1
|
Ivey AD, Pratt HG, Niemann B, Ranson K, Puleo A, Fagan BM, Rao P, Landreth KM, Liu TW, Boone BA. Pancreatectomy Induces Cancer-Promoting Neutrophil Extracellular Traps. Ann Surg Oncol 2024; 31:3707-3717. [PMID: 38238536 DOI: 10.1245/s10434-023-14841-1] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 12/13/2023] [Indexed: 05/09/2024]
Abstract
BACKGROUND Neutrophil extracellular traps (NETs) occur when neutrophil chromatin is decondensed and extruded into the extracellular space in a web-like structure. Originally described as an anti-microbial function, this process has been implicated in the pathogenesis of pancreatic disease. In addition, NETs are upregulated during physiologic wound-healing and coagulation. This study evaluated how the inflammatory response to pancreatic surgery influences NET formation. METHODS For this study, 126 patients undergoing pancreatectomy gave consent before participation. Plasma was collected at several time points (preoperatively and through the postoperative outpatient visit). Plasma levels of NET markers, including cell-free DNA (cfDNA), citrullinated histone H3 (CitH3), interleukin (IL)-8, IL-6, and granulocyte colony-stimulating factor (G-CSF) were measured using enzyme-linked immunosorbent assay (ELISA). Patient clinical data were retrospectively collected from a prospectively maintained database. RESULTS After pancreatic resection, NET markers (cfDNA and CitH3) were elevated, peaking on postoperative days 3 and 4. This increase in NETs was due to an inherent change in neutrophil biology. Postoperatively, NET-inducing cytokines (IL-8, IL-6, and G-CSF) were increased, peaking early in the postoperative course. The patients undergoing the robotic approach had a reduction in NETs during the postoperative period compared with those who underwent the open approach. The patients who experienced a pancreatic leak had an increase in NET markers during the postoperative period. CONCLUSIONS Pancreatectomy induces cancer-promoting NET formation. The minimally invasive robotic approach may induce fewer NETs, although the current analysis was limited by selection bias. Pancreatic leak resulted in increased NETs. Further study into the potential for NET inhibition during the perioperative period is warranted.
Collapse
Affiliation(s)
- Abby D Ivey
- Cancer Cell Biology, West Virginia University, Morgantown, WV, USA
| | - Hillary G Pratt
- Cancer Cell Biology, West Virginia University, Morgantown, WV, USA
| | - Britney Niemann
- Department of Surgery, West Virginia University, Morgantown, WV, USA
| | - Kristen Ranson
- Department of Surgery, West Virginia University, Morgantown, WV, USA
| | - Amanda Puleo
- Department of Surgery, West Virginia University, Morgantown, WV, USA
| | - B Matthew Fagan
- Department of Surgery, West Virginia University, Morgantown, WV, USA
| | - Pavan Rao
- Department of Surgery, West Virginia University, Morgantown, WV, USA
- Department of Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Kaitlyn M Landreth
- Microbiology, Immunology and Cell Biology, West Virginia University, Morgantown, WV, USA
| | - Tracy W Liu
- Cancer Cell Biology, West Virginia University, Morgantown, WV, USA
- Microbiology, Immunology and Cell Biology, West Virginia University, Morgantown, WV, USA
| | - Brian A Boone
- Cancer Cell Biology, West Virginia University, Morgantown, WV, USA.
- Department of Surgery, West Virginia University, Morgantown, WV, USA.
- Microbiology, Immunology and Cell Biology, West Virginia University, Morgantown, WV, USA.
