The impact of perioperative inotropes on the incidence of pancreatic leak following pancreaticoduodenectomy

A Simple Classification of Pancreatic Duct Size and Texture Predicts Postoperative Pancreatic Fistula: A classification of the International Study Group of Pancreatic Surgery

OBJECTIVE

The aim of this study was to develop a classification system for pancreas-associated risk factors in pancreatoduodenectomy (PD).

SUMMARY BACKGROUND DATA

Postoperative pancreatic fistula (POPF) is the most relevant PD-associated complication. A simple standardized surgical reporting system based on pancreas-associated risk factors is lacking.

METHODS

A systematic literature search was conducted to identify studies investigating clinically relevant (CR) POPF (CR-POPF) and pancreas-associated risk factors after PD. A meta-analysis of CR-POPF rate for texture of the pancreas (soft vs not-soft) and main pancreatic duct (MPD) diameter was performed using the Mantel-Haenszel method. Based on the results, the International Study Group of Pancreatic Surgery (ISGPS) proposes the following classification: A, not-soft (hard) texture and MPD >3 mm; B, not-soft (hard) texture and MPD ≤3 mm; C, soft texture and MPD >3 mm; D, soft texture and MPD ≤3 mm. The classification was evaluated in a multi-institutional, international cohort.

RESULTS

Of the 2917 articles identified, 108 studies were included in the analyses. Soft pancreatic texture was significantly associated with the development of CR-POPF [odds ratio (OR) 4.24, 95% confidence interval (CI) 3.67-4.89, P < 0.01) following PD. Similarly, MPD diameter ≤3 mm significantly increased CR-POPF risk compared with >3 mm diameter MPDs (OR 3.66, 95% CI 2.62-5.12, P < 0.01). The proposed 4-stage system was confirmed in an independent cohort of 5533 patients with CR-POPF rates of 3.5%, 6.2%, 16.6%, and 23.2% for type A-D, respectively ( P < 0.001).

CONCLUSION

For future pancreatic surgical outcomes studies, the ISGPS recommends reporting these risk factors according to the proposed classification system for better comparability of results.

A comparative study on analgesic and non-analgesic outcomes of inter pleural analgesia compared to thoracic epidural analgesia in open pancreatico-duodenectomy

Backgrounds/Aims

Thoracic epidural analgesia (TEA) is an established analgesic method in open Kausch-Whipple pancreaticoduodenectomy (KWPD). Although, it can cause hemodynamic instability and neurological complications. Inter pleural analgesia (IPA) is an alternative option. We aim to evaluate the effectiveness of IPA versus TEA after KWPD.

Methods

We retrospectively studied the efficacy of IPA against TEA in patients, operated by a single surgeon. The primary outcome was the analgesic efficacy and secondary outcomes were analgesia-related complications, inotrope use, and duration.

Results

Forty patients (TEA, 22; IPA, 18) were included. Both groups were well matched for patient characteristics, type, and duration of surgery. TEA was associated with higher analgesia-related complications (n = 8, 36.4% vs. n = 1, 5.6%; p = 0.027). TEA complications included analgesia not working (n = 4), leakage (n = 2), refractory hemodynamic instability (n = 1), and lower limb anaesthesia (n = 1). One patient in the IPA group encountered leakage. TEA was associated with longer inotrope requirement (35 vs. 18 hours; p = 0.047). There was no significant difference in intensive care unit (ITU) admission rate (81.8% vs. 77.8%; p > 0.999), median ITU stay (3 vs. 2 days, p = 0.385), or hospital stay (11 days in both groups).

Conclusions

In open KWPD, IPA is not inferior to TEA in its efficacy of pain control. IPA was associated with less analgesia-related complications and shorter inotrope requirements. However, this was a small retrospective study. Larger randomized controlled trials are needed to study the effectiveness of IPA.