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Miyamoto R, Takahashi A, Ogura T, Kitamura K, Ishida H, Matsudaira S, Suzuki Y, Shimizu S, Kawashima Y. Impact of endoscopic ultrasound-guided transmural drainage for postoperative pancreatic fistula after pancreatic surgery. DEN Open 2024; 4:e270. [PMID: 37404728 PMCID: PMC10315642 DOI: 10.1002/deo2.270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 06/20/2023] [Accepted: 06/22/2023] [Indexed: 07/06/2023]
Abstract
Objectives Postoperative pancreatic fistula (POPF) is a major cause of morbidity after pancreatic surgery. Recently, endoscopic ultrasound-guided transmural drainage (EUS-TD) has been widely used to manage pancreatic pseudocysts after acute pancreatitis. Several studies have reported the effectiveness of EUS-TD for POPF, although there is insufficient evidence regarding the performance of EUS-TD for POPF. We herein report on the safety, efficacy, and appropriate timing of EUS-TD for POPF compared with conventional percutaneous intervention. Methods Eight patients who underwent EUS-TD of POPF and 36 patients who underwent percutaneous intervention were retrospectively enrolled. Clinical outcomes, including technical success, clinical success, and complications, were analyzed among the two groups. Results In terms of clinical outcomes between the EUS-TD and percutaneous intervention groups, significant differences were observed in the number of interventions (1 vs. 4, p = 0.011), period of clinical success (6 days vs. 11 days, p = 0.001), incidence of complications (0 vs. 3, p = 0.021), postoperative hospital stays (27 days vs. 34 days, p = 0.027), and recurrence of POPF (0 vs. 5, p = 0.001). Conclusions EUS-TD for POPF appears to be safe and technically feasible. This approach should be considered a therapeutic option in patients with POPF after pancreatic surgery.
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Affiliation(s)
- Ryoichi Miyamoto
- Department of Gastroenterological SurgerySaitama Cancer CenterSaitamaJapan
- Department of Gastroenterological SurgeryTokyo Medical University Ibaraki Medical CenterIbarakiJapan
| | - Amane Takahashi
- Department of Gastroenterological SurgerySaitama Cancer CenterSaitamaJapan
| | - Toshiro Ogura
- Department of Gastroenterological SurgerySaitama Cancer CenterSaitamaJapan
| | - Kei Kitamura
- Department of Gastroenterological SurgerySaitama Cancer CenterSaitamaJapan
| | - Hiroyuki Ishida
- Department of Gastroenterological SurgerySaitama Cancer CenterSaitamaJapan
| | | | - Yuko Suzuki
- Department of GastroenterologySaitama Cancer CenterSaitamaJapan
| | - Satoshi Shimizu
- Department of GastroenterologySaitama Cancer CenterSaitamaJapan
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Suto H, Matsukawa H, Ando Y, Oshima M, Fuke T, Norikane T, Sanomura T, Kamada H, Kobara H, Masaki T, Kumamoto K, Okano K. A combined score for predicting clinically relevant postoperative pancreatic fistula based on inflammatory parameters and drainage fluid culture results on postoperative day 3. World J Surg 2024. [PMID: 38448035 DOI: 10.1002/wjs.12131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 02/25/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatic resection can lead to severe postoperative complications. POPF is defined based on postoperative day (POD) 3 drainage fluid amylase level. POPF correlates with inflammatory parameters as well as drainage fluid bacterial infection. However, a standardized model based on these factors for predicting CR-POPF remains elusive. We aimed to identify inflammatory parameter- and drainage fluid culture-related risk factors for CR-POPF on POD 3 after pancreatoduodenectomy (PD) and distal pancreatectomy (DP). METHODS Data from 351 patients who underwent PD or DP between 2013 and 2022 at a single institution were retrospectively analyzed. Risk factors for CR-POPF were investigated using multivariate analyses, and a prediction model combining the risk factors for CR-POPF was developed. RESULTS Of the 351 patients, 254 and 97 underwent PD and DP, respectively. Multivariate analyses revealed that drainage fluid amylase level ≥722 IU/L, culture positivity, as well as neutrophil count ≥5473/mm3 on POD 3 were independent risk factors for CR-POPF in PD group. Similarly, drainage fluid, amylase level ≥500 IU/L, and culture positivity on POD 3 as well as pancreatic thickness ≥11.1 mm were independent risk factors in the DP group. The model for predicting CR-POPF achieved the maximum overall accuracy rate when the number of risk factors was ≥2 in both the PD and DP groups. CONCLUSIONS Inflammatory parameters on POD 3 significantly influence the risk of CR-POPF onset after pancreatectomy. The combined models based on these values can accurately predict the risk of CR-POPF after pancreatectomy.
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Affiliation(s)
- Hironobu Suto
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan
| | - Hiroyuki Matsukawa
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan
| | - Yasuhisa Ando
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan
| | - Minoru Oshima
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan
| | - Takuro Fuke
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan
| | - Takashi Norikane
- Department of Radiology, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan
| | - Takayuki Sanomura
- Department of Radiology, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan
| | - Hideki Kamada
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan
| | - Hideki Kobara
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan
| | - Tsutomu Masaki
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan
| | - Kensuke Kumamoto
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan
| | - Keiichi Okano
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan
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Vouros D, Bramis K, Alexakis N, Kotsarinis V, Antonakis P, Memos N, Konstadoulakis M, Toutouzas K. Completion Pancreatectomy. Indications and Outcomes: A Systematic Review. Am Surg 2023; 89:6134-6146. [PMID: 37295804 DOI: 10.1177/00031348231183121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND/OBJECTIVE (S) Completion pancreatectomy (C.P.) is one acceptable treatment of choice in clinical scenarios such as management of post-pancreatectomy complications and recurrence in the pancreatic remnant. Studies referring to completion pancreatectomy as a distinct operation are limited, without emphasizing at the operation itself, rather reporting completion pancreatectomy as a possible option for treatment of various diseases. The identification of indications of CP in various pathologies and the clinical outcomes are therefore mandatory. METHODS A systematic literature search was performed in the Pubmed and Scopus Databases (February 2020),guided by the PRISMA protocol, for all studies reporting CP as a surgical procedure with reference at indications for performing it combined with postoperative morbidity and/or mortality. RESULTS Out of 1647 studies, 32 studies from 10 countries with 2775 patients in total, of whom 561 (20.2%) CPs met the inclusion criteria and were included in the analysis. Inclusion year ranged from 1964 to 2018 and were published from 1992 until 2019. 17 studies with a total number of 249 CPs were performed for post-pancreatectomy complications. Mortality rate was 44.5% (111 out of 249). Morbidity rate was (72.6%). 12 studies with 225 CPs were performed for isolated local recurrence after initial resection with a morbidity rate of 21.5% and 0% mortality rate in the early postoperative period. Two studies with a total number of 12 patients reported CP as a treatment option for recurrent neuroendocrine neoplasms. The mortality in those studies was 8% (1/12) and the mean morbidity rate was 58.3% (7/12). Finally, CP for refractory chronic pancreatitis was presented in one study with morbidity and mortality rates of 19% and 0%, respectively. CONCLUSION Completion pancreatectomy is a distinct treatment option for various pathologies. Morbidity and mortality rates depend on the indications of performing CP, the status performance of the patients and whether the operation is performed electively or urgently.