| |
Collapse
|
2
|
Boyev A, Azimuddin A, Newhook TE, Maxwell JE, Prakash LR, Bruno ML, Arvide EM, Dewhurst WL, Kim MP, Ikoma N, Snyder RA, Lee JE, Katz MHG, Tzeng CWD. Evaluation and Recalibration of Risk-Stratified Pancreatoduodenectomy Drain Fluid Amylase Removal Criteria. J Gastrointest Surg 2023; 27:2806-2814. [PMID: 37935998 DOI: 10.1007/s11605-023-05863-x] [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: 05/31/2023] [Accepted: 09/29/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND Risk-stratified drain fluid amylase cutoff values for postoperative day 1 (POD1) (DFA1) and POD3 (DFA3) can guide early drain removal after pancreatoduodenectomy (PD). The aim of this study was to evaluate and recalibrate cutoff values instituted in Feb 2019 using a prospective sequential cohort. METHODS We performed a single-institution prospective cohort study of consecutive patients who underwent pancreatoduodenectomy following implementation of institution-specific DFA cutoffs in February 2019 through April 2022. DFA values, drain removal, and clinically relevant postoperative pancreatic fistulas (CR-POPF) were analyzed. Receiver operating characteristic (ROC) curve analysis determined optimal cutoff values. RESULTS In total, 267 patients, 173 (65%) low-risk and 94 (35%) high-risk, underwent 228 (85%) open and 39 (15%) robotic pancreatoduodenectomies. Seven (4%) low-risk patients and 21 (22%) high-risk patients developed CR-POPF. Drains were removed in 147 (55%) patients before/on POD3, with 1 (0.7%) CR-POPF. In low-risk patients, CR-POPF was excluded with 100% sensitivity if DFA1 < 286 (area under curve, AUC = 0.893, p = 0.001) or DFA3 < 97 (AUC = 0.856, p = 0.002). DFA1 < 137 (AUC = 0.786, p < 0.001) or DFA3 < 56 (AUC = 0.819, p < 0.001) were 100% sensitive in high-risk patients. Previously established DFA1 cutoffs of 100 (low-risk) and < 26 (high-risk) were 100% sensitive, while DFA3 cutoffs of 300 (low-risk) and 200 (high-risk) had 57% and 91% sensitivity. CONCLUSIONS Within a learning health system, we recalibrated post-PD drain removal thresholds to DFA1 ≤ 300 and DFA3 ≤ 100 for low-risk and DFA1 ≤ 100 and DFA3 ≤ 50 for high-risk patients. This methodology is generalizable to other centers for developing institution-specific criteria to optimize safe early drain removal.
Collapse
Affiliation(s)
- Artem Boyev
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Ahad Azimuddin
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Timothy E Newhook
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Jessica E Maxwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Laura R Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Morgan L Bruno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Elsa M Arvide
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Whitney L Dewhurst
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Michael P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Rebecca A Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1484, Houston, TX, 77030, USA.
| |
Collapse
|
3
|
Devière J. Endoscopic Ultrasound-Guided Pancreatic Duct Interventions. Gastrointest Endosc Clin N Am 2023; 33:845-854. [PMID: 37709415 DOI: 10.1016/j.giec.2023.04.005] [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: 09/16/2023]
Abstract
Endoscopic ultrasound (EUS)-guided pancreatic duct drainage is one of the most challenging procedures in therapeutic endoscopy. Technical success is lower than for other therapeutic EUS procedures. However, when successful in a clear clinical indication, this procedure can offer a useful therapeutic alternative and improves the overall clinical success of the endoscopic approach. Current challenges include the standardization of clinical indications and of the techniques used for accessing the pancreatic duct, the strategy for mid-term and long-term management, and definition of the scope of the training that should be offered to a few highly experienced endoscopists.
Collapse
Affiliation(s)
- Jacques Devière
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, 808 Route de Lennik, Brussels B1070, Belgium.
