive Surgery, and Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Takao Ohtsuka
- Department of Digestive Surgery, and Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| |
Collapse
|
13
|
Pergolini I, Scheufele F, Demir E, Schorn S, Friess H, Ceyhan GO, Demir IE. Continuous irrigation after pancreatectomy: a systematic review. Langenbecks Arch Surg 2023; 408:348. [PMID: 37659027 PMCID: PMC10474975 DOI: 10.1007/s00423-023-03070-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 08/15/2023] [Indexed: 09/05/2023]
Abstract
PURPOSE Prevention and management of postoperative pancreatic fistula (POPF) after pancreatic resections is still an unresolved issue. Continuous irrigation of the peripancreatic area is frequently used to treat necrotizing pancreatitis, but its use after elective pancreatic surgery is not well-known. With this systematic review, we sought to evaluate the current knowledge and expertise regarding the use of continuous irrigation in the surgical area to prevent or treat POPF after elective pancreatic resections. METHODS A systematic search of the literature was conducted according to the PRISMA 2020 guidelines, screening the databases of Pubmed, Scopus, Web of Science, and Ovid MEDLINE. Because of the heterogeneity of the included articles, a statistical inference could not be performed and the literature was reviewed only descriptively. The study was pre-registered online (OSF Registry). RESULTS Nine studies were included. Three studies provided data regarding the prophylactic use of continuous irrigation after distal and limited pancreatectomies. Here, patients after irrigation showed a lower rate of clinically relevant POPF, related complications, lengths of stay, and mortality. Six other papers reported the use of local lavage to treat clinically relevant POPF and subsequent fluid collections, with successful outcomes. CONCLUSION In the current literature, only a few publications are focused on the use of continuous irrigation after pancreatic resection to prevent or manage POPF. The included studies showed promising results, and this technique may be useful in patients at high risk of POPF. Further investigations and randomized trials are needed.
Collapse
Affiliation(s)
- Ilaria Pergolini
- Department of Surgery, Technical University of Munich, Klinikum rechts der Isar, Ismaninger Straße 22, 81675, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site, Munich, Germany
- CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany
| | - Florian Scheufele
- Department of Surgery, Technical University of Munich, Klinikum rechts der Isar, Ismaninger Straße 22, 81675, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site, Munich, Germany
- CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany
| | - Elke Demir
- Department of Surgery, Technical University of Munich, Klinikum rechts der Isar, Ismaninger Straße 22, 81675, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site, Munich, Germany
- CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany
| | - Stephan Schorn
- Department of Surgery, Technical University of Munich, Klinikum rechts der Isar, Ismaninger Straße 22, 81675, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site, Munich, Germany
- CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany
| | - Helmut Friess
- Department of Surgery, Technical University of Munich, Klinikum rechts der Isar, Ismaninger Straße 22, 81675, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site, Munich, Germany
- CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany
| | - Güralp O Ceyhan
- Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Ihsan Ekin Demir
- Department of Surgery, Technical University of Munich, Klinikum rechts der Isar, Ismaninger Straße 22, 81675, Munich, Germany.
- German Cancer Consortium (DKTK), Partner Site, Munich, Germany.
- CRC 1321 Modelling and Targeting Pancreatic Cancer, Munich, Germany.
- Department of General Surgery, HPB-Unit, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey.
- Else Kröner Clinician Scientist Professor for Translational Pancreatic Surgery, Munich, Germany.
| |
Collapse
|
14
|
Jabłońska B, Mrowiec S. Pancreatectomy and Pancreatic Surgery. Life (Basel) 2023; 13:1400. [PMID: 37374182 PMCID: PMC10326818 DOI: 10.3390/life13061400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Pancreatectomy, including pancreaticoduodenectomy (PD), as well as central pancreatectomy (CP), distal pancreatectomy (DP) and total/subtotal pancreatectomy, is a major, complex and difficult surgical procedure performed for various benign and malignant pancreatic diseases: from chronic pancreatitis, through benign cystic tumors and neuroendocrine neoplasms to malignant neoplasms, including pancreatic ductal adenocarcinoma (PDAC) [...].
Collapse
Affiliation(s)
- Beata Jabłońska
- Department of Digestive Tract Surgery, Medical University of Silesia, 40-752 Katowice, Poland;
| | | |
Collapse
|
15
|
Șandra-Petrescu F, Tzatzarakis E, Mansour Basha M, Rückert F, Reissfelder C, Birgin E, Rahbari NN. Impact of spleen preservation on the incidence of postoperative pancreatic fistula after distal pancreatectomy: Is less more? Pancreatology 2022; 22:1013-1019. [PMID: 35945100 DOI: 10.1016/j.pan.2022.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/11/2022] [Accepted: 07/24/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) remains a major complication after distal pancreatectomy (DP) with a significant impact on patients' quality of life. There is limited evidence that preservation of the spleen reduces the risk of POPF. Therefore, we aimed to investigate the impact of splenectomy on perioperative outcome. METHODS Data from patients who underwent DP for malignant and benign disease at our institution between 2004 and 2021 were reviewed. Patients were grouped according to spleen preservation (SP-DP) and splenectomy (DPS). Intraoperative parameters and postoperative outcomes were compared between groups. Univariable and multivariable analyses were used to investigate factors that influence the occurrence of clinically relevant (cr)POPF. RESULTS A total of 199 patients were included, of whom 61 (30.7%) patients underwent SP-DP. Patients who underwent SP-DP had a significantly lower rate of crPOPF (p = 0.022), shorter hospital stay (p = 0.003), and less readmissions (p = 0.012). On multivariate analysis, obesity (OR 2.88, p = 0.021), benign lesions (OR 2.35, p = 0.018), postoperative acute pancreatitis (OR 2.53, p = 0.028), and splenectomy (OR 2.83, p = 0.011) were independent risk factors associated with the onset of crPOPF. DISCUSSION Preservation of the spleen reduces the risk of crPOPF in patients undergoing distal pancreatectomy for benign and malignant disease.
Collapse
Affiliation(s)
- Flavius Șandra-Petrescu
- Department of Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Emmanouil Tzatzarakis
- Department of Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Mamdouh Mansour Basha
- Department of Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Felix Rückert
- Department of Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Christoph Reissfelder
- Department of Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Emrullah Birgin
- Department of Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nuh N Rahbari
- Department of Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
| |
Collapse
|
16
|
Jia B, Chen Q, Jiang P, Liu Y. An analysis of the effectiveness of stapler closure combined with a titanium clip in distal pancreatectomy. Surg Today 2022; 52:1430-1437. [PMID: 35138460 DOI: 10.1007/s00595-022-02470-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/09/2022] [Indexed: 10/19/2022]
Abstract
PURPOSES Postoperative pancreatic fistula is the most common and severe postoperative complication of distal pancreatectomy. Treatment of pancreatic stump to reduce the incidence of postoperative pancreatic fistula is crucial. This study evaluated the effectiveness of stapler closure combined with a titanium clip in distal pancreatectomy. METHODS Prospectively collected data of consecutive patients who underwent distal pancreatectomy from April 2013 to May 2020 with pancreatic transection performed by the bare stapler method (131 patients), stapler + hand-sewn closure method (199 patients), and stapler + titanium clip method (209 patients) were reviewed retrospectively and compared between groups. RESULTS No statistically significant differences were observed in basic data among the three groups. There were also no significant differences among the three groups in terms of the intraoperative data or tumor pathological types, except for the number of laparoscopic treatment cases (23, 53, and 80 for bare stapler method, stapler + hand-sewn closure method, and stapler + titanium clip method, respectively; P < 0.05) and pancreatic neuroendocrine tumor cases (15, 29, and 12, respectively; P < 0.05). There were no significant differences in postoperative complications or parameters, except for the number of clinical pancreatic fistula cases (31, 27, and 13 for bare stapler method, stapler + hand-sewn closure method, and stapler + titanium clip method, respectively; P < 0.05) and postoperative length of hospital stay (11.6 ± 8.3, 10.6 ± 9.7, and 9.3 ± 6.9 days, respectively; P < 0.05). The stapler + titanium clip group had a significantly lower number of clinical pancreatic fistula cases and shorter postoperative length of hospital stay than the other groups. The univariate analysis showed that pancreatic resection line thickness was an independent risk factor for clinical pancreatic fistula after operation. CONCLUSION Stapler closure combined with titanium clips to reinforce the pancreatic stump is simple and easy to implement, effectively reduces the incidence of clinical pancreatic fistula, and shortens the postoperative length of hospital stay.
