Intraoperative pancreas stump perfusion assessment during pancreaticoduodenectomy: A systematic scoping review

BACKGROUND

Post-operative pancreatic fistula (POPF) is the primary cause of morbidity following pancreaticoduodenectomy. Rates of POPF have remained high despite well known risk factors. The theory that hypoperfusion of the pancreatic stump leads to anastomotic failure has recently gained interest.

AIM

To define the published literature with regards to intraoperative pancreas perfusion assessment and its correlation with POPF.

METHODS

A systematic search of available literature was performed in November 2022. Data extracted included study characteristics, method of assessment of pancreas stump perfusion, POPF and other post-pancreatic surgery specific complications.

RESULTS

Five eligible studies comprised two prospective non-randomised studies and three case reports, total 156 patients. Four studies used indocyanine green fluorescence angiography to assess the pancreatic stump, with the remaining study assessing pancreas perfusion by visual inspection of arterial bleeding of the pancreatic stump. There was significant heterogeneity in the definition of POPF. Studies had a combined POPF rate of 12%; intraoperative perfusion assessment revealed hypoperfusion was present in 39% of patients who developed POPF. The rate of POPF was 11% in patients with no evidence of hypoperfusion and 13% in those with evidence of hypoperfusion, suggesting that not all hypoperfusion gives rise to POPF and further analysis is required to analyse if there is a clinically relevant cut off. Significant variance in practice was seen in the pancreatic stump management once hypoperfusion was identified.

CONCLUSION

The current published evidence around pancreas perfusion during pancreaticoduodenectomy is of poor quality. It does not support a causative link between hypoperfusion and POPF. Further well-designed prospective studies are required to investigate this.

Predictors of post-operative pancreatic fistula formation in pancreatic neuroendocrine tumors: A national surgical quality improvement program analysis

BACKGROUND

Post-operative pancreatic fistula (POPF) is a serious complication following pancreas surgery. We aimed to establish factors associated with POPF specifically in patients with pancreatic neuroendocrine tumors (PNET).

METHODS

The 2014-2018 American College of Surgeons National Surgical Quality Improvement Program database was querried for patients undergoing resection for PNET. The impact of patient, tumor, and operative factors on POPF formation was evaluated.

RESULTS

3532 patient underwent resections for PNET. The POPF rate was significantly higher in patients with PNET (24.8%) versus non-PNET (16.4%) (p < 0.0001). Male sex (OR 1.45, 95% CI 1.11-1.89), enucleation (OR 3.14, 95% CI 1.10-8.98), pancreaticoduodenectomy (OR 1.51, 95% CI 1.13-2.03), small duct size <3 mm (OR 3.24, 95% CI 1.62-6.48), and soft gland texture (OR 1.81, 95% CI 1.18-2.77) were independently associated with POPF in PNET patients on multivariable analysis.

CONCLUSIONS

POPF is more common in patients undergoing resection for PNET and is dictated primarily by surgical approach and gland characteristics.

Higher cumulative fluid follows a pancreaticoduodenectomy as a single modifiable factor for post-operative pancreatic fistula: Risk factor analysis

BACKGROUND

Postoperative pancreatic fistula (POPF) is one of the major complications after pancreaticoduodenectomy. There have been many studies into the risk factors determining POPF. Some studies have reported a higher peri-operative fluid balance associated with POPF, however, the pertinent findings remain controversial. The aims of this study were to determine risk factors of clinically relevant-post operative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy and an association between peri-operative fluid balance and the incidence of CR-POPF.

MATERIALS AND METHODS

This is a retrospective cohort study included all adult patients who underwent an elective open pancreaticoduodenectomy in our center from 2005 to 2018. Patients who did not have POPF related data were excluded from study. We divided patients into CR-POPF and no CR-POPF group. Peri-operative data including amount and type of fluid were compared between two groups. Logistic regression analysis was used to identify the independent risk factors of CR-POPF.