| |
Collapse
|
4
|
Portela R, Dayyeh BA, Vahibe A, Ghanem OM. Pancreatic Leak After a Laparoscopic Sleeve Gastrectomy. Obes Surg 2022; 32:2825-2827. [PMID: 35689143 DOI: 10.1007/s11695-022-06137-2] [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: 03/07/2022] [Revised: 05/29/2022] [Accepted: 06/01/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Severe adhesions in patients with previous abdominal operations may lead to a more challenging subsequent bariatric surgery [1, 2]. In this context, sleeve gastrectomy (SG) is the preferred weight loss surgery since it solely involves stomach resection (without bowel involvement) in one abdominal compartment. Additionally, SG has lower complication rates and a shorter operative time than other bariatric procedures [3, 4]. In this paper, we present a multimedia video of the management of a pancreatic leak after SG in a patient with multiple previous abdominal surgeries. MATERIALS AND METHODS A 40-year-old female with a BMI of 36 kg/m2 and obesity-related comorbidities presented to our clinic for bariatric surgery evaluation. The patient had a history of a motor vehicle accident requiring a splenectomy, a liver laceration requiring packing and reoperation with an open abdomen for more than a month. This was followed by a hernia repair with component separation. Preoperative workup was completed, including an upper endoscopy (EGD) that was negative for esophagitis. The computed tomography (CT) scan showed an area in the left upper quadrant with no bowel loops adherent to the abdominal wall, thus a safer area for accessing the abdominal cavity (Fig. 1). The SG itself was challenging due to severe adhesions. These adhesions were between the bowel and abdominal wall, bowel and bowel, stomach and liver, and posterior stomach and pancreas (video). Once adhesiolysis was completed, the stomach was tailored successfully without intraoperative complications. The patient was discharged on postoperative day 1 with stable vitals and laboratory exams while tolerating a liquid diet. RESULTS On postoperative day 2, the patient returned to the emergency department with abdominal pain, increased heart rate (120 per minute), and a white blood cell count (WBC) of 20,000 th/µL. The CT scan showed a left upper quadrant collection with no evidence of air or contrast extravasation from the sleeve, as shown in Fig. 2. The patient became unstable and did not respond adequately to resuscitation efforts. Due to the extensive dissection in the primary operation, we elected to perform a laparoscopic exploration on an urgent basis. A collection (dark fluid) was noted in the left upper quadrant, but no sleeve staple line leak was found even with the air leak test (Fig. 2). Drainage and wash out were completed, and 2 abdominal drains were placed. Although the patient had symptomatic improvement postoperatively, an EGD with fluoroscopy was repeated, and no leak was noted (Fig. 3). The fluid evaluation showed increased lipase suggesting the diagnosis of a pancreatic leak. A liquid diet was initiated, and the initial drain in the left upper quadrant was exchanged to a higher caliber one (16F 40 cm locking loop drain). The patient was stable and eventually discharged home on postoperative day 6. Eventually, the drains were draining less than 10 mL and then downsized and removed. The patient's weight loss journey continued afterward with no other complications at 10-month follow-up. CONCLUSIONS Pancreatic leak is a rare but potentially severe complication after SG, especially in the difficult abdomen.
Collapse
Affiliation(s)
- Ray Portela
- Department of Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Barham Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Ahmet Vahibe
- Department of Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA
| | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, 200 1st St SW, Rochester, MN, 55905, USA.
| |
Collapse
|
5
|
Smith KD, Barth RJ, Colacchio TA, Chevalier JI, Bergmann LE, Purich ED, Gardner TB. Effect of intraoperative secretin on operative outcomes in pancreatic resection: A randomized controlled trial. Pancreatology 2021; 21:515-521. [PMID: 33602643 DOI: 10.1016/j.pan.2021.02.002] [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: 10/22/2020] [Revised: 01/25/2021] [Accepted: 02/01/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Objectives: We performed a randomized, double-blind, placebo-controlled trial to determine if using Secretin intra-operatively to identify leaks and subsequently target operative intervention would decrease the frequency of clinically significant post-operative pancreatic fistula formation. METHODS Patients undergoing pancreaticoduodenectomy or distal pancreatectomy were randomized to receive intra-operative Secretin or placebo intra-operatively following the completed pancreaticojejunostomy or closure of the cut remnant stump. If a potential leak was identified, targeted therapy with directed suture placement was performed. RESULTS 170 patients were randomized; 83 receiving placebo and 87 receiving Secretin. The rate of clinically significant fistula formation was 3% (3/87) in the Secretin group and 6% (5/83) in the placebo group (p = 0.489). The rate of biochemical leak was 29% (25/87) in the Secretin group and 19% (16/83) in the placebo group (p = 0.157). There were no Grade C post-operative fistula in either group. Of the 9% of patients in the Secretin group who had a targeted intra-operative intervention, none developed a clinically significant fistula. Adverse events were similar between groups. CONCLUSIONS Compared to placebo, intra-operative Secretin administration was not associated with an overall reduction in clinically significant pancreatic fistula formation. However, patients with an intra-operative leak identified by Secretin may benefit from intervention (clinicaltrials.gov: NCT02160808).
