Risk factors for postoperative pancreatic fistula in patients with insulinomas: analysis of 292 consecutive cases

Comparative pharmacokinetics of seven bioactive components in normal, sham-operated, and myocardial ischemia-reperfusion injury rats after oral administration of the Salvia Miltiorrhiza-Moutan Cortex herb pair

Recently the Salvia Miltiorrhiza-Moutan Cortex (SM-MC) herb pair is considered as a promising Chinese medicinal mixture exhibiting a range of pharmacological activities, including treating cardiovascular disease due to its unique composition. In this study, we conducted the comparative pharmacokinetic analysis of seven main bioactive components of SM-MC in a different model rat. A straightforward ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) strategy that could simultaneously evaluate the levels of seven compounds was used to ensure the reliability of these pharmacokinetic analyses in rat plasma. The rat plasma samples were collected from normal, sham-operated, and myocardial ischemia-reperfusion injury (MIRI) groups at predetermined time points after the administration of SM-MC. The main pharmacokinetic parameters were detected and calculated. We successfully assessed the maximum concentration (C_max ), time to C_max (T_max ), the elimination rate constant (λ_z ), total half-life (t_1/2 ), total body clearance (CL), and the area under the concentration-time curve from 0 to last sampling time (AUC_0-t ) and extrapolated to infinity (AUC_0-∞ ). To sum up, an optimized UPLC-MS/MS approach that could be used to rapidly, simultaneously, and sensitively detect seven bioactive compounds derived from SM-MC extract preparations was successfully developed, which may offer a pharmacokinetic basis for preclinical and clinical studies of SM-MC herb pair for treating MIRI.

Modified Blumgart anastomosis without pancreatic duct-to-jejunum mucosa anastomosis for pancreatoduodenectomy: a feasible and safe novel technique

Objective

This study proposed a modified Blumgart anastomosis (m-BA) that uses a firm ligation of the main pancreatic duct with a supporting tube to replace the pancreatic duct-to-jejunum mucosa anastomosis, with the aim of simplifying the complicated steps of the conventional BA (c-BA). Thus, we observe if a difference in the risk of postoperative pancreatic fistula (POPF) exists between the two methods.

Methods

The m-BA anastomosis method has been used since 2010. From October 2011 to October 2015, 147 patients who underwent pancreatoduodenectomy (PD) using BA in Tianjin Medical University Cancer Institute and Hospital were enrolled in this study. According to the type of pancreatojejunostomy (PJ), 50 patients underwent m-BA and 97 received c-BA. The two patient cohorts were compared prospectively to some extent but not randomized, and the evaluated variables were operation time, the incidence rate of POPF, and other perioperative complications.

Results

The operation time showed no significant difference (P > 0.05) between the two groups, but the time of duct-to-mucosa anastomosis in the m-BA group was much shorter than that in the c-BA group ( P < 0.001). The incidence rate of clinically relevant POPF was 12.0% (6/50) in the modified group and 10.3% (10/97) in the conventional group ( P > 0.05), which means that the modified anastomosis method did not cause additional pancreatic leakage. The mean length of postoperative hospital stay of the m-BA group was 23 days, and that of the c-BA group was 22 days ( P > 0.05).

Conclusions

Compared with the conventional BA, we suggest that the modified BA is a feasible, safe, and effective operation method for P J of PD with no sacrifice of surgical quality. In the multivariate analysis, we also found that body mass index (≥ 25 kg/m²) increased the risk of POPF.

Diagnosis and surgical management of insulinomas in 33 consecutive patients at a single institution

PURPOSE

The purpose of this study was to evaluate the diagnosis and surgical management of insulinomas in a single-center setting.

METHODS

Demographic details, clinical presentation, preoperative diagnosis, surgical strategy, and outcomes of 33 consecutive patients who underwent surgery for insulinoma were analyzed retrospectively.