RESULTS

There were 223 pancreaticoduodenectomies done in our center during that period. The incidence of CR-POPF was 15.2 %. Patients in CR-POPF group had significant higher BMI, higher serum globulin level, smaller pancreatic duct diameter and higher cumulative fluid balance per body weight (FBPBW) at post-operative day 3. Multivariable analysis showed BMI >23 kg/m², diagnosis other than pancreatic duct adenocarcinoma or chronic pancreatitis and higher cumulative FBPBW at post-operative day 3 were the independent risk factors for CR-POPF.

CONCLUSIONS

Post-operative fluid balance was the post-operative modifiable risk factor to reduce CR-POPF. Higher positive post-operative fluid balance should be avoided especially in higher CR-POPF risk patients.

Delayed pancreatic fistula: An unaccustomed complication following pancreaticoduodenectomy- a rare case report

Introduction

and Importance: Post-operative pancreatic fistula is a morbid complication after pancreaticoduodenectomy. Though most of them present in the immediate post-operative period, few case reports have mentioned it even 7 years after index surgery. Here, we report a delayed presentation of pancreatic fistula 6 months after surgery.

Case presentation

A 57 year old female underwent Whipple's pancreaticoduodenectomy for pancreatic head adenocarcinoma and was discharged with an uneventful post-operative recovery. She presented after 6 months with complaints of abdominal pain and distension which upon evaluation was found to be a pancreatic enzyme rich mutiloculated collection. It was managed with per-cutaneous drain placement.

Clinical discussion

Pancreatic fistula remained a major cause of morbidity and mortality even after 100 years of its existence. It can be overt fistula which manifest in the immediate post-operative period or occult fistula which manifests long after primary surgery. Various causes of delayed fistula are anastomotic site stricture, previous chemotherapy, infection. The management options available are percutaneous drainage, endoscopic stenting of anastomotic stricture or redoing the anastomosis.

Conclusion

Pancreatic fistula can have a delayed presentation which can be diagnosed and managed with regular follow up.

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POPF is a morbid complication following PD.

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It can be occult and overt.

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Usually presents in the early post-operative period.

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Few cases has been described upto 7 years.

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Variuos management options are available.

Lymphopenia following pancreaticoduodenectomy is associated with pancreatic fistula formation

Backgrounds/Aims

Post-operative pancreatic fistulas (POPF) are a major source of morbidity following pancreaticoduodenectomy (PD). This study aims to investigate if persistent lymphopenia, a known marker of sepsis, can act as an additional marker of POPF with clinical implications that could help direct drain management.

Methods

A retrospective chart review of all patients who underwent PD in a single hospital network from 2008 to 2018. Persistent lymphopenia was defined as lymphopenia beyond post-operative day #3.

Results

Of the 201 patients who underwent PD during the study period 161 patients had relevant laboratory data, 81 of whom had persistent lymphopenia. 17 patients with persistent lymphopenia went on to develop a POPF, compared to 7 patients without. Persistent lymphopenia had a negative predictive value of 91.3%. Multivariate analysis revealed only persistent lymphopenia as being independently associated with POPF (HR 2.57, 95% CI 1.07-6.643, p=0.039). Patients with persistent lymphopenia were more likely to have a complication requiring intervention (56.8% vs 35.0%, p<0.001).

Conclusions

Persistent lymphopenia is a readily available early marker of POPF that holds the potential to identify clinically relevant POPF in patients where no surgical drain is present, and to act as an adjunct of drain amylase helping to guide drain management.

Should Drains Suck? A Propensity Score Analysis of Closed-Suction Versus Closed-Gravity Drainage After Pancreatectomy

BACKGROUND

Post-operative pancreatic fistula (POPF) remains one of the most common complications after pancreatic surgery. We previously reported that the majority of US surgeons leave drains after pancreatectomy. However, there remains controversy and surgeon bias on the use of gravity compared with suction drainage with limited data on patient outcomes to guide management.