Collapse
Affiliation(s)
| | - Richard J Barth
- Section of General Surgery, Dartmouth-Hitchcock Medical Center, USA
| | | | - Jessica I Chevalier
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, USA
| | | | | | - Timothy B Gardner
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, USA.
| |
Collapse
|
6
|
Choi JU, Hwang S, Chung YK. Management of intractable pancreatic leak from iatrogenic pancreatic duct injury following resection of choledochal cyst in an adult patient. Ann Hepatobiliary Pancreat Surg 2020; 24:228-233. [PMID: 32457272 PMCID: PMC7271105 DOI: 10.14701/ahbps.2020.24.2.228] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 03/13/2020] [Accepted: 03/15/2020] [Indexed: 11/30/2022] Open
Abstract
Iatrogenic pancreatic duct injury can occur during resection of the choledochal cyst (CC). We herein present a case of postoperative pancreatic fistula (POPF) developed after resection of the CC in an adult patient with variant anomalous union of pancreatobiliary duct. The 55-year-old female patient underwent surgery after the diagnosis of CC-associated gallbladder cancer. During surgery, the CC mass was accidentally pulled out, by which the intrapancreatic CC portion was torn out from the main pancreatic duct. Since the pancreatic duct stump was not identified due to its small size, repair was not possible. The excavated defect at the pancreas head was closed securely combined with insertion of multiple drains. Postoperative POPF and peripancreatic fluid collection developed and the patient had to be fasted for 4 weeks. She was first discharged at 6 weeks after surgery. At 10 weeks, she was readmitted due to progression of peripancreatic fluid collection, which was controlled by percutaneous drain insertion. At 6 months, she was readmitted again due to repeated progression of peripancreatic fluid collection, which were controlled by endoscopic transmural duodenocystostomy. It took 8 months to resolve the pancreatic duct injury-associated pancreatitis. The experience in this case suggests that iatrogenic pancreatic duct injury during resection of CC can induce catastrophic complications, thus special attention should be paid to prevent pancreatic duct injury.
Collapse
Affiliation(s)
- Jin Uk Choi
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong-Kyu Chung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
7
|
Cai J, Ramanathan R, Zenati MS, Al Abbas A, Hogg ME, Zeh HJ, Zureikat AH. Robotic Pancreaticoduodenectomy Is Associated with Decreased Clinically Relevant Pancreatic Fistulas: a Propensity-Matched Analysis. J Gastrointest Surg 2020; 24:1111-1118. [PMID: 31267434 DOI: 10.1007/s11605-019-04274-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [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: 02/27/2019] [Accepted: 05/17/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD) is a major complication that adversely affects recovery. The robotic approach may decrease the incidence of this complication. This propensity-matched analysis evaluates the impact of robotic PD (RPD) on CR-POPF. METHODS Patients undergoing PD after the learning curve at a high-volume academic medical center were reviewed. CR-POPF outcomes after open PD (OPD) and RPD were compared. Logistic regression and propensity score matching (PSM) were used to define the independent effect of RPD on CR-POPF. RESULTS Of 865 PDs performed over the study period, 405 (46.8%) were OPD and 460 (53.2%) were RPD. RPD was associated with a similar overall POPF rate, but a lower incidence of CR-POPF (6.7% vs. 15.8%, p < 0.001). On multivariate analysis, RPD was an independent predictor of lower CR-POPF (OR 0.278, p < 0.001). Following propensity matching, RPD continued to be protective against the occurrence of CR-POPF (coefficient = - 0.113, p = 0.001). CONCLUSIONS This is the largest single-center PSM analysis to evaluate the impact of robotic approach on pancreatoduodenectomy and suggests that RPD can minimize the clinical impact of pancreatic leaks after PD.