RESULTS

The median time from the first onset of symptoms to diagnosis was 24 months (range 3 days to 50 years). All cases presented with Whipple's triad and had a fasting insulin to glucose ratio higher than 0.33. The preoperative detection rates of transabdominal ultrasonography, CT, MRI, and EUS were 22 % (2/9), 72 % (23/32), 75 % (9/12), and 80 % (4/5), respectively. Intraoperative manual palpation localized all cases. Enucleation was performed in 58 % of cases (19/33), partial pancreatic resection in 39 % (13/33), and enucleation plus partial resection in 3 % (1/33). Pancreatic fistula was the most common complication and occurred in 15 patients (45 %), including seven grade A, five grade B, and three grade C fistulas. There was no mortality. When compared with partial pancreatectomy, enucleation held a significant advantage in operative time and operative bleeding, with no significant differences in demographic data and postoperative complications. During a median follow-up period of 32 months, two patients were lost to follow-up and the remaining 31 patients were without evidence of recurrence.

CONCLUSIONS

A fasting insulin release index larger than 0.3 is a reliable indicator for the diagnosis of insulinoma. Intraoperative palpation by an experienced surgeon can effectively complement an uncertain preoperative localization. Compared with partial pancreatic resection, enucleation showed significant benefit in terms of intraoperative blood loss and operation time.

Propensity score-matched analysis of robotic versus open surgical enucleation for small pancreatic neuroendocrine tumours

BACKGROUND

Enucleation of pancreatic neuroendocrine tumours (pNETs) via robotic surgery has rarely been described. This study sought to assess the safety and efficiency of robotic surgery for the enucleation of small pNETs.

METHODS

A comparison was conducted of enucleation of pNETs smaller than 2 cm by robotic or open surgery between January 2000 and May 2015. Propensity score matching was used to balance sex, age, BMI, tumour location and tumour diameter. Pathological results, safety-related outcomes (postoperative pancreatic fistula (POPF) rate, estimated blood loss, and short-term mortality and morbidity) and efficiency-related outcomes (duration of surgery and postoperative length of hospital stay) were compared between the groups.

RESULTS

A cohort of 120 patients with pNET were enrolled in the study (1 : 1 matched for open or robotic surgery, 60 per group). Ninety-three patients (77·5 per cent) had a grade 1 tumour and 114 (95·0 per cent) had an insulinoma. Robotic surgery had a conversion rate of 5 per cent (3 of 60), and was not associated with an increased POPF rate (10 per cent versus 17 per cent after open surgery; P = 0·283) or grade III-V surgical complications according to the Dindo-Clavien classification (3 versus 10 per cent respectively; P = 0·272). Estimated blood loss was reduced with the robotic approach (32·5 versus 80·0 ml in the open group; P = 0·008), as was duration of surgery (117 versus 150 min; P < 0·001). Length of hospital stay after surgery was similar in the two groups (12·0 versus 13·5 days respectively; P = 0·071).

CONCLUSION

Robotic surgery for enucleation of pNETs smaller than 2 cm did not increase POPF or major complication rates, and reduced the duration of surgery and estimated blood loss, compared with open surgery.

REGISTRATION NUMBER

NCT02125929 ( https://www.clinicaltrials.gov/).

The Effect of Body Mass Index on Surgical Outcomes in Patients Undergoing Pancreatic Resection: A Systematic Review and Meta-Analysis

OBJECTIVES

Previous studies that investigated the association between body mass index (BMI) and pancreatectomy outcomes have produced conflicting conclusions. We conducted this meta-analysis to assess the association between them.

METHODS

We searched PubMed, EMBASE, and Cochrane Library databases up to December 28, 2014. Patients were divided into high-BMI group (BMI ≥ 25 kg/m) and normal-BMI group (BMI < 25 kg/m). Postoperative and intraoperative outcomes were evaluated. Meta-regression and subgroup analysis were performed to evaluate any factors accountable for the heterogeneity. Meta-analysis was performed using a random-effect model.

RESULTS

We included 22 studies involving 8994 patients. Patients in the high-BMI group had significantly increased postoperative pancreatic fistula rate (odds ratio [OR],1.96; 95% confidence interval [CI], 1.43-2.67), delayed gastric emptying rate (OR, 1.62; 95% CI, 1.15-2.29), wound infection rate (OR, 1.43; 95% CI, 1.07-1.93), operation time (mean difference [MD],15; 95% CI, 13.40-16.60), blood loss (MD, 270.71; 95% CI, 248.93-292.49), and length of hospital stay (MD, 2.87; 95% CI, 1.51-4.24). For modest heterogeneity in postoperative pancreatic fistula, regional distribution tended to be the contributor.