Collapse
Affiliation(s)
- Baoxing Jia
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Qingmin Chen
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Peiqiang Jiang
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Yahui Liu
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130021, Jilin, China.
| |
Collapse
|
17
|
Risk Factor Identification for Delayed Gastric Emptying after Distal Pancreatectomy-An Evaluation of 1688 Patients Based on the German StuDoQ|Pancreas Registry. J Clin Med 2022; 11:jcm11195539. [PMID: 36233403 PMCID: PMC9572291 DOI: 10.3390/jcm11195539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/17/2022] [Accepted: 09/18/2022] [Indexed: 11/17/2022] Open
Abstract
Delayed gastric emptying (DGE) ranks as one of the most frequent complications in pancreatic surgery. It leads to increased costs for healthcare systems, lengthened hospital stays and reduced quality of life. Data about DGE after distal pancreatectomy (DP) are scarce. The StuDoQ|Pancreas registry of the German Society of General and Visceral Surgery provided data of patients who underwent distal pancreatectomy from 1 January 2014 to 31 December 2018. The retrospective evaluation included comprehensive data: 1688 patients were enrolled; DGE occurred 160 times (9.5%); grade “A” was reported for 98 (61.3%), grade “B” for 41 (25.6%) and grade “C” for 21 (13.1%) patients. In univariate analysis pancreatic fistulas were associated with higher frequencies of intraabdominal abscesses (9.1% vs. 2%, p > 0.001), postpancreatectomy haemorrhage (8.1% vs. 3.7%, >0.001) and DGE (14.5% vs. 6%, p < 0.001). According to multivariate analysis, “abscesses with invasive therapy” (p < 0.001), “other surgical complications” (p < 0.001), prolonged “stays in ICU” (p < 0.001), lengthened duration of surgery (p < 0.001) and conventional surgery (p = 0.007) were identified as independent risk factors for DGE. Perioperative and postoperative factors were identified as risk factors for DGE. Following research should examine this highly relevant topic in a prospective, register-based manner. As there is no causal therapy for DGE, its avoidance is of major importance.
Collapse
|
18
|
Arnold P, Belchos J, Meagher A, Robbins C, Sparks Joplin T, Ortiz D, Ferries I, Hartwell J. Postoperative Pancreatic Fistula Following Traumatic Splenectomy: A Morbid and Costly Complication. J Surg Res 2022; 280:35-43. [PMID: 35952555 DOI: 10.1016/j.jss.2022.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 06/29/2022] [Accepted: 07/04/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Development of clinically relevant postoperative pancreatic fistula (CR-POPF) in adult splenectomies following trauma occur in 1%-3% of cases. We hypothesized that the use of sutures in splenic hilum ligation compared to staples was associated with a reduced rate of CR-POPF incidence. METHODS Adult trauma patients (age ≥17 y) that underwent nonelective splenectomy from 2010 to 2020 were retrospectively evaluated from the trauma registries of all three adult level 1 trauma centers in Indiana. Patients were excluded if they were pregnant, currently incarcerated, expired within 72 h of admission, or had a pancreatic injury diagnosed preoperatively or intraoperatively. A Firth logistic regression using a penalized-maximum likelihood estimate for rare events was used for univariate predictive modeling (SPSS 28.0) of surgical technique on CR-POPF development. RESULTS Four hundred nineteen adult splenectomies following trauma were conducted; 278 were included. CR-POPF developed in 14 cases (5.0%). Sutures alone were used in 200 cases: seven developed CR-POPF (3.5%). Staples alone or in combination with sutures were used in 74 cases: seven developed CR-POPF (9.5%). There was no statistically significant difference between the use of sutures alone compared to the use of staples alone (P = 0.123) or in combination (P = 0.100) in CR-POPF incidence. CONCLUSIONS Our 10-y retrospective review of CR-POPF finds the complication to be rare but morbid. This study was underpowered to show any difference in surgical technique. However, we do propose a new institutional norm that CR-POPF develop in 5% of splenectomies after trauma and conclude that further study of optimal technique for emergent splenectomy is warranted.
Collapse
Affiliation(s)
- Peter Arnold
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana.
| | - Jessica Belchos
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana; Ascension St. Vincent Hospital, Indianapolis, Indiana
| | - Ashley Meagher
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana
| | - Christopher Robbins
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana
| | - Tasha Sparks Joplin
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana
| | - Damaris Ortiz
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana; Sidney & Lois Eskenazi Hospital, Indianapolis, Indiana
| | - Ian Ferries
- Ascension St. Vincent Hospital, Indianapolis, Indiana
| | - Jennifer Hartwell
- Indiana University School of Medicine, Department of Surgery, Indianapolis, Indiana
| |
Collapse
|
19
|
Using a Reinforced Stapler Decreases the Incidence of Postoperative Pancreatic Fistula After Distal Pancreatectomy: A Systematic Review and Meta-Analysis. World J Surg 2022; 46:1969-1979. [PMID: 35525852 DOI: 10.1007/s00268-022-06572-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND There is no consensus on the pancreatic transection during distal pancreatectomy (DP) to reduce postoperative pancreatic fistula (POPF). This meta-analysis aimed to evaluate the effects of a reinforced stapler on the postoperative outcomes of DP. METHODS We systematically searched electronic databases and bibliographic reference lists in The PubMed/MEDLINE, Google Scholar, Cochrane Library's Controlled Trials Registry and Database of Systematic Reviews, Embase, and Scopus. Review Manager Software was used for pooled estimates. RESULTS Seven eligible studies published between 2007 and 2021 were included with 553 patients (267 patients in the reinforced stapler group and 286 patients in the standard stapler group). The reinforced stapler reduced the POPF grade B and C (OR = 0.33; 95% CI [0.19, 0.57], p < 0.01). There was no difference between the reinforced stapler group and standard stapler group in terms of mortality rate (OR = 0.39; 95% CI [0.04, 3.57], p = 0.40), postoperative haemorrhage (OR = 0.53; 95% CI [0.20, 1.43], p = 0.21), and reoperation rate (OR = 0.91; 95% CI [0.40, 2.06], p = 0.82). CONCLUSIONS Reinforced stapling in DP is safe and seems to reduce POPF grade B/C with similar mortality rates, postoperative bleeding, and reoperation rate. The protocol of this systematic review with meta-analysis was registered in PROSPERO (ID: CRD42021286849).