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Affiliation(s)
- Dimitrios Vouros
- 1st Department of Propaedeutic Surgery, Athens Medical School, National and Kapodistrian University of Athens, Hippocration General Athens Hospital, Athens, Greece
| | - Konstantinos Bramis
- 2nd Department of Surgery, School of Medicine, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Alexakis
- 1st Department of Propaedeutic Surgery, Athens Medical School, National and Kapodistrian University of Athens, Hippocration General Athens Hospital, Athens, Greece
| | - Vasileios Kotsarinis
- 1st Department of Propaedeutic Surgery, Athens Medical School, National and Kapodistrian University of Athens, Hippocration General Athens Hospital, Athens, Greece
| | - Pantelis Antonakis
- 2nd Department of Surgery, School of Medicine, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Memos
- 2nd Department of Surgery, School of Medicine, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Manousos Konstadoulakis
- 2nd Department of Surgery, School of Medicine, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Toutouzas
- 1st Department of Propaedeutic Surgery, Athens Medical School, National and Kapodistrian University of Athens, Hippocration General Athens Hospital, Athens, Greece
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Bramis K, Vouros D, Kotsarinis V, Frountzas M, Antonakis P, Memos N, Alexakis N, Konstadoulakis M, Toutouzas K. Completion Pancreatectomy as a Treatment Option for Complications Following Pancreatoduodenectomy. Am Surg 2023; 89:6348-6350. [PMID: 37159926 DOI: 10.1177/00031348231175500] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Pancreatoduodenectomy remains a complex abdominal operation for hpb surgeons. Significant complications keep on occurring to many patients undergoing Whipple procedure. We present ten patients, who required completion pancreatectomy in the early postoperative period after Whipples procedure, due to postoperative complications. Indications for completion pancreatectomy included: Sepsis secondary to uncontrolled GRADE C postoperative pancreatic fistula, pancreatic leak and bleeding, postoperative hemorrhage, pancreatic leak with gastrointestinal anastomosis dehiscence, and hepaticojejunal anastomosis dehiscence combined with hemorrhage. Completion pancreatectomy was carried out at a mean interval of 9 days following Whipple procedure. Six patients (60%) survived the operation and discharged from the hospital, with a median survival of 21.3 months. Four patients (40%) died in the early post-operative period due to sepsis (10%) and multiple organ failure (30%). Completion pancreatectomy after pancreatoduodenectomy is rarely indicated and it can be considered as a salvage procedure in the management of severe life-threatening post pancreatic surgery complications.
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Affiliation(s)
- Konstantinos Bramis
- Department of Surgery, School of Medicine, Aretaieion Hospital, National and Kapodistrian University of Athens, Greece
| | - Dimitrios Vouros
- Propaedeutic Department of Surgery, School of Medicine, Hippokrateion General Hospital, National and Kapodistrian University of Athens, Greece
| | - Vasileios Kotsarinis
- Propaedeutic Department of Surgery, School of Medicine, Hippokrateion General Hospital, National and Kapodistrian University of Athens, Greece
| | - Maximos Frountzas
- Propaedeutic Department of Surgery, School of Medicine, Hippokrateion General Hospital, National and Kapodistrian University of Athens, Greece
| | - Pantelis Antonakis
- Department of Surgery, School of Medicine, Aretaieion Hospital, National and Kapodistrian University of Athens, Greece
| | - Nikolaos Memos
- Department of Surgery, School of Medicine, Aretaieion Hospital, National and Kapodistrian University of Athens, Greece
| | - Nikolaos Alexakis
- Propaedeutic Department of Surgery, School of Medicine, Hippokrateion General Hospital, National and Kapodistrian University of Athens, Greece
| | - Manousos Konstadoulakis
- Department of Surgery, School of Medicine, Aretaieion Hospital, National and Kapodistrian University of Athens, Greece
| | - Konstantinos Toutouzas
- Propaedeutic Department of Surgery, School of Medicine, Hippokrateion General Hospital, National and Kapodistrian University of Athens, Greece
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Doll PM, Bolm L, Braun R, Honselmann KC, Deichmann S, Kulemann B, Kuchyn I, Zemskov S, Bausch D, Keck T, Wellner UF, Lapshyn H. The impact of intra- and postoperative fluid balance in pancreatic surgery - A retrospective cohort study. Pancreatology 2023; 23:689-696. [PMID: 37532635 DOI: 10.1016/j.pan.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 06/14/2023] [Accepted: 07/16/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND/OBJECTIVES The aim of this study was to evaluate the impact of perioperative fluid administration in pancreatic surgery. METHODS Patients who underwent pancreatic resections were identified from our institution's prospectively maintained database. Fluid balances were recorded intraoperatively and at 24hr postoperatively. Patients were stratified into tertiles of fluid administration (low, medium, high). Adjusted multivariable analysis was performed and outcome measures were postoperative complications. RESULTS A total of 211 patients were included from 2012 to 2017. Complication rates were POPF(B/C) 19.4%, DGE(B/C) 14.7%, PPH(C) 10.0% and CDC ≥ IIIb 26.1%. In multivariable analysis, high perioperative fluid balance was an independent risk factor associated with POPF (OR = 10.5, 95%CI 2.7-40.7, p = .001), CDC (OR = 2.5, 95%CI 1.2-5.3, p < .002), DGE (OR = 2.3, 95%CI 1.0-5.2, p = .017), PPH (OR = 6.7 95%CI 2.2-20.0, p = .038) and reoperation (OR = 3.1, 95%CI 1.6-6.2, p = .006). In multivariable analysis with intraoperative and postoperative fluid balances as separate predictors, intraoperative (OR = 2,5, 95%CI 1.2-5.5, p = .04) and postoperative fluid balance (OR = 2.5, 95%CI 1.2-5.5, p = .02) were predictors of POPF. Postoperative fluid balance was the only predictor for mortality (OR = 4.5, 95%CI 1.0-18.9, p = .041) and predictor for CDC (OR = 2.0, 95%CI 1.0-4.0, p = .043) and OHS days (OR = 6.9, 95%CI 0.03-13.7, p = .038). CONCLUSIONS High postoperative fluid balance in particular is associated with postoperative morbidity. Maintaining a fluid-restrictive strategy postoperatively should be recommended for patients undergoing pancreatic surgery.
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Affiliation(s)
- Patricia Marie Doll
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Louisa Bolm
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Ruediger Braun
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Kim C Honselmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Steffen Deichmann
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Birte Kulemann
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Iurii Kuchyn
- Department of Anesthesiology, National Medical University Named after O. O. Bogomolets, Taras Shevchenko Boulevard, 13, Kyiv, 01601, Ukraine
| | - Sergii Zemskov
- Department of Surgery, National Medical University Named after O. O. Bogomolets, Taras Shevchenko Boulevard, 13, Kyiv, 01601, Ukraine
| | - Dirk Bausch
- Department of Surgery, Marien Hospital Herne, University Hospital of Ruhr University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Tobias Keck
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany.
| | - Ulrich Friedrich Wellner
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
| | - Hryhoriy Lapshyn
- Department of Surgery, University Medical Center Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23562, Luebeck, Germany
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Ikuta S, Nakajima T, Kasai M, Fujikawa M, Aihara T, Yamanaka N. Perioperative Fluid Balance and the Risk of Postoperative Pancreatic Fistula After Pancreaticoduodenectomy: A Propensity Score-adjusted Analysis. Anticancer Res 2023; 43:4179-4187. [PMID: 37648332 DOI: 10.21873/anticanres.16609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND/AIM The impact of perioperative fluid management on postoperative morbidity after pancreaticoduodenectomy (PD) remains uncertain. This study aimed to investigate the independent association between perioperative fluid balance (FB) and clinically relevant postoperative pancreatic fistula (POPF) in PD patients. PATIENTS AND METHODS A total of 243 consecutive open PD patients were included. Intra- and postoperative FB until postoperative day 3 were calculated, and their predictive performance for POPF was assessed using receiver operating characteristic (ROC) analysis. Propensity score (PS) was estimated as the probability of having higher FB, and factors associated with POPF were identified using crude and PS-adjusted logistic regression models. RESULTS POPF occurred in 60 patients (24.7%). ROC analysis showed the highest predictive value for total FB on postoperative days 1 and 2, with a cut-off value of 1,585 ml (area under the ROC curve=0.74). Patients with FB ≥1,585 ml had a significantly higher POPF rate (48.3%) compared to those with lower FB (11.0%, PS-adjusted p<0.001). Male sex, body mass index ≥25 kg/m2, non-pancreatic ductal adenocarcinoma, biliary drainage, main pancreatic duct diameter <3 mm, and higher FB showed significant associations with POPF in crude univariate analysis. Higher FB remained a significant factor in both crude multivariate and PS-adjusted analysis [crude multivariate: odds ratio (OR)=8.0; PS-adjusted univariate: OR=4.2; PS-adjusted multivariate: OR=6.1, all p<0.001]. CONCLUSION Higher early postoperative FB, a potentially modifiable factor, may be independently associated with increased risk of POPF in PD patients.