METHODS

Demographics, comorbidities, perioperative, and outcome data were captured from the most recent ACS National Surgical Quality Improvement Program (NSQIP)-targeted pancreatectomy databases. This is a retrospective cohort analysis comparing closed-suction to closed-gravity drains with multivariate analysis and propensity score matching (PSM).

RESULTS

Of 9232 patients that underwent a pancreatectomy with closed drain placement, 1345 (15%) were to gravity and 7887 (85%) were to suction. On multivariate and PSM, stratified by surgery-type, there was no difference in biochemical leak (Whipple, 4 vs. 4%; distal, 8 vs. 6%) or clinically relevant (CR)-POPF (Whipple, 13 vs. 15%; distal, 12 vs. 15%). On multivariate analysis, there was an increase in organ-space surgical site infections with suction drains for patients undergoing Whipple procedure (12 vs. 16%, p = 0.004), which did not persist on PSM (p = 0.088). Finally, there were no significant differences in amylase level, time to drain removal, or superficial surgical site infections for patients undergoing either procedure based on drain type.

CONCLUSION

The majority of drains utilized after pancreatectomy in the USA are placed to suction, though a significant proportion are kept to gravity. Neither type of drain is associated with increased CR-POPF or other post-operative outcomes compared with the other; therefore, both types remain reasonable options if drains are to be placed.

Roux-en-Y versus single loop reconstruction in pancreaticoduodenectomy: A systematic review and meta-analysis

BACKGROUND

Post-operative pancreatic fistula (POPF) and delayed gastric emptying (DGE) both remain problematic complications following pancreaticoduodenectomy. This systematic review and meta-analysis evaluates whether Roux-en-Y compared to a single loop reconstruction in pancreaticoduodenectomy significantly reduces rates of these complications.

METHODS

A systematic review and meta-analysis was conducted according to the PRISMA guidelines by screening EMBASE, MEDLINE/PubMed, CENTRAL and bibliographic reference lists for comparative studies meeting the predetermined inclusion criteria. Post-operative outcome measures included: POPF, DGE, bile leak, operating time, blood loss, need for transfusion, wound infection, intra-abdominal collection, post-pancreatectomy haemorrhage, overall morbidity, re-operation, overall mortality, hospital length of stay. Pooled odds ratios or mean differences with 95% confidence intervals were calculated using either fixed- or random-effects models.

RESULTS

Fourteen studies were identified including four randomised controlled trials (RCTs) and 10 observational studies reporting a total of 2,031 patients. Data synthesis showed no statistically significant difference between the two groups in any of the outcome measures except operating time, which was longer in those undergoing Roux-en-Y reconstruction.

DISCUSSION

Roux-en-Y is not superior to single loop reconstruction in pancreaticoduodenectomy but may prolong operating time. Future high-quality randomised studies with appropriate study design and sample size power calculation may be required to further validate this conclusion.

Preoperative anthropomorphic radiographic measurements can predict postoperative pancreatic fistula formation following pancreatoduodenectomy

BACKGROUND

Postoperative pancreatic fistulae (POPF) are a major contributing factor to pancreatoduodenectomy-associated morbidity. Established risk calculators mostly rely on subjective or intraoperative assessments. We hypothesized that various objective preoperatively determined computed tomography (CT) measurements could predict POPF as well as validated models and allow for more informed operative consent in high-risk patients.

METHODS

Patients undergoing elective pancreatoduodenectomies between January 2013 and April 2018 were identified in a prospective database. Comparative statistical analyses and multivariable logistic regression models were generated to predict POPF development. Model performance was tested with receiver operating characteristics (ROC) curves. Pancreatic neck attenuation (Hounsfield units) was measured in triplicate by pancreatic protocol CT (venous phase, coronal plane) anterior to the portal vein. A pancreatic density index (PDI) was created to adjust for differences in contrast timing by dividing the mean of these measurements by the portal vein attenuation. Total areas of subcutaneous fat and skeletal muscle were calculated at the L3 vertebral level on axial CT. Pancreatic duct (PD) diameter was determined by CT.