Collapse
Affiliation(s)
- Jianpeng Cai
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Rajesh Ramanathan
- Department of Surgery, University of Pittsburgh Medical Center, 5150 Centre Ave, Suite 421, Pittsburgh, PA, 15232, USA
| | - Mazen S Zenati
- Department of Surgery and Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amr Al Abbas
- Department of Surgery, University of Pittsburgh Medical Center, 5150 Centre Ave, Suite 421, Pittsburgh, PA, 15232, USA
| | - Melissa E Hogg
- Department of Surgery, NorthShore Hospital, Chicago, IL, USA
| | - Herbert J Zeh
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, 5150 Centre Ave, Suite 421, Pittsburgh, PA, 15232, USA.
| |
Collapse
|
8
|
Gupta V, Kumar S, Gupta V, Joshi P, Rahul R, Yadav RK, Dangi A, Chandra A. Blumgart's technique of pancreaticojejunostomy: Analysis of safety and outcomes. Hepatobiliary Pancreat Dis Int 2019; 18:181-187. [PMID: 30772208 DOI: 10.1016/j.hbpd.2019.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 08/06/2018] [Accepted: 01/25/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Blumgart's pancreaticojejunostomy (PJ) has been described with low pancreatic leak rates. This study aimed to evaluate our experience with this technique regarding the pancreatic leak and other perioperative outcomes. METHODS We performed a single-center retrospective analysis of a cohort of 81 patients who underwent pancreaticoduodenectomy in our department from January 2011 to February 2018. The primary endpoint was the occurrence of a clinically relevant postoperative pancreatic fistula (CR-POPF) and analysis of its risk factors. RESULTS The CR-POPF rate was 12.3%. Fistula risk score (FRS) was the only significant risk factor for the occurrence of overall POPF in multivariate analysis. However, none of the other factors including FRS was found to be significantly associated with CR-POPF risk. A strong positive correlation was found between the CR-POPF and the incidence of delayed gastric emptying, post-pancreatectomy hemorrhage and increased length of hospital stay. CONCLUSION Blumgart's technique is a safe technique of pancreatico-enteric anastomosis with low rates of CR-POPF. CR-POPF with this technique is independent of most of the preoperative and intraoperative factors. Therefore, this technique can be used for all types of the pancreas with consistently good results.
Collapse
Affiliation(s)
- Vishal Gupta
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Saket Kumar
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Vivek Gupta
- Department of Human Organ Transplant, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Pradeep Joshi
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Rahul Rahul
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Rakesh Kumar Yadav
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Amit Dangi
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India
| | - Abhijit Chandra
- Department of Surgical Gastroenterology, King George's Medical University, Lucknow 226003, Uttar Pradesh, India.
| |
Collapse
|
9
|
Sulzer JK, Sastry AV, Meyer LM, Cochran A, Buhrman WC, Baker EH, Martinie JB, Iannitti DA, Vrochides D. The impact of intraoperative goal-directed fluid therapy on complications after pancreaticoduodenectomy. Ann Med Surg (Lond) 2018; 36:23-28. [PMID: 30370053 PMCID: PMC6199772 DOI: 10.1016/j.amsu.2018.10.018] [Citation(s) in RCA: 6] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 10/10/2018] [Accepted: 10/11/2018] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Optimal fluid balance is critical to minimize anastomotic edema in patients undergoing pancreaticoduodenectomy. We examined the effects of decreased fluid administration on rates of postoperative pancreatic leak and delayed gastric emptying. METHODS Retrospective study of 105 patients undergoing pancreaticoduodenectomy at a single institution from January 2015 through July 2016. Stroke volume variation (SVV) was tracked and titrated during the procedure. A comparative analysis of postoperative complications was performed between patients with a median SVV < 12 during the extirpative and reconstructive phases of the procedure compared with patients with an SVV ≥ 12. RESULTS Of 64 patients who met selection criteria, 42 (65.6%) had a SVV < 12 and 22 (34.4%) had a SVV ≥ 12. Patients with an SVV ≥ 12 during the extirpative phase of the procedure had lower rates of postoperative pancreatic leaks compared to patients with an SVV < 12 (5.9% vs 21.3%)). Patients with an SVV ≥ 12 during the extirpative phase had lower rates of postoperative delayed gastric emptying compared to patients with an SVV < 12 (41.2% vs 46.8%). CONCLUSION Goal-directed fluid restriction before the reconstructive phase of pancreaticoduodenectomy may contribute to lower postoperative rates of pancreatic leak and delayed gastric emptying.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Dionisios Vrochides