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Affiliation(s)
| | | | - Meidai Kasai
- Department of Surgery, Meiwa Hospital, Hyogo, Japan
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Kimura K, Minagawa R, Yamaoka T, Izumi T, Takahashi YU, Nakanishi M, Tokunaga T, Matsuda D, Honma K, Nagata S, Minami K, Nishizaki T. Stent Graft of Pseudoaneurysm Rupture After Subtotal Stomach-preserving Pancreaticoduodenectomy. Anticancer Res 2023; 43:3639-3645. [PMID: 37500164 DOI: 10.21873/anticanres.16544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND/AIM Pseudoaneurysm rupture (PR) after subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) is a potentially fatal complication. PATIENTS AND METHODS This study included 122 patients who underwent SSPPD at the Matsuyama Red Cross Hospital between January 2016 and December 2021. RESULTS PR occurred in five patients (4.1%) after SSPPD. Preoperative diagnoses were cancers of the pancreatic head, distal bile duct, and gallbladder. All patients had postoperative Grade B or C pancreatic fistulas. PR occurred on postoperative days 8, 13, 20, 45, and 46. Bleeding sites were at the gastroduodenal artery transection, left gastric artery, and right hepatic artery. Four patients underwent peripheral stent graft placement, and one underwent haemostasis by coiling. Stent grafts for the gastroduodenal artery transected stamp were placed in the common hepatic artery, and in the superior mesenteric artery for PR in the right hepatic artery. All patients who underwent stent graft placement were treated with antiplatelet therapy; no complications or stent occlusion were observed in these patients. However, two patients died of cancer recurrence, 4 and 8 months after stent graft placement. The longest survival post stent graft placement was 50 months. CONCLUSION Peripheral stent graft placement for the treatment of PR after SSPPD can maintain peripheral blood flow and haemostasis.
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Affiliation(s)
- Koichi Kimura
- Department of Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan;
| | - Ryosuke Minagawa
- Department of Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Terutoshi Yamaoka
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Takuma Izumi
- Department of Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Y U Takahashi
- Department of Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Mitsuru Nakanishi
- Department of Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Takayuki Tokunaga
- Department of Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Daisuke Matsuda
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Kenichi Honma
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Shigeyuki Nagata
- Department of Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Kazuhito Minami
- Department of Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
| | - Takashi Nishizaki
- Department of Surgery, Matsuyama Red Cross Hospital, Matsuyama, Japan
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Yu X, Wang W, Yu S, Yang C, Huang X, Yuan Z. The role of main pancreatic duct stent in the enucleation of benign/borderline pancreatic head tumors: a cohort study. Langenbecks Arch Surg 2023; 408:198. [PMID: 37204475 DOI: 10.1007/s00423-023-02921-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 04/29/2023] [Indexed: 05/20/2023]
Abstract
PURPOSE This study aimed to reveal the role of preoperative main pancreatic duct (MPD) stent placement in reducing the intraoperative main pancreatic duct injury rate and the incidence of postoperative pancreatic leakage following pancreatic tumor enucleation. METHODS A retrospective cohort analysis was performed for all patients with benign/borderline pancreatic head tumors who were treated with enucleation. The patients were divided into two groups (standard vs. stent) depending on whether they underwent main pancreatic duct stent placement prior to surgery. RESULTS Thirty-three patients were finally included in the analytical cohort. Compared with the standard group, patients in the stent group had a shorter distance between tumors and main pancreatic duct (p=0.01) and presented with larger tumors (p<0.01). The rates of POPF (grade B&C) were 39.1% (9/23) and 20% (2/10) in the standard and stent groups, respectively (p<0.01). Major postoperative complications occurred more frequently in the standard group than in the stent group (14 versus 2; p<0.01). No significant differences in mortality, in-hospital stay or medical cost were observed between the two groups (p>0.05). CONCLUSIONS MPD stent placement prior to surgery may facilitate pancreatic tumor enucleation, minimize MPD injury and decrease the occurrence of postoperative fistula.
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Affiliation(s)
- Xinzhe Yu
- Department of General Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Yi-Shan Road 600, Shanghai, 200233, China
- Department of Hepato-Pancreato-Biliary Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Wang
- Department of Hepato-Pancreato-Biliary Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Song Yu
- Department of Hepato-Pancreato-Biliary Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chuanxin Yang
- Department of General Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Yi-Shan Road 600, Shanghai, 200233, China
| | - Xinyu Huang
- Department of General Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Yi-Shan Road 600, Shanghai, 200233, China.
- Department of Hepato-Pancreato-Biliary Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Zhou Yuan
- Department of General Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Yi-Shan Road 600, Shanghai, 200233, China.
- Department of Hepato-Pancreato-Biliary Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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9
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Donovan EC, Prakash LR, Chiang YJ, Bruno ML, Maxwell JE, Ikoma N, Tzeng CWD, Katz MHG, Lee JE, Kim MP. Incidence of Postoperative Complications Following Pancreatectomy for Pancreatic Cystic Lesions or Pancreatic Cancer. J Gastrointest Surg 2023; 27:319-327. [PMID: 36443557 DOI: 10.1007/s11605-022-05534-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 10/15/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND In contrast to pancreatic ductal adenocarcinoma (PDAC), the risks of pancreatectomy for mucinous pancreatic cysts (MCs) are balanced against the putative goal of removing potentially malignant tumors. Despite undergoing similar operations, different rates of perioperative complications and morbidity between MC and PDAC patient populations may affect recommendations for resection. We therefore sought to compare the rates of postoperative complications between patients undergoing pancreatectomies for MCs or PDAC. METHODS A prospectively maintained institutional database was used to identify patients who underwent surgical resection for MCs or PDAC from July 2011 to August 2019. Patient demographics, complications, and perioperative data were compared between groups. RESULTS A total of 103 patients underwent surgical resection for MCs and 428 patients underwent resection for PDAC. Combined major 90-day postoperative complications were similar between MC and PDAC patients undergoing pancreaticoduodenectomy (PD, 32.5% vs. 20.0%, p = 0.068) or distal pancreatectomy (DP, 30.2% vs. 20.5%, p = 0.172). The most frequent complications were postoperative pancreatic fistula (POPF), abscess, and postoperative bleeding. The incidence of 90-day ISGPS Grade B/C POPF was higher in cyst patients undergoing PD (17.5% vs. 4.1%, p = 0.003) but not DP (25.4% vs. 20.5%, p = 0.473). No significant differences in operative time or length of stay between MCs and PDAC cohorts were observed. CONCLUSIONS POPFs occur more frequently and at higher grades in patients undergoing PD for MCs than for PDAC and should inform patient selection. Accordingly, the perioperative management of MC patients undergoing PD should emphasize POPF risk mitigation.