Collapse
|
20
|
Girish S, Kapil N, Kannan N. Central Pancreatectomy: Significance of Vascularity on Anastomotic Integrity and a Note on Reconstructive Technique. Cureus 2021; 13:e18617. [PMID: 34765372 PMCID: PMC8573194 DOI: 10.7759/cureus.18617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2021] [Indexed: 11/05/2022] Open
Abstract
Central pancreatectomy is a pancreatic parenchymal sparing surgery usually indicated for benign and borderline malignant tumors of the neck and proximal body of the pancreas. Due to the presence of extensive intra-pancreatic spread, pancreatic parenchyma sparing procedures such as central pancreatectomy are invariably deferred in pancreatic malignancy. The need for management of two pancreatic stumps with a usually soft texture and non-dilated ducts, given the indications, increases the risk of pancreatic fistula and therefore morbidity. Proximal stump management is usually a closure either by suture or stapler with reinforcements; the technique preferred depends on the experience of the surgeon and is mostly extrapolated from distal pancreatectomy. Distal stump management is the Achilles’ heel owing to the texture of the pancreas and pancreatic duct size. Need for additional mobilization may have a bearing on the perfusion of the pancreatic stump and hence may lead to clinically relevant leaks. The use of octreotide accentuating the said vascular insufficiency may not be an overstatement. Here we present a case of solid pseudopapillary tumor (SPT) of the neck and proximal body of the pancreas in which a central pancreatectomy with falciform patch closure of the proximal stump and binding pancreaticogastrostomy (PG) was contemplated and further we discuss the types of reconstruction with special reference to the vascular pattern of distal pancreas.
Collapse
Affiliation(s)
- Suraj Girish
- General Surgery, Meenakshi Medical College and Research Institute, Kanchipuram, IND
| | - Nagaraj Kapil
- Surgical Gastroenterology, Meenakshi Medical College and Research Institute, Kanchipuram, IND
| | - Naveen Kannan
- General Surgery, Meenakshi Medical College Hospital and Research Institute, Kanchipuram, IND
| |
Collapse
|
21
|
Chong E, Ratnayake B, Lee S, French JJ, Wilson C, Roberts KJ, Loveday BPT, Manas D, Windsor J, White S, Pandanaboyana S. Systematic review and meta-analysis of risk factors of postoperative pancreatic fistula after distal pancreatectomy in the era of 2016 International Study Group pancreatic fistula definition. HPB (Oxford) 2021; 23:1139-1151. [PMID: 33820687 DOI: 10.1016/j.hpb.2021.02.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/23/2021] [Accepted: 02/25/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Risk factors for the development of clinically relevant POPF (CR-POPF) following distal pancreatectomy (DP) need clarification particularly following the 2016 International Study Group of Pancreatic Fistula (ISGPF) definition. METHODS A systemic search of MEDLINE, Pubmed, Scopus, and EMBASE were conducted using the PRISMA framework. Studies were evaluated for risk factors for the development CR-POPF after DP using the 2016 ISGPF definition. Further subgroup analysis was undertaken on studies ≥10 patients in exposed and non-exposed subgroups. RESULTS Forty-three studies with 8864 patients were included in the meta-analysis. The weighted rate of CR-POPF was 20.4% (95%-CI: 17.7-23.4%). Smoking (OR 1.29, 95%-CI: 1.08-1.53, p = 0.02) and open DP (OR 1.43, 95%-CI: 1.02-2.01, p = 0.04) were found to be significant risk factors of CR-POPF. Diabetes (OR 0.81, 95%-CI: 0.68-0.95, p = 0.02) was a significant protective factor against CR-POPF. Substantial heterogeneity was observed in the comparisons of pancreatic texture and body mass index. Seventeen risk factors achieved significance in a univariate or multivariate comparison as reported by individual studies in the narrative synthesis, however, they remain difficult to interpret as statistically significant comparisons were not uniform. CONCLUSION This meta-analysis found smoking and open DP to be risk factors and diabetes to be protective factor of CR-POPF in the era of 2016 ISGPF definition.
Collapse
Affiliation(s)
- Eric Chong
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Bathiya Ratnayake
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Shiela Lee
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, United Kingdom
| | - Jeremy J French
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, United Kingdom
| | - Colin Wilson
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, United Kingdom
| | - Keith J Roberts
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Benjamin P T Loveday
- Hepatobiliary and Upper Gastrointestinal Unit, Royal Melbourne Hospital, Victoria, Australia; Department of Surgical Oncology, Peter MacCallum Cancer Centre, Victoria, Australia
| | - Derek Manas
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, United Kingdom
| | - John Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Steve White
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, United Kingdom
| | - Sanjay Pandanaboyana
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, United Kingdom; Population Health Sciences Institute, Newcastle University, Newcastle, United Kingdom.
| |
Collapse
|
22
|
Kang MK, Kim H, Byun Y, Han Y, Choi YJ, Kang JS, Kwon W, Han IW, Shin SH, Choi DW, You Y, Heo JS, Jang JY. Optimal stapler cartridge selection to reduce post-operative pancreatic fistula according to the pancreatic characteristics in stapler closure distal pancreatectomy. HPB (Oxford) 2021; 23:633-640. [PMID: 33012640 DOI: 10.1016/j.hpb.2020.09.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/05/2020] [Accepted: 09/07/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is associated with potentially fatal complications, but there is lack of data on relationship between pancreas thickness, and stapler size and the POPF rate. This study aimed to suggest optimal stapler that reduces POPF rate according to the pancreas thickness. METHODS This retrospective cohort study was conducted in two tertiary high-volume pancreas centers. 599 patients who underwent distal pancreatectomy were assessed for stump reinforcement methods, pathology findings, pancreas thickness, and cartridge used. The cartridges were grouped as I, II, III according to the closed height ≤1.5 mm, 1.8 mm, and ≥2.0 mm, respectively. RESULTS The POPF rate increased according to the thickness. The stapler Groups I, II, and III had an overall POPF rate of 66.4% vs. 61.7% vs. 57.8%, but Group II stapler cartridge showed a significant reduction in the POPF rate than other cartridges in pancreas with thickness <13 mm (53.5% vs. 21.7% vs. 36.0%, p = 0.031). There was no significant difference between the POPF rate according to stapler groups when the pancreas was thicker than 13 mm. CONCLUSION Thickness is the strongest risk factor in predicting POPF. Use of Group II stapler cartridge for pancreas with a thickness of <13 mm can help reduce POPF.
Collapse
Affiliation(s)
- Min Kyu Kang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hongbeom Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yoonhyeong Byun
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Youngmin Han
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yoo Jin Choi
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jae Seung Kang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - In Woong Han
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sang Hyun Shin
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Wook Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yunghun You
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jin Seok Heo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
23
|
Iwamoto K, Saito T, Takemoto Y, Ueno K, Yanagihara M, Furuya-Kondo T, Kurazumi H, Tanaka Y, Taura Y, Harada E, Hamano K. Autologous transplantation of multilayered fibroblast sheets prevents postoperative pancreatic fistula by regulating fibrosis and angiogenesis. Am J Transl Res 2021; 13:1257-1268. [PMID: 33841654 PMCID: PMC8014429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/11/2021] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Postoperative pancreatic fistula (POPF) is a serious complication after gastrointestinal or pancreatic surgery. Despite intensive investigations, the occurrence has not significantly decreased in the past decades. The aims of this study were to clarify the pathophysiology of POPF and establish the preventive measures using multilayered fibroblast sheets. METHODS We developed a pancreatic fistula (PF) model of rat with transection of the splenic duct and surrounding pancreatic parenchyma. Multilayered fibroblast sheets prepared from tails were autologously transplanted to this model. The preventive effect was biochemically and histologically evaluated by measuring the ascitic levels of pancreatic enzymes and conducting immunohistochemistry and real-time polymerase chain reaction analyses of pancreatic tissue. Findings were compared to those obtained with acellular materials simply sealing the wound. RESULTS In the PF model, the ascitic levels of pancreatic enzymes were transiently up-regulated. Inflammation and necrosis were histologically observed in a wide range. Islets were damaged even in remote areas. Transplantation of multilayered fibroblast sheets dramatically reduced the ascitic leakage of enzymes, suppressed inflammation, and broadly preserved the islets. Compared with acellular materials, these sheets offered superior prevention of cellular activity through the spaciotemporal regulation of fibrosis and angiogenesis. Notably, the leakage hole appeared to have been plugged with the fibrotic matrix, which might have been the most crucial mechanism minimizing pancreatic damage. CONCLUSIONS The autologous transplantation of multilayered fibroblast sheets significantly prevented PF and protected the pancreas, underscoring the potential utility of this approach for POPF prevention.