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA
| |
Collapse
|
10
|
Jwa EK, Hwang S. Extended pancreatic transection for secure pancreatic reconstruction during pancreaticoduodenectomy. Ann Hepatobiliary Pancreat Surg 2017; 21:138-145. [PMID: 28990000 PMCID: PMC5620474 DOI: 10.14701/ahbps.2017.21.3.138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 08/11/2017] [Accepted: 08/17/2017] [Indexed: 12/30/2022] Open
Abstract
Backgrounds/Aims Pancreaticoduodenectomy (PD) is associated with various surgical complications including healing failure of the pancreaticojejunostomy (PJ). This study intended to ensure blood supply to the pancreatic stump through extended pancreatic transection (EPT). Methods This study assessed whether EPT reduces PJ-associated complications and whether EPT is harmful on the remnant pancreatic function. The EPT group included 19 patients undergoing PD, pylorus-preserving PD (PPPD) or hepatopancreaticoduodenectomy. The propensity score matched control group included 45 patients who had undergone PPPD. Pancreatic transection was performed at the level of the celiac axis in the EPT group, by which the pancreatic body was additionally removed by 3 cm in length comparing with the conventional pancreatic transection. Results A small invagination fissure suspected as the embryonic fusion site was identified at the ventro-caudal edge of the pancreatic body in all patients undergoing EPT. A sizable fissure permitting easy separation of the pancreatic parenchyma was identified in 15 of 19 patients (78.9%). The incidence of significant postoperative pancreatic fistula was significantly lower in the EPT group than in the control group (p=0.047). There was no significant increase in the postoperative de novo diabetes mellitus in EPT group (p=0.60). Conclusions The EPT technique contributes to the prevention of major pancreatic fistula without impairing remnant pancreatic function. EPT is feasible for routine clinical application or at least in patients with any known risk of PJ leak.
Collapse
Affiliation(s)
- Eun-Kyoung Jwa
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
11
|
Yoon YI, Hwang S, Cho YJ, Ha TY, Song GW, Jung DH. Therapeutic effect of trans-drain administration of antibiotics in patients showing intractable pancreatic leak-associated pus drainage after pancreaticoduodenectomy. Korean J Hepatobiliary Pancreat Surg 2015; 19:17-24. [PMID: 26155272 PMCID: PMC4494091 DOI: 10.14701/kjhbps.2015.19.1.17] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Revised: 02/10/2015] [Accepted: 02/19/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUNDS/AIMS To cope with intractable pus drainage from persistent pancreatic leak after pancreaticoduodenectomy (PD), we have empirically performed local administration of high-concentration antibiotics cocktail solution into abdominal drains. The purpose of this study was to assess its therapeutic effect in patients showing intractable pus drainage after PD. METHODS The study group was 10 patients who underwent trans-drain administration of high-concentration antibiotics cocktail solution. Another 10 patients were selected through propensity score matching for the control group. Their medical records were retrospectively reviewed with focus on comparison of pancreatic fistula (PF)-associated clinical sequences. RESULTS Postoperative PF of grade B and C occurred in 7 and 3 patients in the study group and 9 and 1 patient in the control group, respectively (p=0.58). In the study group, a mean of 1.8 sessions of antibiotics cocktail solution (imipenem 500 mg and vancomycin 500 mg dissolved in 20 ml of normal saline) was administered. Two patients showed procedure-associated febrile episodes that were spontaneously controlled within 48 hours. At 2-4 days after the first-session of antibiotics administration, pus-like drain discharge turned to be serous with significantly decreased amount. The study group showed shortened postoperative hospital stay comparing to the control group (25.2±4.6 vs. 31.8±5.6 days, p=0.011). In both groups, no patient received radiological or surgical intervention due to PF-associated complications. CONCLUSIONS The results of our study demonstrated that trans-drain administration of antibiotics could be an effective therapeutic option for pancreaticojejunostomy leak-associated infection. Further validation of our result is necessary in large patient populations from multiple centers.