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Affiliation(s)
- Eileen C Donovan
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Laura R Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Morgan L Bruno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jessica E Maxwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. .,Department of Genetics, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, FCT17.6006, Unit 1484, Houston, TX, 77030, USA.
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10
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Radulova-Mauersberger O, Oehme F, Doerell A, Frohneberg L, Hempel S, Weitz J, Welsch T, Distler M, Teske C. Selective Decontamination of the Digestive Tract in Pancreatic Head Resections-A Propensity Score-Matched Analysis. J Clin Med 2022; 12. [PMID: 36615050 DOI: 10.3390/jcm12010250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 12/19/2022] [Accepted: 12/24/2022] [Indexed: 12/30/2022] Open
Abstract
(1) Background: The postoperative morbidity rate after pancreatic head resection remains high, partly due to infectious complications. The primary aim of this study was to analyze the influence of selective decontamination of the digestive tract (SDD) on the postoperative infection rate after pancreatic surgery. (2) Methods: From January 2019, the standard of care for patients undergoing pancreatic head resections at the Department for Visceral, Thoracic, and Vascular Surgery, University Hospital Dresden was the preoperative oral administration of SDD. The influence of SDD was evaluated for patients operated on between January 2019 and June 2020 in comparison to a propensity score-matched cohort, extracted from an existing database including all pancreatic resections from 2012 to 2018. The primary endpoint of the study was the shift of the bacterial load on the intraoperative bile swab test. The secondary endpoint was the association of SDD with postoperative complications. (3) Results: In total, 200 patients either with SDD (n = 100; 50%) or without SDD (non-SDD, n = 100; 50%) were analyzed. In the patient group without a preoperative biliary stent, 44% (n = 11) of the non-SDD group displayed positive bacterial results, whereas that was the case for only 21.7% (n = 10) in the SDD group (p = 0.05). Particularly, Enterobacter species (spp.) were reduced from 41.2% (n = 14) (non-SDD group) to 23.5% (n = 12) (SDD group) (p = 0.08), and Citrobacter spp. were reduced by 13.7% (p = 0.09) from the non-SDD to the SDD cohort. In patients with a preoperative biliary stent, the Gram-negative Enterobacter spp. were significantly reduced from 52.2% (n = 12) in the non-SDD group to 26.8% (n = 11) in the SDD group (p = 0.04). Similarly, Citrobacter spp. decreased by 20.6% from 30.4% (n = 7) to 9.8% (n = 4) in the non-SDD compared to the SDD group (p = 0.04). In general, deep fluid collection and abscesses occurred more frequently in the non-SDD group (36%; n = 36 vs. 27%; n = 27; p = 0.17). (4) Conclusions: Adoption of SDD before pancreatic head surgery may reduce the bacterial load in bile fluid. SDD administration does not significantly affect the postoperative infectious complication rate after pancreatic head resections.
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11
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Pausch TM, Bartel M, Cui J, Aubert O, Mitzscherling C, Liu X, Gesslein B, Schuisky P, Kommoss FKF, Bruckner T, Golriz M, Mehrabi A, Hackert T. SmartPAN: in vitro and in vivo proof-of-safety assessments for an intra-operative predictive indicator of postoperative pancreatic fistula. Basic Clin Pharmacol Toxicol 2022; 130:542-552. [PMID: 35040273 DOI: 10.1111/bcpt.13708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 12/07/2021] [Accepted: 01/12/2022] [Indexed: 12/01/2022]
Abstract
Pancreatic surgery is complicated by untreated fluid leakage, but no tenable techniques exist to detect and close leakage sites during surgery. A novel hydrogel called SmartPAN has been developed to meet this need and is here assessed for safety before trials on human patients. Firstly, resazurin assays were used to test the cytotoxic effects of SmartPAN's active bromothymol blue (BTB) indicator and its solution of phosphate-buffered saline (PBS) on normal (HPDE: Human Pancreatic Duct Epithelial) or carcinomic (FAMPAC) human pancreatic cells. Cells incubated with BTB showed no significant reduction in cell viability below threshold safety levels. However, PBS had a mild cytotoxic effect on FAMPAC cells. Secondly, SmartPAN's pathological effects were evaluated in vivo by applying 4 mL SmartPAN to a porcine (Sus scrofa domesticus) model of pancreatic resection. There were no significant differences in macroscopic and microscopic pathologies between pigs treated with SmartPAN or saline. Thirdly, measurements using HPLC-MS/MS demonstrate that BTB does not cross into the bloodstream and was eliminated from the body within two days of surgery. Overall, SmartPAN appears safe in the short-term and ready for first-in-human trials because its components are either biocompatible or quickly neutralized by dilution and drainage.
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Affiliation(s)
- Thomas M Pausch
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Marc Bartel
- Institute of Legal and Traffic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Jiaqu Cui
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Ophelia Aubert
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Clara Mitzscherling
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Xinchun Liu
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | | | | | - Felix K F Kommoss
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Legal and Traffic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Mohammad Golriz
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
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12
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Giuliani A, Avella P, Segreto AL, Izzo ML, Buondonno A, Coluzzi M, Cappuccio M, Brunese MC, Vaschetti R, Scacchi A, Guerra G, Amato B, Calise F, Rocca A. Postoperative Outcomes Analysis After Pancreatic Duct Occlusion: A Safe Option to Treat the Pancreatic Stump After Pancreaticoduodenectomy in Low-Volume Centers. Front Surg 2022; 8:804675. [PMID: 34993230 PMCID: PMC8725883 DOI: 10.3389/fsurg.2021.804675] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/25/2021] [Indexed: 12/07/2022] Open
Abstract
Background: Surgical resection is the only possible choice of treatment in several pancreatic disorders that included periampullar neoplasms. The development of a postoperative pancreatic fistula (POPF) is the main complication. Despite three different surgical strategies that have been proposed–pancreatojejunostomy (PJ), pancreatogastrostomy (PG), and pancreatic duct occlusion (DO)–none of them has been clearly validated to be superior. The aim of this study was to analyse the postoperative outcomes after DO. Methods: We retrospectively reviewed 56 consecutive patients who underwent Whipple's procedure from January 2007 to December 2014 in a tertiary Hepatobiliary Surgery and Liver Transplant Unit. After pancreatic resection in open surgery, we performed DO of the Wirsung duct with Cyanoacrylate glue independently from the stump characteristics. The mean follow-up was 24.5 months. Results: In total, 29 (60.4%) were men and 19 were (39.6%) women with a mean age of 62.79 (SD ± 10.02) years. Surgical indications were in 95% of cases malignant diseases. The incidence of POPF after DO was 31 (64.5%): 10 (20.8%) patients had a Grade A fistula, 18 (37.5%) Grade B fistula, and 3 (6.2%) Grade C fistula. No statistical differences were demonstrated in the development of POPF according to pancreatic duct diameter groups (p = 0.2145). Nevertheless, the POPF rate was significantly higher in the soft pancreatic group (p = 0.0164). The mean operative time was 358.12 min (SD ± 77.03, range: 221–480 min). Hospital stay was significantly longer in patients who developed POPF (p < 0.001). According to the Clavien-Dindo (CD) classification, seven of 48 (14.58%) patients were classified as CD III–IV. At the last follow-up, 27 of the 31 (87%) patients were alive. Conclusions: Duct occlusion could be proposed as a safe alternative to pancreatic anastomosis especially in low-/medium-volume centers in selected cases at higher risk of clinically relevant POPF.