Collapse
Affiliation(s)
- Keisuke Iwamoto
- Department of Surgery and Clinical Science, Yamaguchi University Graduate School of MedicineYamaguchi, Japan
| | - Toshiro Saito
- Department of Surgery and Clinical Science, Yamaguchi University Graduate School of MedicineYamaguchi, Japan
| | - Yoshihiro Takemoto
- Department of Surgery and Clinical Science, Yamaguchi University Graduate School of MedicineYamaguchi, Japan
| | - Koji Ueno
- Department of Surgery and Clinical Science, Yamaguchi University Graduate School of MedicineYamaguchi, Japan
| | - Masashi Yanagihara
- Department of Surgery and Clinical Science, Yamaguchi University Graduate School of MedicineYamaguchi, Japan
| | - Tomoko Furuya-Kondo
- Department of Molecular Pathology, Yamaguchi University Graduate School of MedicineYamaguchi, Japan
| | - Hiroshi Kurazumi
- Department of Surgery and Clinical Science, Yamaguchi University Graduate School of MedicineYamaguchi, Japan
| | - Yuya Tanaka
- Department of Surgery and Clinical Science, Yamaguchi University Graduate School of MedicineYamaguchi, Japan
| | - Yohei Taura
- Department of Surgery and Clinical Science, Yamaguchi University Graduate School of MedicineYamaguchi, Japan
| | - Eijiro Harada
- Department of Surgery and Clinical Science, Yamaguchi University Graduate School of MedicineYamaguchi, Japan
| | - Kimikazu Hamano
- Department of Surgery and Clinical Science, Yamaguchi University Graduate School of MedicineYamaguchi, Japan
| |
Collapse
|
24
|
Uranues S, Fingerhut A, Belyaev O, Zerbi A, Boggi U, Hoffmann MW, Reim D, Esposito A, Primavesi F, Kornprat P, Coppola R, Fragulidis GP, Serradilla-Martin M, Alimoglu O, Peri A, Diaconescu B. Clinical Impact of Stump Closure Reinforced With Hemopatch on the Prevention of Clinically Relevant Pancreatic Fistula After Distal Pancreatectomy: A Multicenter Randomized Trial. ANNALS OF SURGERY OPEN 2021; 2:e033. [PMID: 37638240 PMCID: PMC10455066 DOI: 10.1097/as9.0000000000000033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 12/24/2020] [Indexed: 01/02/2023] Open
Abstract
Introduction Postoperative pancreatic fistula (POPF) is the most dreaded complication after distal pancreatectomy (DP). This multicenter randomized trial evaluated the efficacy, safety, and tolerance of Hemopatch in preventing clinically relevant (grades B/C according to the ISGPS classification) POPF after DP. Material and methods After stump closure, patients were randomized to affix Hemopatch to the stump or not. Statistical significance was set at 0.025. Clinical significance was defined as the number of patients needed to treat (NNT) to avoid 1 B/C POPF. Results Of 631 eligible patients, 360 were randomized and 315 analyzed per protocol (155 in the standard closure group; 160 in the Hemopatch group). The rates of B/C POPF (the primary endpoint) were 23.2% and 16.3% (P = 0.120), while the number of patients with 1 or more complications (including patients with B/C POPF) was 34.8% and 24.4% (P = 0.049) in the standard and Hemopatch groups, respectively. In patients with hand-sewn stump and main duct closure, the rates were 26.2% versus 10.0% (P = 0.014) and 23.3% versus 7.7% (P = 0.015) in the standard and Hemopatch groups, respectively. The NNT in these 2 subgroups was 6 and 6.4, respectively. Conclusion The results of the first randomized trial evaluating Hemopatch-reinforced pancreatic stump after DP to prevent type B/C POPF do not allow us to conclude that the risk of B/C POPF was lower. Based on the NNT, however, routine use of Hemopatch after DP may result in fewer complications (including POPF) overall, especially in cases with hand-sewn closure of the pancreatic stump or main pancreatic duct.
Collapse
Affiliation(s)
- Selman Uranues
- From the Section for Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Abraham Fingerhut
- From the Section for Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Minimally Invasive Surgery Center, Shanghai, P. R. China
| | - Orlin Belyaev
- Klinik für Allgemein- und Viszeralchirurgie St. Josef-Hospital, Bochum, Germany
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano (MI), Italy Humanitas University, Pieve Emanuele (MI), Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Matthias W. Hoffmann
- Department of General and Visceral Surgery, Raphaelsklinik Münster, Münster, Germany
| | - Daniel Reim
- Klinik und Poliklinik für Chirurgie, Klinikum Rechts der Isar, Technische Universität München, München, Germany
| | - Alessandro Esposito
- Department of General and Pancreatic Surgery—Pancreas Institute, University of Verona, Verona Hospital Trust, Verona, Italy
| | - Florian Primavesi
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
- Department of Surgery, Salzkammergut-Klinikum, Vöcklabruck, Austria
| | - Peter Kornprat
- Clinical Division of General, Visceral and Transplantation Surgery, Medical University of Graz, Austria
| | - Roberto Coppola
- Department of Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | - Georgio P. Fragulidis
- 2nd Department of Surgery “Aretaieio” Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Mario Serradilla-Martin
- Department of Surgery, Instituto de Investigación Sanitaria Aragón, Miguel Servet University Hospital, Zaragoza, Spain
| | - Orhan Alimoglu
- Department of General Surgery, Faculty of Medicine, Istanbul Medeniyet University Goztepe Training & Research Hospital, Istanbul, Turkey
| | - Andrea Peri
- General Surgery, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Bogdan Diaconescu
- Anatomy Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| |
Collapse
|
25
|
Vuorela T, Mustonen H, Kokkola A, Haglund C, Seppanen H. Impact of pasireotide on postoperative pancreatic fistulas following distal resections. Langenbecks Arch Surg 2021; 406:735-742. [PMID: 33474568 PMCID: PMC8106579 DOI: 10.1007/s00423-021-02083-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 01/07/2021] [Indexed: 11/28/2022]
Abstract
Purpose Postoperative pancreatic fistula (POPF), a difficult complication after surgery, can cause peripancreatic fluid collection and infections in the operative area. In addition, pancreatic fluid is corrosive and can lead to postoperative bleeding. Clinically significant grade B and C fistulas (CR-POPF) increase postoperative morbidity, resulting in a prolonged hospital stay. Delaying adjuvant therapy due to fistula formation in cancer patients can affect their prognosis. In this study, we aimed to determine if pasireotide affects fistula formation, and the severity of other complications in patients following pancreatic distal resections. Data and methods Between 2000 and 2016, 258 distal pancreatectomies were performed at Helsinki University Hospital and were included in our analysis. Pasireotide was administered to patients undergoing distal resections between July 2014 and December 2016. Patients received 900-μg pasireotide administered twice daily perioperatively. Other patients who received octreotide treatment were analyzed separately. Complications such as fistulas (POPF), delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), reoperations, and mortality were recorded and analyzed 90 days postoperatively. Results Overall, 47 (18%) patients received pasireotide and 31 (12%) octreotide, while 180 patients (70%) who received neither constituted the control group. There were 40 (16%) clinically relevant grade B and C POPFs: seven (15%) in the pasireotide group, three (10%) in the octreotide group, and 30 (17%) in the control group (p = 0.739). Severe complications categorized as Clavien–Dindo grade III or IV were recorded in 64 (25%) patients: 17 (27%) in the pasireotide group, 4 (6%) in the octreotide group, and 43 (67%) in the control group (p = 0.059). We found no 90-day mortality. Conclusions In this study, pasireotide did not reduce clinically relevant POPFs or severe complications following pancreatic distal resection.