CONCLUSIONS

High BMI not only increased the surgical difficulty but also decreased the surgical safety for pancreatectomy.

Duct-to-Mucosa vs Invagination for Pancreaticojejunostomy after Pancreaticoduodenectomy: A Prospective, Randomized Controlled Trial from a Single Surgeon

BACKGROUND

Pancreatic fistula (PF) is the most common significant complication after pancreaticoduodenectomy. Invagination and duct-to-mucosa anastomoses are anastomotic techniques that are commonly performed after pancreaticoduodenectomy. There are conflicting data on invagination vs duct-to-mucosa anastomoses about which is superior for minimizing the risk of PF. In addition, all previous studies involved multiple operating surgeons and failed to control for variation in surgeon expertise.

STUDY DESIGN

This was a randomized controlled study comparing the outcomes of PD between patients who underwent invagination vs those who had duct-to-mucosa anastomoses. All 132 patients were operated on between October 2012 and March 2015 by a single surgeon experienced in both procedures. Pancreatic fistula was the main end point.

RESULTS

Overall and clinically relevant rates of PF rate were 29.5% and 10.6%, respectively. Overall PF rates in the patients treated with invagination vs duct-to-mucosa anastomoses were 30.9% vs 28.5% (p = 0.729), respectively and the corresponding clinically relevant PF rates were 17.6% vs 3.1%, respectively (p = 0.004). Although the overall complication rates were similar in the 2 groups, severe complications were significantly more frequent in the patients treated with invagination (p = 0.013). Duct-to-mucosa anastomosis was also associated with shorter postoperative hospital stay (13 vs 15 days; p = 0.021). There was one perioperative death. Independent variables for the risk of PF were the diameter of the pancreatic duct (greater risk with smaller diameter), the underlying pathology, and male sex.

CONCLUSIONS

Both methods yield similar overall rates for PF, but the rate of clinically relevant PF is lower in patients treated with duct-to-mucosa anastomosis. Additional single-surgeon studies or multi-institution randomized trials controlling for comparable expertise in both procedures should be conducted to confirm these results.

Laparoscopic versus open enucleation for pancreatic neoplasms: clinical outcomes and pancreatic function analysis

BACKGROUND

The studies comparing laparoscopic enucleation (LE) with open enucleation (OE) are limited. This study aimed to compare perioperative outcomes of patients undergoing LE and OE and to assess the pancreatic function after LE.

METHODS

Between February 2001 and July 2014, patients who underwent enucleation were reviewed. Patients were divided into two groups as LE and OE. Data considered for comparison analysis were patient demographics, intraoperative variables, morbidity, postoperative hospital stay, mortality, pathologic findings, and long-term follow-up (including pancreatic function).

RESULTS

Thirty-seven patients (15 LE and 22 OE) were included in the final analysis. Baseline characteristics were similar in the two groups. LE group showed significantly shorter operating time (118.2 ± 33.1 vs. 155.2 ± 44.3 min, p = 0.009), lower estimated blood loss (80.0 ± 71.2 vs. 195.5 ± 103.4 ml, p = 0.001), shorter first flatus time (1.8 ± 1.0 vs. 3.4 ± 1.8 days, p = 0.004), shorter diet start time (2.4 ± 1.0 vs. 4.4 ± 2.0 days, p = 0.001), shorter postoperative hospital stay (7.9 ± 3.4 vs. 11.2 ± 5.7 days, p = 0.046). Postoperative outcomes, including morbidity (40.0 vs. 45.5 %, p = 1.000), grade B/C pancreatic fistula rates (20.0 vs. 13.6 %, p = 0.874), and mortality, were similar in the two groups. The median follow-up period was 47 months (range 7-163 months). No local recurrence or distant metastasis was detected in either group. Only one patient (4.8 %) underwent OE developed new-onset diabetes, in comparison with none in the LE group. One patient (7.1 %) had weight loss and received pancreatic enzyme supplementation in the LE group, in comparison with two patients (9.5 %) in the OE group.