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Affiliation(s)
- Antonio Giuliani
- Unit of General and Emergency Surgery, AOR "San Carlo", Potenza, Italy.,Unit of Hepatobiliary Surgery and Liver Transplant Centre, "Cardarelli" Hospital, Naples, Italy
| | - Pasquale Avella
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
| | - Anna Lucia Segreto
- Department of General Surgery "SS. Antonio e Biagio e Cesare Arrigo" Hospital, Alessandria, Italy
| | - Maria Lucia Izzo
- Unit of General and Emergency Surgery, AOR "San Carlo", Potenza, Italy
| | - Antonio Buondonno
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
| | | | - Micaela Cappuccio
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
| | - Maria Chiara Brunese
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
| | - Roberto Vaschetti
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
| | - Andrea Scacchi
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
| | - Germano Guerra
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
| | - Bruno Amato
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Fulvio Calise
- Unit of Hepatobiliary Surgery and Liver Transplant Centre, "Cardarelli" Hospital, Naples, Italy.,HPB Surgery Unit, Pineta Grande Hospital, Campania, Italy
| | - Aldo Rocca
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy.,HPB Surgery Unit, Pineta Grande Hospital, Campania, Italy
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13
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Grego A, Friziero A, Serafini S, Belluzzi A, Moletta L, Saadeh LM, Sperti C. Does Pancreatic Fistula Affect Long-Term Survival after Resection for Pancreatic Cancer? A Systematic Review and Meta-Analysis. Cancers (Basel) 2021; 13:5803. [PMID: 34830957 DOI: 10.3390/cancers13225803] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/03/2021] [Accepted: 11/17/2021] [Indexed: 02/05/2023] Open
Abstract
Simple Summary The real influence of postoperative pancreatic fistula (POPF) on long-term survival after pancreatic cancer resection is unclear. The purpose of the present study was therefore to conduct a systematic review and meta-analysis of the impact of POPF on the disease-free and overall survival of patients with pancreatic cancer. Our results highlighted that clinically relevant POPF after surgery for PDAC seems to be significantly associated with shorter DFS and OS. Confirmation, with future studies, of a negative impact of POPF on survival may encourage the widespread use of risk-stratification tools for assessing fistula, centralization of patients, and probably a closer oncological follow-up. Abstract Background: The impact of postoperative pancreatic fistula (POPF) on survival after resection for pancreatic ductal adenocarcinoma (PDAC) remains unclear. Methods: The MEDLINE, Scopus, Embase, Web of Science, and Cochrane Library databases were searched for studies reporting on survival in patients with and without POPF. A meta-analysis was performed to investigate the impact of POPF on disease-free survival (DFS) and overall survival (OS). Results: Sixteen retrospective cohort studies concerning a total of 5019 patients with an overall clinically relevant POPF (CR-POPF) rate of 12.63% (n = 634 patients) were considered. Five of eleven studies including DFS data reported higher recurrence rates in patients with POPF, and one study showed a higher recurrence rate in the peritoneal cavity. Six of sixteen studies reported worse OS rates in patients with POPF. Sufficient data for a meta-analysis were available in 11 studies for DFS, and in 16 studies for OS. The meta-analysis identified a shorter DFS in patients with CR-POPF (HR 1.59, p = 0.0025), and a worse OS in patients with POPF, CR-POPF (HR 1.15, p = 0.0043), grade-C POPF (HR 2.21, p = 0.0007), or CR-POPF after neoadjuvant therapy. Conclusions: CR-POPF after resection for PDAC is significantly associated with worse overall and disease-free survival.
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14
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Arjunan R, Karthik SDS, Chowdappa R, Althaf S, Srinivas C. Contemporary Surgical, Oncological, and Survival Outcomes of Pancreaticoduodenectomy for Periampullary Tumours: a 5-Year Experience from Tertiary Cancer Center. Indian J Surg Oncol 2021; 12:603-610. [PMID: 34658591 DOI: 10.1007/s13193-021-01385-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 07/09/2021] [Indexed: 10/20/2022] Open
Abstract
With advances in surgical management of pancreaticoduodenectomy (PD), mortality rate for PD has been reported to be less than 5%. Postoperative pancreatic fistula (POPF) remains a major complication and morbidity after PD with incidence of up to 40%. This is a retrospective analysis of patients who underwent PD in a tertiary cancer referral center in southern India. Data was collected for the patients operated during the period from Jan 2014 to Dec 2018. Surgicopathological, oncological, and survival outcomes were described. Of 76 patients presumed as operable, 16 were excluded and data analyzed for 60 patients. Forty-four percent underwent classical Whipple's PD and 56% pylorus-preserving PD. The most common postoperative complications were wound infection (25%); pneumonia (20%); clinically relevant POPF (13%); and delayed gastric emptying (19%). Thirty-day in-hospital mortality was 5%, 90-day mortality was 8.3%, and fistula-related mortality was 1.6%. Ampullary cancer was the most common histology. Three-year survival rate was 23.3% with a mean overall survival of 33.2 months with significantly better survival in the node negative than positive group (41.3 vs 20.5 months, P = 0.003) and significantly lower survival in pancreatic head cancer than other tumor histologies (16.6 vs 37.3 months, P = 0.002). Multivariate analysis has shown pancreatic head histology (HR = 2.38, 95% CI (1.08-5.26), P = 0.033) and nodal positivity (HR = 2.38, 95% CI (1.27-4.44), P = 0.007) as poor prognostic factors. Pancreaticoduodenectomy is a safe operation in experienced hands. Adhering to a meticulous adaptable reproducible anastomotic technique with standard perioperative management strategies significantly decreases the operative morbidity and mortality.
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Affiliation(s)
- Ravi Arjunan
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Dr. M. H. Marigowda Road, Bengaluru, 560029 India
| | - S D S Karthik
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Dr. M. H. Marigowda Road, Bengaluru, 560029 India
| | - Ramachandra Chowdappa
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Dr. M. H. Marigowda Road, Bengaluru, 560029 India
| | - Syed Althaf
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Dr. M. H. Marigowda Road, Bengaluru, 560029 India
| | - Chunduri Srinivas
- Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Dr. M. H. Marigowda Road, Bengaluru, 560029 India
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15
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Acher AW, Stahl C, Barrett JR, Schwartz PB, Aiken T, Ronnekleiv-Kelly S, Minter RM, Leverson G, Weber SM, Abbott DE. Clinical and Cost Profile of Controlled Grade B Postoperative Pancreatic Fistula: Rationale for Their Consideration as Low Risk. J Gastrointest Surg 2021; 25:2336-2343. [PMID: 33555526 DOI: 10.1007/s11605-021-04928-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 01/15/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Despite standardization, the 2016 ISGPF criteria are limited by their wider applicability and oversimplification of grade B POPF. This work applied the 2016 ISGPF grading criteria within a US academic cancer center to verify clinical and fiscal distinctions and sought to improve grading criteria for grade B POPF. METHODS The 2008-2018 cost and NSQIP data from pancreaticoduodenectomy to postoperative day 90 were merged. All POPFs were coded by 2016 ISGPF criteria. The Clavien-Dindo Classification (CD) defined complication severity. On sub-analyses, grade B POPFs were divided into those with adequate drainage and those requiring additional drainage. Chi-square, ANOVA, and Fisher's least significant difference test were employed. RESULTS Two hundred thirty-two patients were in the final analyses, 72 (31%) of whom had POPFs: 16 (7%) biochemical leaks, 54 (23%) grade B (28% required additional drainage), and 2 (1%) grade C. There was no significant difference in length of stay, CD, readmission, or cost in patients without a POPF, with biochemical leak or grade B POPF. On sub-analyses, 92% of adequately drained grade B POPFs had CD 1-2 and readmission equivalent to patients without POPF (p > 0.05). One hundred percent of grade B POPF requiring drainage had CD 3-4a, and 67% were readmitted. Cost was significantly increased in grade B POPF requiring additional drainage (p = 0.02) and grade C POPF (p < 0.01). CONCLUSIONS This analysis did not confirm an incremental increase in morbidity and cost with POPF grade. Sub-analyses enabled accurate clinical and cost distinctions in grade B POPF; adequately drained grade B POPF are low risk and clinically insignificant.