Collapse
Affiliation(s)
- Tiina Vuorela
- Department of Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
| | - H Mustonen
- Department of Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - A Kokkola
- Department of Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - C Haglund
- Department of Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.,Translational Cancer Medicine Research Program, Faculty of Medicine, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - H Seppanen
- Department of Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.,Translational Cancer Medicine Research Program, Faculty of Medicine, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| |
Collapse
|
26
|
Risk Factors for Clinically Relevant Postoperative Pancreatic Fistula (CR-POPF) after Distal Pancreatectomy: A Single Center Retrospective Study. Can J Gastroenterol Hepatol 2021; 2021:8874504. [PMID: 33542910 PMCID: PMC7840268 DOI: 10.1155/2021/8874504] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 11/15/2020] [Accepted: 01/07/2021] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Clinically relevant postoperative pancreatic fistula (CR-POPF) is the considerable contributor to major complications after pancreatectomy. The purpose of this study was to evaluate the potential risk factor contributing to CR-POPF following distal pancreatectomy (DP) and discuss the risk factors of pancreatic fistula in order to interpret the clinical importance. METHODS In this retrospective study, 263 patients who underwent DP at Ningbo Medical Center Li Huili Hospital between January 2011 and January 2020 were reviewed in accordance with relevant guidelines and regulations. Patients' demographics and clinical parameters were evaluated using univariate and multivariate analyses to identify the risk factors contributing to CR-POPF. P < 0.05 was considered statistically significant. RESULTS In all of the 263 patients with DP, pancreatic fistula was the most common surgical complication (19.0%). The univariate analysis of 18 factors showed that the patients with a malignant tumor, soft pancreas, and patient without ligation of the main pancreatic duct were more likely to develop pancreatic fistula. However, on multivariate analysis, the soft texture of the pancreas (OR = 2.381, 95% CI = 1.271-4.460, P=0.001) and the ligation of the main pancreatic duct (OR = 0.388, 95% CI = 0.207-0.726, P=0.002) were only an independent influencing factor for CR-POPF. CONCLUSIONS As a conclusion, pancreatic fistula was the most common surgical complication after DP. The soft texture of the pancreas and the absence of ligation of the main pancreatic duct can increase the risk of CR-POPF.
Collapse
|
27
|
Leon P, Giannone F, Belfiori G, Falconi M, Crippa S, Boggi U, Menonna F, Al Sadairi AR, Piardi T, Sulpice L, Gardini A, Sega V, Chirica M, Ravazzoni F, Giannandrea G, Pessaux P, de Blasi V, Navarro F, Panaro F. The Oncologic Impact of Pancreatic Fistula After Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma of the Body and the Tail: A Multicenter Retrospective Cohort Analysis. Ann Surg Oncol 2020; 28:3171-3183. [PMID: 33156465 DOI: 10.1245/s10434-020-09310-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/13/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The aim of this study was to assess the impact of clinically relevant postoperative pancreatic fistula (CR-POPF) on patient disease-specific survival and recurrence after curative distal pancreatectomy (DP) for pancreatic cancer. DESIGN This was a retrospective case-control analysis. METHODS We examined the data of adult patients with a diagnosis of pancreatic ductal adenocarcinoma (PDAC) of the body and tail of the pancreas undergoing curative DP, over a 10-year period in 12 European surgical departments, from a prospectively implemented database. RESULTS Among the 382 included patients, 283 met the strict inclusion criteria; 139 were males (49.1%) and the median age of the entire population was 70 years (range 37-88). A total of 121 POPFs were observed (42.8%), 42 (14.9%) of which were CR-POPFs. The median follow-up period was 24 months (range 3-120). Although poorer in the POPF group, overall survival (OS) and disease-free survival (DFS) did not differ significantly between patients with and without CR-POPF (p = 0.224 and p = 0.165, respectively). CR-POPF was not significantly associated with local or peritoneal recurrence (p = 0.559 and p = 0.302, respectively). A smaller percentage of patients benefited from adjuvant chemotherapy after POPF (76.2% vs. 83.8%), but the difference was not significant (p = 0.228). CONCLUSIONS CR-POPF is a major complication after DP but it did not affect the postoperative therapeutic path or long-term oncologic outcomes. CR-POPF was not a predictive factor for disease recurrence and was not associated with an increased incidence of peritoneal or local relapse. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT04348084.
Collapse
Affiliation(s)
- Piera Leon
- Department of Surgery/Division of HBP Surgery and Transplantation, "Saint Eloi" Montpellier University Hospital, Montpellier, France.
| | - Fabio Giannone
- Department of Surgery/Division of HBP Surgery and Transplantation, "Saint Eloi" Montpellier University Hospital, Montpellier, France
| | - Giulio Belfiori
- "San Raffaele" IRCCS Hospital, Università Vita - Salute, Milan, Italy
| | - Massimo Falconi
- "San Raffaele" IRCCS Hospital, Università Vita - Salute, Milan, Italy
| | - Stefano Crippa
- "San Raffaele" IRCCS Hospital, Università Vita - Salute, Milan, Italy
| | - Ugo Boggi
- "Cisanello" University Hospital, Pisa, Italy
| | | | | | | | | | | | | | | | | | | | | | - Vito de Blasi
- Hospital Centre of Luxembourg, Luxembourg City, Luxembourg
| | - Francis Navarro
- Department of Surgery/Division of HBP Surgery and Transplantation, "Saint Eloi" Montpellier University Hospital, Montpellier, France
| | - Fabrizio Panaro
- Department of Surgery/Division of HBP Surgery and Transplantation, "Saint Eloi" Montpellier University Hospital, Montpellier, France
| |
Collapse
|
28
|
Aoki T, Mansour DA, Koizumi T, Matsuda K, Kusano T, Wada Y, Hakozaki T, Tomioka K, Hirai T, Yamazaki T, Watanabe M, Otsuka K, Gahin AEA, Murakami M. Preventing clinically relevant pancreatic fistula with combination of linear stapling plus continuous suture of the stump in laparoscopic distal pancreatectomy. BMC Surg 2020; 20:223. [PMID: 33023558 PMCID: PMC7541328 DOI: 10.1186/s12893-020-00876-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 09/22/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Pancreatic fistula is one of the serious complications for patients undergoing distal pancreatectomy, which leads to significant morbidity. The aim of our study is to compare linear stapling closure plus continuous suture with linear stapling closure alone during laparoscopic distal pancreatectomy (LDP) in terms of clinically relevant postoperative pancreatic fistula (POPF) rate. METHODS Twenty-two patients underwent LDP at our institution between 2011 and 2013. Twelve patients had linear stapling closure with peri-firing compression (LSC) alone compared with ten patients who had linear stapling closure, peri-firing compression plus continuous suture (LSC/CS) for stump closure of remnant pancreas in LDP. Biochemical leak and clinically relevant POPF were compared between both groups. RESULTS POPF occurred in 4 of 12 (33.3%) patients with linear stapling closure while no patient developed a clinically relevant POPF in the triple combination of linear stapling, peri-firing compression plus continuous suture group (p = 0.043).1 patient (8.3%) in the LSC group and 5 patients (50%) in the LSC/CS group had evidence of a biochemical leak. There were no significant differences in operative time (188.3 vs 187.0 min) and blood loss (135 vs. 240 g) between both groups but there was a significantly of shorter length of hospital stay (11.9 vs. 19.9 days) in LSC/CS group (p = 0.037). There was no mortality in either group. CONCLUSIONS The triple combination of linear stapling, peri-firing compression plus continuous suture in LDP has effectively prevented occurrence of clinically relevant ISGPF POPF. TRIAL REGISTRATION The study was retrospectively registered September 30, 2019 at Showa University Ethics Committee as IRB protocol numbers 2943.