Collapse
Affiliation(s)
- Young-In Yoon
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yu-Jeong Cho
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
12
|
Reddymasu SC, Pakseresht K, Moloney B, Alsop B, Oropezia-Vail M, Olyaee M. Incidence of pancreatic fistula after distal pancreatectomy and efficacy of endoscopic therapy for its management: results from a tertiary care center. Case Rep Gastroenterol 2013; 7:332-9. [PMID: 24019766 PMCID: PMC3764947 DOI: 10.1159/000354136] [Citation(s) in RCA: 11] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Pancreatic fistula is a known complication of distal pancreatectomy. Endotherapy with pancreatic duct stent placement and pancreatic sphincterotomy has been shown to be effective in its management; however, experience of endotherapy in the management of this complication has not been extensively reported from the United States. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic stent placement has also been proposed to prevent this complication after distal pancreatectomy. In our cohort of 59 patients who underwent distal pancreatectomy, 13 (22%) developed a pancreatic fistula in the immediate postoperative period, of whom 8 (14%) patients (5 female, mean age 52 years) were referred for an ERCP because of ongoing symptoms related to the pancreatic fistula. The pancreatic fistula resolved in all patients after a median duration of 62 days from the index ERCP. The median number of ERCPs required to document resolution of the pancreatic fistula was 2. Although a sizeable percentage of patients develop a pancreatic fistula after distal pancreatectomy, only a small percentage of patients require ERCP for management of this complication. Given the high success rate of endotherapy in resolving pancreatic fistula and the fact that the majority of patients who undergo distal pancreatectomy never require an ERCP, performing ERCP for prophylactic pancreatic duct stent prior to distal pancreatectomy might not be necessary.
Collapse
Affiliation(s)
- Savio C Reddymasu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Creighton University Medical Center, Omaha, Nebr., USA
| | | | | | | | | | | |
Collapse
|
13
|
Nguyen JH. Distinguishing between parenchymal and anastomotic leakage at duct-to-mucosa pancreatic reconstruction in pancreaticoduodenectomy. World J Gastroenterol 2008; 14:6648-54. [PMID: 19034967 PMCID: PMC2773306 DOI: 10.3748/wjg.14.6648] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To distinguish anastomotic from parenchymal leakage at duct-to-mucosa reconstruction of the pancreatic remnant.
METHODS: We reviewed the charts of 68 pancreaticod-uodenectomies performed between 5/2000 and 12/2005 with end-to-side duct-to-mucosa pancreatojejunostomy (PJ). The results of pancreatography, as well as peripancreatic drain volumes, and amylase levels were analyzed.
RESULTS: Of 68 pancreatojejunostomies, 48 had no leak by pancreatography and had low-drain amylase (normal); eight had no pancreatographic leak but had elevated drain amylase (parenchymal leak); and 12 had pancreatographic leak and elevated drain amylase (anastomotic leak). Although drain volumes in the parenchymal leak group were significantly elevated at postoperative day (POD) 4, no difference was found at POD 7. Drain amylase level was not significantly different at POD 4. In contrast, at POD 7, the anastomotic-leak group had significantly elevated drain amylase level compared with normal and parenchymal-leak groups (14158 ± 24083 IU/L vs 89 ± 139 IU/L and 1707 ± 1515 IU/L, respectively, P = 0.012).
CONCLUSION: For pancreatic remnant reconstruction after pancreaticoduodenectomy, a combination of pancreatogram and peripancreatic drain amylase levels can be used to distinguish between parenchymal and anastomotic leakage at pancreatic remnant reconstruction.
Collapse
|