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Affiliation(s)
- Alexandra W Acher
- Department of General Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53792, USA. .,Clinical Science Center, 600 Highland Avenue, Box 7375, Madison, WI, 53792, USA.
| | - Christopher Stahl
- Department of General Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53792, USA
| | - James R Barrett
- Department of General Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53792, USA
| | - Patrick B Schwartz
- Department of General Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53792, USA
| | - Taylor Aiken
- Department of General Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53792, USA
| | - Sean Ronnekleiv-Kelly
- Department of General Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53792, USA
| | - Rebecca M Minter
- Department of General Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53792, USA
| | - Glen Leverson
- Department of General Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53792, USA
| | - Sharon M Weber
- Department of General Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53792, USA
| | - Daniel E Abbott
- Department of General Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53792, USA
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16
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Honselmann KC, Antoine C, Frohneberg L, Deichmann S, Bolm L, Braun R, Lapshyn H, Petrova E, Keck T, Wellner U, Bausch D. A simple nomogram for early postoperative risk prediction of clinically relevant pancreatic fistula after pancreatoduodenectomy. Langenbecks Arch Surg 2021; 406:2343-2355. [PMID: 34009458 PMCID: PMC8578094 DOI: 10.1007/s00423-021-02184-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 04/28/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE Postoperative pancreatic fistulae (POPF) present a serious and life-threatening complication after pancreatic head resections (PD). Therefore, reliable risk stratification to identify those at risk is urgently needed. The aim of this study was to identify postoperative laboratory parameters for the prediction of POPF in the early postoperative period. METHODS One hundred eighty-two patients who underwent PD from 2012 until 2017 were retrospectively analyzed. Multivariate logistic regression was performed using the GLM (general linear model) method for model building. Two nomograms were created based on the GLM models of postoperative day one and postoperative day one to five. A cohort of 48 patients operated between 2018 and 2019 served as internal validation. RESULTS Clinically relevant pancreatic fistulae (CR-POPF) were present in 16% (n = 29) of patients. Patients with CR-POPF experienced significantly more insufficiencies of gastroenterostomies, delayed gastric emptying, and more extraluminal bleeding than patients without CR-POPF. Multivariate analysis revealed multiple postoperative predictive models, the best one including ASA, main pancreatic duct diameter, operation time, and serum lipase as well as leucocytes on day one. This model was able to predict CR-POPF with an accuracy of 90% and an AUC of 0.903. Two nomograms were created for easier use. CONCLUSION Clinically relevant fistula can be predicted using simple laboratory and clinical parameters. Not serum amylase, but serum lipase is an independent predictor of CR-POPF. Our simple nomograms may help in the identification of patients for early postoperative interventions.
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Affiliation(s)
- K C Honselmann
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - C Antoine
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - L Frohneberg
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - S Deichmann
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - L Bolm
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - R Braun
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - H Lapshyn
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - E Petrova
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - T Keck
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - U Wellner
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - D Bausch
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany. .,Department of Surgery, Marien Hospital Herne-University Medical Center of the Ruhr-Universität Bochum, Hölkeskampring 40, 44625, Herne, Germany.
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17
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Pandrowala S, Parray A, Chaudhari V, Shrikhande SV, Bhandare MS. Portal Annular Pancreas (PAP): an Underestimated Devil in Pancreatic Surgery-Systematic Review of Literature and Case Report. J Gastrointest Surg 2021; 25:1332-9. [PMID: 33555524 DOI: 10.1007/s11605-021-04927-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 01/15/2021] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Portal annular pancreas (PAP) is an anatomic variation due to aberrant fusion of the ventral and dorsal pancreatic buds around the portal vein. In this article, we present a case report with a systematic review of literature of patients undergoing major pancreatic surgery with associated PAP. We also intend to discuss and suggest possible surgical strategies to minimise major postoperative complications. METHODS A systematic literature search was conducted using the terms "circumportal," "periportal," "pancreas," "annular pancreas," "portal annular pancreas" and "pancreas anomaly." All articles describing portal annular pancreas with surgical resection were included. RESULTS We identified a total of 53 patients of PAP from 29 articles, who underwent pancreatic resection with a median age of 65 years. POPF (postoperative pancreatic fistula) was demonstrated in 42.55% of patients and 34% had CR (clinically relevant)-POPF. Following pancreaticoduodenectomy, pancreatic stump was reconstructed in all patients with either pancreaticojejunostomy or pancreaticogastrostomy. Standard line of pancreatic transection, i.e., division of anteportal portion at the pancreatic neck and stapling of the retroportal process, resulted in 71% incidence of CR-POPF, whereas it was only 16% when extended resection was performed to achieve single pancreatic stump and 12.5% when retroportal portion was sutured or ligated. Amongst distal pancreatic resections, 66% had POPF and 33% developed CR-POPF. CONCLUSION It is of utmost importance for pancreatic surgeons to diligently look for and identify PAP in the preoperative imaging. Additional imaging in the form of MRCP helps to define abnormal pancreatic ductal anatomy. Surgeons need to be cognisant of pancreatic stump management in patients with PAP to reduce associated higher rates of POPF.
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18
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Magistri P, Boggi U, Esposito A, Carrano FM, Pesi B, Ballarin R, De Pastena M, Menonna F, Moraldi L, Melis M, Coratti A, Newman E, Napoli N, Ramera M, Di Benedetto F. Robotic vs open distal pancreatectomy: A multi-institutional matched comparison analysis. J Hepatobiliary Pancreat Sci 2020; 28:1098-1106. [PMID: 33314791 DOI: 10.1002/jhbp.881] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 11/05/2020] [Accepted: 11/09/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pancreatic surgery is still a challenge even in high-volume centers. Clinically relevant postoperative pancreatic fistula (CR-POPF) represents the greatest contributor to major morbidity and mortality, especially following pancreatic distal resection. In this study, we compared robotic distal pancreatectomy (RDP) to open distal pancreatectomy (ODP) in terms of CR-POPF development and analyzed oncologic efficacy of RDP in the subgroup of patients with pancreatic ductal adenocarcinoma (PDAC). METHODS We collected data from five high-volume centers for pancreatic surgery and performed a matched comparison analysis to compare short and long-term outcomes after ODP or RDP. Patients were matched with a 2:1 ratio according to age, ASA (American Society of Anesthesiologists) score, body mass index (BMI), final pathology, and TNM (Tumour, Node, Metastasis) staging system VIII ed. RESULTS Two hundred and forty-six patients who underwent 82 RDPs and 164 ODPs were included. No differences were found in the incidence of CR-POPF. In the PDAC group, median DFS and OS were 10.8 months and 14.8 months in the ODP group and 10.4 months and 15 months in the RDP group, respectively. CONCLUSIONS Robotic distal pancreatectomy is a safe surgical strategy for PDAC and incidence of CR-POPF is equivalent between RDP and ODP. RDP should be considered equivalent to ODP in terms of oncological efficacy when performed in high-volume and proficient centers.