Collapse
Affiliation(s)
- Takeshi Aoki
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan.
| | - Doaa A Mansour
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
- General Surgery Department, Cairo University Hospitals, Kasr Alainy, Al-Saray street, El-Manial, Cairo, 11956, Egypt
| | - Tomotake Koizumi
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
| | - Kazuhiro Matsuda
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
| | - Tomokazu Kusano
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
| | - Yusuke Wada
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
| | - Tomoki Hakozaki
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
| | - Kodai Tomioka
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
| | - Takahito Hirai
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
| | - Tatsuya Yamazaki
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
| | - Makoto Watanabe
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
| | - Koji Otsuka
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
| | - Ahmed Elewa Abbas Gahin
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
- General Surgery Department, National Hepatology and Tropical Medicine Research Institute, 10. Kasr Alainy street, Cairo, 11562, Egypt
| | - Masahiko Murakami
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
| |
Collapse
|
29
|
Utilization of the Falciform Ligament to Buttress the Pancreatic Transection Staple Line: A Novel Technique. Surg Laparosc Endosc Percutan Tech 2020; 30:e39-e42. [PMID: 32941356 DOI: 10.1097/sle.0000000000000839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) remains a common complication after distal pancreatectomy and is a major source of operative morbidity. Although various mechanical, biological, and synthetic aids have been used to reduce the risk of POPF, none have a proven benefit. MATERIALS AND METHODS The authors describe (and present a video, Supplemental Digital Content 1, http://links.lww.com/SLE/A256) a novel technique in which the autologous falciform ligament was harvested, wrapped around the pancreas at the site of proposed pancreatic transection, and secured with sutures to buttress the pancreatic transection staple line. The pancreas was then transected with a triple-row stapler. RESULTS Two male patients aged 40 and 57 years each with a 4.3 and 4.2 cm solid mass in the body of the pancreas respectively underwent laparoscopic anterior radical antegrade modular pancreaticosplenectomy, the former patient underwent an en block transverse colectomy for suspected malignancy. Both patients had soft pancreata. They experienced no POPF, made an uneventful recovery, and were discharged from the hospital on the second and fourth postoperative days, respectively. No pancreatic complications were encountered at 5 and 6 months follow-up, respectively. CONCLUSIONS The use of the falciform ligament to buttress the staple line at the time of pancreatic transection is a novel technique. Its potential benefit in reducing the risk of POPF warrants further assessment.
Collapse
|
30
|
Song KB, Hong S, Kim HJ, Park Y, Kwon J, Lee W, Jun E, Lee JH, Hwang DW, Kim SC. Predictive Factors Associated with Complications after Laparoscopic Distal Pancreatectomy. J Clin Med 2020; 9:2766. [PMID: 32858997 PMCID: PMC7563868 DOI: 10.3390/jcm9092766] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 02/08/2023] Open
Abstract
Although laparoscopic distal pancreatectomy (LDP) has become more popular, the postoperative complication rate remains high. We sought to identify the risk factors for post-LDP complications. We examined 1227 patients who underwent LDP between March 2005 and December 2015 at a single large-volume center. We used logistic regression for the analysis. The overall (13.2%) and major (3.3%) complication rates were determined. Postoperative pancreatic fistula was the most frequent complication, and 58 patients (4.7%) had clinically significant (grade B) pancreatic fistulas. No 90-day mortality was recorded. Long operative time (≥200 min), large estimated blood loss (≥320 mL), LDP performed by an inexperienced surgeon (<50 cases), and concomitant splenectomy were identified as risk factors for overall complications using a logistic regression model. For major complications, male sex (p = 0.020), long operative time (p = 0.005), and LDP performed by an inexperienced surgeon (p = 0.026) were significant predictive factors. Using logistic regression analysis, surgery-related factors, including long operative time and LDP performed by an inexperienced surgeon, were correlated with overall and major complications of LDP. As LDP is a technically challenging procedure, surgery-related variables emerged as the main risk factors for postoperative complications. Appropriate patient selection and sufficient surgeon experience may be essential to reduce the complications of LDP.
Collapse
Affiliation(s)
- Ki Byung Song
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (K.B.S.); (S.H.); (Y.P.); (J.K.); (W.L.); (E.J.); (J.H.L.); (D.W.H.)
| | - Sarang Hong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (K.B.S.); (S.H.); (Y.P.); (J.K.); (W.L.); (E.J.); (J.H.L.); (D.W.H.)
| | - Hwa Jung Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea;
| | - Yejong Park
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (K.B.S.); (S.H.); (Y.P.); (J.K.); (W.L.); (E.J.); (J.H.L.); (D.W.H.)
| | - Jaewoo Kwon
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (K.B.S.); (S.H.); (Y.P.); (J.K.); (W.L.); (E.J.); (J.H.L.); (D.W.H.)
| | - Woohyung Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (K.B.S.); (S.H.); (Y.P.); (J.K.); (W.L.); (E.J.); (J.H.L.); (D.W.H.)
| | - Eunsung Jun
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (K.B.S.); (S.H.); (Y.P.); (J.K.); (W.L.); (E.J.); (J.H.L.); (D.W.H.)
| | - Jae Hoon Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (K.B.S.); (S.H.); (Y.P.); (J.K.); (W.L.); (E.J.); (J.H.L.); (D.W.H.)
| | - Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (K.B.S.); (S.H.); (Y.P.); (J.K.); (W.L.); (E.J.); (J.H.L.); (D.W.H.)
| | - Song Cheol Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (K.B.S.); (S.H.); (Y.P.); (J.K.); (W.L.); (E.J.); (J.H.L.); (D.W.H.)
| |
Collapse
|
31
|
Sullivan BJ, Leigh NL, Bekhor EY, Carpiniello M, Solomon D, Magge DR, Sarpel U, Golas BJ, Labow DM. Distal pancreatectomy in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: Identifying risk and improving patient selection. Am J Surg 2020; 220:1235-1241. [PMID: 32654767 DOI: 10.1016/j.amjsurg.2020.06.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 04/22/2020] [Accepted: 06/25/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has become a principal tool in the management of peritoneal carcinomatosis (PC), but inclusion of pancreatic resection to obtain optimal debulking remains controversial. METHODS We performed a retrospective review of 419 patients with PC who underwent CRS/HIPEC. The patients were divided into two cohorts, those with distal pancreatectomy (DP) and those without (NP), and morbidity and survival outcomes were compared. RESULTS The DP cohort (n = 37) and the NP cohort (n = 371) had similar clinicopathologic characteristics (age, p = 0.596; gender, p = 0.328; ASA, p = 0.072). Operative time, number of organs resected, and EBL were greater in the DP cohort (<0.0001). A complete cytoreduction was achieved in 90% of the NP cohort versus 69% of the DP cohort (p = 0.0004). Major perioperative morbidity was more common in those with pancreatic resection (41% vs 19%, p = 0.002). However, there was no significant difference in 90-day mortality or overall survival. CONCLUSION Achieving complete cytoreduction is critical to improving long term outcomes for patients with PC. Although pancreatic resections are associated with higher morbidity, short-term survival is not impacted adversely. Pancreatic involvement should not be a strict exclusion criterion for CRS/HIPEC, but patients need to be selected carefully, with close attention to disease burden prior to proceeding.