CONCLUSIONS

LE is a safe and feasible technique for the benign or low malignant-potential pancreatic neoplasms. Compared to OE, LE had shorter operating time, lower estimated blood loss, and faster recovery. LE could preserve the pancreatic function as the OE.

Enucleation of pancreatic lesions: indications, outcomes, and risk factors for clinical pancreatic fistula

BACKGROUND

There are few large samples and single-center series that focus on the outcomes of pancreatic enucleation and risk factors for clinical pancreatic fistula (PF). This study aimed to evaluate the indications, short- and long-term results, and risk factors for clinical PF after pancreatic enucleation.

METHODS

Patients who underwent pancreatic enucleation from January 2005 to April 2011 at the Peking Union Medical College Hospital in China were included. Clinical data were collected and analyzed.

RESULTS

A total of 119 patients underwent enucleation. PF was the most common complication; the incidence of clinical PF (grades B and C) was 27.7 %. The most common indications were endocrine neoplasms (76.5 %). During a median follow-up of 41 months, no patient developed exocrine insufficiency. Three elderly patients developed non-insulin-dependent diabetes mellitus. One patient with VIPoma developed recurrence and liver metastasis. New York Heart Association (NYHA) class II or III (P = 0.009; hazard ratio (HR) 3.191; 95 % confidence interval (CI) 1.334-7.632), operative time ≥180 min (P = 0.025; HR 2.664; 95 % CI 1.112-6.386) were the independent risk factors for clinical PF.

CONCLUSION

Enucleation is a safe and effective treatment for benign and low malignant lesions of the pancreas. NYHA class II or III and operation time of ≥180 min are independent risk factors for clinical PF.

[Chinese herbal medicine Fuzheng Huayu recipe inhibits liver fibrosis by mediating the transforming growth factor-β1/Smads signaling pathway]

OBJECTIVE

To investigate the mechanism of Fuzheng Huayu recipe (FZHY), a compound traditional Chinese herbal medicine, against liver fibrosis related to transforming growth factor-β1 (TGF-β1)/Smads signaling transduction.

METHODS

The research consisted of in vitro and in vivo experiments. In the in vivo experiment, 37 male Wistar rats were divided into 3 groups: 5 rats in normal group, 18 and 14 rats respectively in model and FZHY groups. Liver fibrosis was induced in rats of the model group and the FZHY group by intraperitoneal injection of dimethylnitrosamine with a dose of 10μg/kg body weight for 4 weeks. Rats in the FZHY group were administered with FZHY for 4 weeks after liver fibrosis was induced. After the treatment of FZHY, hydroxyproline (Hyp) content in rat liver tissue was assayed by Jamall's method and protein expressions of TGF-β1, TGF-β1 receptor I (TβR-I), Smad2, Smad3 and phosphorylated-Smad2/3 were analyzed by Western blotting. In the in vitro experiment, hepatic stellate cells (HSCs) were isolated from normal rats by in situ pronase/collagenase perfusion followed by density gradient centrifugation. On the 4th day of cell culture, HSCs were stimulated by 2.5 ng/mL TGF-β1 for 24 h, then incubated with the medium containing 10% FZHY-medicated serum or 10μmol/L SB-431542 (a potent and specific inhibitor of TGF-β1 receptor I kinase) for 24 h. And the HSCs without TGF-β1 stimulating were used as control group. Protein expressions and location of α-smooth muscle actin (α-SMA) and Smad3 in HSCs were assayed by immunofluorescent staining, and the image was analyzed by Image-Pro Plus 6.1 System.

RESULTS

In the in vivo experiment, liver Hyp content in the FZHY group was reduced significantly compared with the model group. FZHY also down-regulated the protein expressions of TGF-β1, TβR-I and p-Smad2/3 in fibrotic liver tissue. In the in vitro experiment, FZHY-medicated serum incubated with TGF-β1-stimulated HSCs significantly down-regulated the protein expression of α-SMA. It also inhibited Smad3 nuclear translocation in TGF-β1-stimulated HSCs.

CONCLUSION

The mechanism of FZHY against liver fibrosis is related to the regulation of TGF-β1 signaling transduction pathway by inhibition of TGF-β1 and TβR-I expressions and Smads activation in fibrotic liver tissue and HSCs.