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Affiliation(s)
- Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, Pisa University Hospital, Pisa, Italy
| | - Alessandro Esposito
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Francesco Maria Carrano
- Department of Surgery, NYU School of Medicine, New York, NY, USA.,Department of General, Emergency and Transplant Surgery, Ospedale di Circolo e "Fondazione Macchi,", ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Benedetta Pesi
- Division of Oncological and Robotic General Surgery, Careggi University Hospital, Florence, Italy
| | - Roberto Ballarin
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Matteo De Pastena
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Francesca Menonna
- Division of General and Transplant Surgery, Pisa University Hospital, Pisa, Italy
| | - Luca Moraldi
- Division of Oncological and Robotic General Surgery, Careggi University Hospital, Florence, Italy
| | | | - Andrea Coratti
- Division of Oncological and Robotic General Surgery, Careggi University Hospital, Florence, Italy
| | - Elliot Newman
- Department of Surgery, NYU School of Medicine, New York, NY, USA
| | - Niccolò Napoli
- Division of General and Transplant Surgery, Pisa University Hospital, Pisa, Italy
| | - Marco Ramera
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
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Furbetta N, Gianardi D, Guadagni S, Di Franco G, Palmeri M, Bianchini M, Pisani K, Di Candio G, Morelli L. Somatostatin administration following pancreatoduodenectomy: a case-matched comparison according to surgical technique, body mass index, American Society of Anesthesiologists' score and Fistula Risk Score. Surg Today 2020; 51:1044-1053. [PMID: 33270148 PMCID: PMC8141487 DOI: 10.1007/s00595-020-02189-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/20/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE This study evaluated the controversial role of somatostatin after pancreatoduodenectomy (PD), stratifying patients for the main risk factors using the most recent postoperative pancreatic fistula (POPF) classification and including only patients who had undergone PD with the same technique of pancreatojejunostomy. METHODS Between November 2010 and February 2020, 218 PD procedures were carried out via personal modified pancreatojejunostomy (mPJ-PD). Somatostatin was routinely administered between 2010 and 2016, while from 2017, 97 mPJ-PD procedures without somatostatin (WS) were performed. The WS group was retrospectively compared with a control (C) group obtained with one-to-one case-control matching according to the body mass index, American Society of Anesthesiologists' score, and Fistula Risk Score (FRS). RESULTS A total of 144 patients (72 WS group versus 72 C group) were compared. In the WS group. 6 patients (8.3%) developed clinically relevant POPF, compared with 8 patients (11.1%) in the C group (p = 0.656). In addition, on analyzing the subgroup of high-risk patients according to the FRS, we did not note any significant differences in POPF occurrence. Furthermore, no marked differences in the morbidity or mortality were found. Digestive bleeding and diabetes onset rates were higher in the WS group than in the control group, but not significantly so. CONCLUSIONS The results of the present study confirm no benefit with the routine administration of somatostatin after PD to prevent POPF, even in high-risk patients. However, a possible role in the prevention of postoperative digestive bleeding and diabetes was observed.
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Affiliation(s)
- Niccolò Furbetta
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
| | - Desirée Gianardi
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
| | - Simone Guadagni
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
| | - Gregorio Di Franco
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
| | - Matteo Palmeri
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
| | - Matteo Bianchini
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
| | - Kevin Pisani
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
| | - Giulio Di Candio
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy
| | - Luca Morelli
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Paradisa 2, 56125, Pisa, Italy.
- EndoCAS (Center for Computer Assisted Surgery), University of Pisa, Pisa, Italy.
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Adamenko O, Ferrari C, Schmidt J. Irrigation and passive drainage of pancreatic stump after distal pancreatectomy in high-risk patients: an innovative approach to reduce pancreatic fistula. Langenbecks Arch Surg 2020; 405:1233-1241. [PMID: 33084924 PMCID: PMC7686191 DOI: 10.1007/s00423-020-02012-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 10/11/2020] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Postoperative pancreatic fistula (POPF) represents the most common form of morbidity after distal pancreatectomy (DP). The aim of this study was to illustrate an innovative technique of irrigation and passive drainage to reduce clinically relevant POPF (CR-POPF) incidence in high-risk patients undergoing DP. MATERIAL AND METHODS Twelve consecutive high-risk patients received irrigation and passive drainage of the pancreatic stump with a Salem sump drainage after DP. The Salem sump was irrigated with 100 ml/h of Ringer solution for 2 postoperative days (POD). In the case of low-drain amylase and lipase levels on POD 3, the irrigation was reduced to 50 ml/h. Persistence of low-drain pancreatic enzymes on POD 4 allowed for interruption of irrigation and subsequent removal of drainage from POD 7 onward in the absence of evidence of any pancreatic fistula. RESULTS Overall, 16.6% of the patients experienced a grade 3 or higher surgical complication. We experienced only one case of POPF: the fistula was classified as grade B and it was managed with radiologic drainage of the fluid collection. We did not experience any case of re-operation nor in-hospital mortality. CONCLUSIONS Irrigation with passive drainage of the pancreatic stump after DP is an interesting approach for CR-POPF prevention in high-risk patients.
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Affiliation(s)
- Olga Adamenko
- Hirslanden Hospitals, Kappelistrasse 7, 8002, Zürich, Switzerland
| | - Carlo Ferrari
- Hirslanden Hospitals, Kappelistrasse 7, 8002, Zürich, Switzerland.
- Università degli Studi di Milano, Via Festa del Perdono 7, Milan, 20122, Italy.
| | - Jan Schmidt
- Hirslanden Hospitals, Kappelistrasse 7, 8002, Zürich, Switzerland
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21
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Sushma N, Gupta P, Kumar H, Sharma V, Mandavdhare H, Kumar-M P, Nada R, Yadav TD, Singh H. Role of ultrasound shear wave elastography in preoperative prediction of pancreatic fistula after pancreaticoduodenectomy. Pancreatology 2020; 20:1764-9. [PMID: 33139201 DOI: 10.1016/j.pan.2020.10.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/15/2020] [Accepted: 10/26/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Majority of predictors of postoperative pancreatic fistula (POPF) use intraoperative variables. We aimed to study the role of preoperative ultrasound shear wave elastography (USWE) to predict POPF. METHODS The consecutive patients who underwent pancreaticoduodenectomy (PD) between January 2019 to March 2020 were prospectively enrolled. All patients underwent USWE assessment at the pancreatic neck level. Intraoperative variables including pancreatic texture, pancreatic duct diameter, blood loss and histological grading of fibrosis were also recorded. Associations between USWE and intraoperative variables and histological grading with the development of POPF were analyzed. RESULTS Of the 62 patients assessed, 50 patients (mean age: 53 ± 14 years; 31 males) were included. POPF and clinically relevant POPF (CRPOPF) were observed in 22 (44%) and 7 (14%) patients respectively. Soft pancreas was an independent predictor of CRPOPF (p = 0.04). The mean USWE valve was significantly lower in patients with CRPOPF as compared to no CRPOPF (9.7 Kpa vs. 12.8Kpa, p = 0.016). At receiver operating characteristic curve analysis, USWE value of 12.65Kpa yielded sensitivity and specificity of 100% and 47%, respectively, for prediction of CRPOPF. USWE showed significant correlation with intraoperative pancreatic texture (Spearman's rank correlation coefficient (ρ) = 0.565, p = 0.001). CONCLUSION USWE helps in preoperative prediction of CRPOPF. This may further help to customize management strategy in high risk patients.