Collapse
Affiliation(s)
| | - Natasha L Leigh
- Division of Surgical Oncology, Mount Sinai St. Luke's Roosevelt, USA
| | - Eliahu Y Bekhor
- Division of Surgical Oncology, Mount Sinai St. Luke's Roosevelt, USA
| | | | - Daniel Solomon
- Division of Surgical Oncology, Mount Sinai St. Luke's Roosevelt, USA
| | - Deepa R Magge
- Division of Surgical Oncology, Mount Sinai St. Luke's Roosevelt, USA
| | - Umut Sarpel
- Division of Surgical Oncology, Mount Sinai St. Luke's Roosevelt, USA
| | - Benjamin J Golas
- Division of Surgical Oncology, Mount Sinai St. Luke's Roosevelt, USA
| | - Daniel M Labow
- Division of Surgical Oncology, Mount Sinai St. Luke's Roosevelt, USA
| |
Collapse
|
32
|
Miao Y, Lu Z, Yeo CJ, Vollmer CM, Fernandez-Del Castillo C, Ghaneh P, Halloran CM, Kleeff J, de Rooij T, Werner J, Falconi M, Friess H, Zeh HJ, Izbicki JR, He J, Laukkarinen J, Dejong CH, Lillemoe KD, Conlon K, Takaori K, Gianotti L, Besselink MG, Del Chiaro M, Montorsi M, Tanaka M, Bockhorn M, Adham M, Oláh A, Salvia R, Shrikhande SV, Hackert T, Shimosegawa T, Zureikat AH, Ceyhan GO, Peng Y, Wang G, Huang X, Dervenis C, Bassi C, Neoptolemos JP, Büchler MW. Management of the pancreatic transection plane after left (distal) pancreatectomy: Expert consensus guidelines by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2020; 168:72-84. [PMID: 32249092 DOI: 10.1016/j.surg.2020.02.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 02/11/2020] [Accepted: 02/18/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The aim was to evaluate the various operative techniques and outcomes used to manage the pancreatic transection plane (or stump) during a left (distal) pancreatectomy and to develop expert consensus guidelines. METHODS Evidence-based, clinically relevant questions were discussed and then were circulated among members of the International Study Group of Pancreatic Surgery. After agreement on the questions and statements, voting in a 9-point Likert scale was used to gauge the level of objective support for each. RESULTS Studies using the International Study Group of Pancreatic Surgery definition of postoperative pancreatic fistula including 16 randomized trials were reviewed to generate a series of statements set into 14 domains. There was strong consensus in the following statements: there was no difference in the postoperative pancreatic fistula rate after left pancreatectomy between the handsewn and stapler techniques; a stapling technique could not be used in all cases of left pancreatectomy; the use of an energy-based tissue sealant or a chemical sealant device or combinations of these did not impact the postoperative pancreatic fistula rate; there was no difference in the postoperative pancreatic fistula rate between the open, laparoscopic, or robotic approaches; and there are 1 or more clinically important, patient-related risk factors associated with the postoperative pancreatic fistula rate. There was weak or conditional agreement on the use of prophylactic somatostatin analogs, stents, stump closure, stump anastomosis, and the role of abdominal drains. CONCLUSION Areas of strong consensus suggests a change in clinical practice and priority setting. Eight domains with lower agreement will require novel approaches and large multicenter studies to determine future key areas of practice.
Collapse
Affiliation(s)
- Yi Miao
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China.
| | - Zipeng Lu
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | - Charles J Yeo
- Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Paula Ghaneh
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Christopher M Halloran
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Jörg Kleeff
- Department of Surgery, Martin-Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Thijs de Rooij
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jens Werner
- Department of General, Visceral, and Transplantation Surgery, Ludwig Maximilians-University, Munich, Germany
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, "Vita-Salute" University, Milan, Italy
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Herbert J Zeh
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jin He
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Cees H Dejong
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Keith D Lillemoe
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kevin Conlon
- Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland
| | - Kyoichi Takaori
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Luca Gianotti
- School of Medicine and Surgery, Milano - Bicocca University, and Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Marco Montorsi
- Humanitas University and Research Hospital IRCCS, Milan, Italy
| | - Masao Tanaka
- Shimonoseki City Hospital, Kyushu University, Shimonoseki, Yamaguchi, Japan
| | - Maximilian Bockhorn
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mustapha Adham
- Department of Digestive & HPB Surgery, Hospital Edouard Herriot, HCL, UCBL1, Lyon, France
| | | | - Roberto Salvia
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Shailesh V Shrikhande
- Department of Gastrointestinal and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Tooru Shimosegawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Amer H Zureikat
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Güralp O Ceyhan
- Department of General Surgery, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Yunpeng Peng
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | - Guangfu Wang
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | - Xumin Huang
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | | | - Claudio Bassi
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - John P Neoptolemos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| |
Collapse
|
33
|
Bashir MU, Kandilis A, Jackson NM, Parikh JA, Jacobs MJ. Distal pancreatectomy outcomes: Perspectives from a community-based teaching institution. Ann Hepatobiliary Pancreat Surg 2020; 24:156-161. [PMID: 32457260 PMCID: PMC7271100 DOI: 10.14701/ahbps.2020.24.2.156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 03/19/2020] [Accepted: 03/19/2020] [Indexed: 12/14/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Muhammad Umair Bashir
- Department of Surgery, Ascension Providence and Providence Park Hospitals, Michigan State University College of Human Medicine, Southfield, MI, USA
| | - Apostolos Kandilis
- Department of Surgery, Ascension Providence and Providence Park Hospitals, Michigan State University College of Human Medicine, Southfield, MI, USA
| | - Nancy M Jackson
- Department of Research, Ascension Providence and Providence Park Hospitals, Michigan State University College of Human Medicine, Southfield, MI, USA
| | - Janak A Parikh
- Department of Surgery, Ascension Providence and Providence Park Hospitals, Michigan State University College of Human Medicine, Southfield, MI, USA
| | - Michael J Jacobs
- Department of Surgery, Ascension Providence and Providence Park Hospitals, Michigan State University College of Human Medicine, Southfield, MI, USA
| |
Collapse
|
34
|
Demir E, Abdelhai K, Demir IE, Jäger C, Scheufele F, Schorn S, Rothe K, Friess H, Ceyhan GO. Association of bacteria in pancreatic fistula fluid with complications after pancreatic surgery. BJS Open 2020; 4:432-437. [PMID: 32297478 PMCID: PMC7260411 DOI: 10.1002/bjs5.50272] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 01/19/2020] [Accepted: 01/28/2020] [Indexed: 01/08/2023] Open
Abstract
Background Pancreatic fistula (PF) is a common complication after pancreatic surgery. It is unclear how microbes in PF fluid affect outcomes and which microbes are present after pancreatoduodenectomy (PD) and distal pancreatectomy (DP). The aim of this study was to compare the microbiological spectrum of PF fluid after PD versus DP, and its association with postoperative complications. Methods Bacterial strains and antibiotic resistance rates of bacterial swabs obtained from the PF fluid of patients who underwent DP or PD were analysed. Cultured bacteria were classified as Enterobacterales and as ‘other intestinal and non‐intestinal microorganisms’ based on whether they are typically part of the normal human intestinal flora. Results A total of 847 patients had a pancreatic resection (PD 600; DP 247) between July 2007 and December 2016. Clinically relevant PF was detected in 131 patients (15·5 per cent). Bacterial swabs were obtained from 108 patients (DP 47; PD 61), of which 19 (17·6 per cent) were sterile. Enterobacterales were detected in 74 per cent of PF fluid swabs after PD, and in 34 per cent after DP. Infected, polymicrobial or multidrug‐resistant PF fluid was more common after PD (rates of 95, 50 and 48 per cent respectively) than after DP (66, 26 and 6 per cent respectively). Patients with higher grade complications (Clavien–Dindo grade IV–V) or grade C PF had more Enterobacterales and multidrug‐resistant Enterobacterales in the PF fluid after
DP. Conclusion Enterobacterales and multidrug‐resistant bacteria are detected frequently after PD and DP, and are associated with more severe complications and PF in patients undergoing
DP.
Collapse
Affiliation(s)
- E Demir
- Department of Surgery, Munich, Germany
| | | | - I E Demir
- Department of Surgery, Munich, Germany.,Hepato-Pancreato-Biliary Unit, Department of General Surgery, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| | - C Jäger
- Department of Surgery, Munich, Germany
| | | | - S Schorn
- Department of Surgery, Munich, Germany
| | - K Rothe
- Institute for Microbiology, Immunology and Hygiene, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - H Friess
- Department of Surgery, Munich, Germany
| | - G O Ceyhan
- Department of Surgery, Munich, Germany.,Hepato-Pancreato-Biliary Unit, Department of General Surgery, Acibadem Mehmet Ali Aydinlar University School of Medicine, Istanbul, Turkey
| |
Collapse
|
35
|
Nishikawa M, Yamamoto J, Hoshikawa M, Einama T, Noro T, Aosasa S, Tsujimoto H, Ueno H, Kishi Y. Stapler sizes optimized for pancreatic thickness can reduce pancreatic fistula incidence after distal pancreatectomy. Surg Today 2019; 50:623-631. [DOI: 10.1007/s00595-019-01929-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 11/18/2019] [Indexed: 12/19/2022]
|
36
|
Ratnayake CBB, Wells C, Hammond J, French JJ, Windsor JA, Pandanaboyana S. Network meta-analysis comparing techniques and outcomes of stump closure after distal pancreatectomy. Br J Surg 2019; 106:1580-1589. [PMID: 31626341 DOI: 10.1002/bjs.11291] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 04/27/2019] [Accepted: 05/30/2019] [Indexed: 01/04/2025]
Abstract
BACKGROUND The incidence of postoperative pancreatic fistula (POPF) after distal pancreatectomy remains high, and different pancreatic stump closure techniques have been used to reduce the incidence. A network meta-analysis was undertaken to compare the most frequently performed pancreatic stump closure techniques after distal pancreatectomy and determine the technique associated with the lowest POPF rate. METHODS A systematic search of the Scopus, PubMed, MEDLINE and Embase databases was conducted to identify eligible RCTs. The primary outcome was the occurrence of clinically relevant POPF. Secondary outcomes were duration of operation, blood loss, intrabdominal collections, postoperative complications and 30-day mortality. RESULTS Sixteen RCTs including 1984 patients and eight different pancreatic stump closure techniques were included in the network meta-analysis. Patch coverage of the pancreatic stump (round ligament or seromuscular patch) after stapler or suture closure ranked best, with the lowest rates of clinically relevant POPF, lowest volume of intraoperative blood loss, fewer intra-abdominal abscesses, and lower rates of overall complications and 30-day mortality. Round ligament patch closure outperformed seromuscular patch closure in preventing clinically relevant POPF with a significantly larger cohort for comparative analysis. Pancreaticoenteric anastomotic closure consistently ranked poorly for most reported postoperative outcomes. CONCLUSION Patch coverage after stapler or suture closure has the lowest POPF rate and best outcomes among stump closure techniques after distal pancreatectomy.
Collapse
Affiliation(s)
- C B B Ratnayake
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Hepatopancreatobiliary Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - C Wells
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Hepatopancreatobiliary Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - J Hammond
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - J J French
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - J A Windsor
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Hepatopancreatobiliary Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand
| | - S Pandanaboyana
- Hepatopancreatobiliary and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK
| |
Collapse
|
37
|
Yoshida Y, Matsumoto I, Matsumoto M, Kawaguchi K, Murase T, Kamei K, Satoi S, Takebe A, Nakai T, Takeyama Y. Transpancreatic mattress suture with Vicryl mesh around the stump decreases postoperative pancreatic fistula after distal pancreatectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2019; 26:510-516. [DOI: 10.1002/jhbp.664] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Yuta Yoshida
- Department of Surgery Faculty of Medicine Kindai University 377‐2 Ohno‐higashi Osakasayama Osaka 589‐8511 Japan
| | - Ippei Matsumoto
- Department of Surgery Faculty of Medicine Kindai University 377‐2 Ohno‐higashi Osakasayama Osaka 589‐8511 Japan
| | - Masataka Matsumoto
- Department of Surgery Faculty of Medicine Kindai University 377‐2 Ohno‐higashi Osakasayama Osaka 589‐8511 Japan
| | - Kohei Kawaguchi
- Department of Surgery Faculty of Medicine Kindai University 377‐2 Ohno‐higashi Osakasayama Osaka 589‐8511 Japan
| | - Takaaki Murase
- Department of Surgery Faculty of Medicine Kindai University 377‐2 Ohno‐higashi Osakasayama Osaka 589‐8511 Japan
| | - Keiko Kamei
- Department of Surgery Faculty of Medicine Kindai University 377‐2 Ohno‐higashi Osakasayama Osaka 589‐8511 Japan
| | - Shumpei Satoi
- Department of Surgery Faculty of Medicine Kindai University 377‐2 Ohno‐higashi Osakasayama Osaka 589‐8511 Japan
| | - Atsushi Takebe
- Department of Surgery Faculty of Medicine Kindai University 377‐2 Ohno‐higashi Osakasayama Osaka 589‐8511 Japan
| | - Takuya Nakai
- Department of Surgery Faculty of Medicine Kindai University 377‐2 Ohno‐higashi Osakasayama Osaka 589‐8511 Japan
| | - Yoshifumi Takeyama
- Department of Surgery Faculty of Medicine Kindai University 377‐2 Ohno‐higashi Osakasayama Osaka 589‐8511 Japan
| |
Collapse
|
38
|
Kaiser J, Niesen W, Probst P, Bruckner T, Doerr-Harim C, Strobel O, Knebel P, Diener MK, Mihaljevic AL, Büchler MW, Hackert T. Abdominal drainage versus no drainage after distal pancreatectomy: study protocol for a randomized controlled trial. Trials 2019; 20:332. [PMID: 31174583 PMCID: PMC6555976 DOI: 10.1186/s13063-019-3442-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 05/13/2019] [Indexed: 12/19/2022] Open
Abstract
Background The placement of prophylactic intra-abdominal drains has been common practice in abdominal operations including pancreatic surgery. The PANDRA trial showed that the omission of drains following pancreatic head resection was non-inferior to intra-abdominal drainage in terms of postoperative reinterventions and superior in terms of clinically relevant pancreatic fistula rate and fistula-associated complications. The aim of the present PANDRA II trial is to evaluate the clinical outcome with versus without prophylactic drain placement after distal pancreatectomy. Methods The PANDRA II trial is a mono-center, randomized controlled, non-inferiority trial with two parallel study groups. In the control group at least one passive intra-abdominal drain is placed at the pancreatic resection margin. In the experimental group no drains are placed. The primary endpoint of this trial will be the Comprehensive Complication Index (CCI) measuring all postoperative complications within 90 days. Secondary endpoints are in-hospital mortality and morbidity, including the rates of postoperative pancreatic fistula, chyle leak, postpancreatectomy hemorrhage, delayed gastric emptying, reinterventions and reoperations, surgical site infection, and abdominal fascia dehiscence. Moreover, length of hospital stay, duration of intensive care unit stay, and the rate of readmission after discharge from hospital (up to day 90 after surgery) are assessed. We will need to analyze 252 patients to test the hypothesis that no drainage is non-inferior to drain placement in terms of the CCI (δ 7.5 points) in a one-sided t test with a one-sided level of significance of 2.5% and a power of 80%. Discussion The results of the PANDRA II trial will help to evaluate the effect of an omission of prophylactic intraperitoneal drainage on the rate of complications after open or minimally invasive distal pancreatectomy. Trial registration German Clinical Trials Register (DRKS), DRKS00013763. Registered on 6 March 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3442-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Joerg Kaiser
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Willem Niesen
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Colette Doerr-Harim
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Phillip Knebel
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - André L Mihaljevic
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
| |
Collapse
|