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Shinde RS, Acharya R, Chaudhari VA, Bhandare MS, Mungroop TH, Klompmaker S, Besselink MG, Shrikhande SV. External validation and comparison of the original, alternative and updated-alternative fistula risk scores for the prediction of postoperative pancreatic fistula after pancreatoduodenectomy. Pancreatology 2020; 20:751-756. [PMID: 32340876 DOI: 10.1016/j.pan.2020.04.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 03/13/2020] [Accepted: 04/07/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Many postoperative pancreatic fistula (POPF) predictions models were developed and validated in western populations. Direct use of these models in the large Indian/Asian population, however, requires proper validation. OBJECTIVE To validate the original, alternative and updated alternative fistula risk score (FRS) models. METHODS A validation study was performed in consecutive patients undergoing pancreatoduodenectomy (PD) from January 2011 to March 2018. The area under the receiver operating curve (ROC) and calibration plots were used to assess the performance of original-FRS (o-FRS), alternative FRS (a-FRS) and updated alternative FRS (ua-FRS) models. RESULTS This cohort consisted of 825 patients of which 66% were males with a median age of 55 years and mean body mass index of 22.6. The majority of tumors (61.8%) were of periampullary origin. Clinically relevant POPF was observed in 16.8% patients. Area under curve (AUC) of ROC for the o-FRS was 0.65, 0.69 for a-FRS and 0.70 for ua-FRS, respectively (p = 0.006). CONCLUSIONS In this large Indian cohort of predominantly periampullary tumors, the ua-FRS performed better than the a-FRS and o-FRS, although differences were small. Since the AUC value of the ua-FRS is at the accepted threshold there might be room for improvement for a FRS.
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Affiliation(s)
- Rajesh S Shinde
- GI & HPB Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Rajgopal Acharya
- GI & HPB Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Vikram A Chaudhari
- GI & HPB Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Manish S Bhandare
- GI & HPB Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Timothy H Mungroop
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Sjors Klompmaker
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Shailesh V Shrikhande
- GI & HPB Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India.
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Miyamoto R, Sano N, Maeda M, Inagawa S, Ohkohchi N. Modified Reinforced Staple Closure Technique Decreases Postoperative Pancreatic Fistula After Distal Pancreatectomy. Indian J Surg Oncol 2019; 10:587-593. [PMID: 31866728 DOI: 10.1007/s13193-019-00958-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 08/06/2019] [Indexed: 01/02/2023] Open
Abstract
Postoperative pancreatic fistula (POPF) is a serious complication that can occur following distal pancreatectomy (DP). Recent studies demonstrated that the use of reinforced staplers with bioabsorbable mesh significantly reduced the incidence of POPF, although the safety and efficacy of this approach remain controversial. Therefore, we originally developed a modified closure technique that combines the use of a reinforced stapler with bioabsorbable mesh with suture closure of the main pancreatic duct. The aim of this study was to determine whether our closure technique is predictive of POPF after DP. Fifty-nine consecutive patients who underwent DP were retrospectively enrolled. Based on the closure technique, we divided the cohort into a suture group (group A; n = 39) and a modified closure group (group B; n = 20). Using multivariate analysis, surgical closure techniques, including our method, and other well-known POPF risk factors were independently assessed. Multivariate logistic regression analysis identified no pathological fibrosis (odds ratio [OR], 5.41; p < 0.01), body mass index (> 25 kg/m2) (OR, 3.01; p = 0.02), and pancreatic stump closure technique (group A) (OR, 2.04; p = 0.01) as independent risk factors for POPF. The present study indicated that our modified closure technique is an additional useful technique to reduce POPF after DP.
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Affiliation(s)
- Ryoichi Miyamoto
- 1Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki 305-8558 Japan
- 2Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery and Organ Transplantation, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575 Japan
| | - Naoki Sano
- 1Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki 305-8558 Japan
| | - Michihiro Maeda
- 1Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki 305-8558 Japan
| | - Satoshi Inagawa
- 1Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki 305-8558 Japan
| | - Nobuhiro Ohkohchi
- 2Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery and Organ Transplantation, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575 Japan
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Virgilio E, LA Torre M, Cavallini M. An Alternative Surgery for an Atypical Kind of Grade C Postoperative Pancreatic Fistula Following Pancreaticoduodenectomy. Anticancer Res 2017; 37:3265-3269. [PMID: 28551674 DOI: 10.21873/anticanres.11690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 04/27/2017] [Accepted: 05/02/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Grade C postoperative pancreatic fistula (POPF) is a life-threatening complication of pancreaticoduodenectomy (PD), with its surgical management remaining under debate. Occasionally, POPF is associated with a compromised anastomotic Roux-limb. Our series focused to this sort of grade C mixed fistula. PATIENTS AND METHODS Between April 2004 and March 2014, 5 out of 12 patients with grade C POPF were classified as grade C mixed POPFs. Surgery consisted of associating resection of the anastomotic jejunal segment with resection and closure of the pancreatic stump. RESULTS Four patients suffered from a grade C mixed POPF discharging into a single dehiscent site; 1 patient was found with two dehiscent points in all (pancreatic anastomosis and jejunal rim). For all of them, the described surgical procedure resulted in complete recovery. CONCLUSION For grade C pancreatico-digestive POPF, resecting anastomotic jejunal segment during dismantling of the pancreatico-digestive anastomosis appears a very promising surgical technique.
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Affiliation(s)
- Edoardo Virgilio
- Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology "Sapienza", St. Andrea Hospital, Rome, Italy
| | - Marco LA Torre
- Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology "Sapienza", St. Andrea Hospital, Rome, Italy
| | - Marco Cavallini
- Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology "Sapienza", St. Andrea Hospital, Rome, Italy
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25
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Denbo JW, Slack RS, Bruno M, Cloyd JM, Prakash L, Fleming JB, Kim MP, Aloia TA, Vauthey JN, Lee JE, Katz MHG. Selective Perioperative Administration of Pasireotide is More Cost-Effective Than Routine Administration for Pancreatic Fistula Prophylaxis. J Gastrointest Surg 2017; 21:636-646. [PMID: 28050766 DOI: 10.1007/s11605-016-3340-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 11/30/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND In a randomized trial, pasireotide significantly decreased the incidence and severity of postoperative pancreatic fistula (POPF). Subsequent analyses concluded that its routine use is cost-effective. We hypothesized that selective administration of the drug to patients at high risk for POPF would be more cost-effective. STUDY DESIGN Consecutive patients who did not receive pasireotide and underwent pancreatoduodenectomy (PD) or distal pancreatectomy (DP) between July 2011 and January 2014 were distributed into groups based on their risk of POPF using a multivariate recursive partitioning regression tree analysis (RPA) of preoperative clinical factors. The costs of treating hypothetical patients in each risk group were then computed based upon actual institutional hospital costs and previously published relative risk values associated with pasireotide. RESULTS Among 315 patients who underwent pancreatectomy, grade B/C POPF occurred in 64 (20%). RPA allocated patients who underwent PD into four groups with a risk for grade B/C POPF of 0, 10, 29, or 60% (P < 0.001) on the basis of diagnosis, pancreatic duct diameter, and body mass index. Patients who underwent DP were allocated to three groups with a grade B/C POPF risk of 14, 26, or 44% (P = 0.05) on the basis of pancreatic duct diameter alone. Although the routine administration of pasireotide to all 315 patients would have theoretically saved $30,892 over standard care, restriction of pasireotide to only patients at high risk for POPF would have led to a cost savings of $831,916. CONCLUSION Preoperative clinical characteristics can be used to characterize patients' risk for POPF following pancreatectomy. Selective administration of pasireotide only to patients at high risk for grade B/C POPF may maximize the cost-efficacy of prophylactic pasireotide.
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Affiliation(s)
- Jason W Denbo
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030, USA
| | - Rebecca S Slack
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Morgan Bruno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030, USA
| | - Jordan M Cloyd
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030, USA
| | - Laura Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030, USA
| | - Jason B Fleming
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030, USA
| | - Michael P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030, USA
| | - Thomas A Aloia
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1484, Houston, TX, 77030, USA.
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