RESULTS

In the study period 220 patients had elective pancreatoduodenectomies with 35 (16%) developing a POPF of any grade. Multivariable regression analysis revealed that demographics (age, sex, and race) were not associated with POPF, yet patients resected for pancreatic adenocarcinoma or chronic pancreatitis were less likely to develop a POPF (10 vs. 24%; p = 0.004). ROC curves were created using various combinations of gland texture, body mass index, skeletal muscle index, sarcopenia, PDI, PD diameter, and subcutaneous fat area indexed for height (SFI). A model replacing gland texture with SFI and PDI (AUC 0.844) had similar predictive performance as the established model (p = 0.169).

CONCLUSION

A combination of preoperative objective CT measurements can adequately predict POPF and is comparable to established models relying on subjective intraoperative variables. Validation in a larger dataset would allow for better preoperative stratification of high-risk patients and improve informed consent among this patient population.

Prolonged operating time is a significant perioperative risk factor for arterial pseudoaneurysm formation and patient death following hemorrhage after pancreaticoduodenectomy

BACKGROUND

Arterial pseudoaneurysm is a rare but potentially fatal complication after pancreaticoduodenectomy (PD). This study aimed to evaluate the incidence and predictors associated with pseudoaneurysm formation and patient death caused by its rupture.

PATIENTS AND METHOD

We retrospectively reviewed the data of 453 patients who underwent PD from April 2007 to February 2019. Uni- and multivariate analysis and receiver operating characteristic (ROC) curve analysis were performed to identify risk factors and optimal cutoff values.

RESULTS

Among the 453 patients, 22 (4.9%) developed pseudoaneurysm after PD. Median duration from surgery to detection of pseudoaneurysm was 17.0 (1-51) days. The locations of pseudoaneurysms were hepatic artery in 8, splenic artery in 3, gastroduodenal artery in 4, gastric artery in 2 and others in 5 patients, and 72.7% (16/22) of patients presented with hemorrhage. All pseudoaneurysms were treated using angioembolization. Lower age (<65.5 years, p = 0.004), prolonged operation time (Cutoff ˃610 min, p = 0.026) and postoperative pancreatic fistula (POPF) (p = 0.013) were the independent risk factors for development of pseudoaneurysm. 6 (27.3%) patients died due to rupture of pseudoaneurysm and prolonged operation time (Cutoff ˃657 min, p = 0.043) was a significant risk factor for death related to pseudoaneurysm.

CONCLUSION

Prolonged operating time was identified as a risk factor for both pseudoaneurysm formation and patient death following pseudoaneurysm bleeding. Interventional radiology treatment offered a central role in the treatment of pseudoaneurysms after PD. Therefore, it is important to have a high index of suspicion in high risk patients of the possibility of pseudoaneurysm formation and bleeding.

Standardization of early drain removal following pancreatic resection: proposal of the "Ottawa pancreatic drain algorithm"

Background

Early drain removal after pancreatic resection is encouraged for individuals with low postoperative day 1 drain amylase levels (POD1 DA) to mitigate associated morbidity. Although various protocols for drain management have been published, there is a need to assess the implementation of a standardized protocol.

Methods

The Ottawa pancreatic drain algorithm (OPDA), based on POD1 DA and effluent volume, was developed and implemented at our institution. A retrospective cohort analysis was conducted of all patients undergoing pancreatic resection January 1, 2016-October 30, 2017, excluding November and December 2016 (one month before and after OPDA implementation).

Results

42 patients pre-implementation and 53 patients post-implementation were included in the analysis. The median day of drain removal was significantly reduced after implementation of the OPDA (8 vs. 5 days; p = 0.01). Early drain removal appeared safe with no difference in reoperation or readmission rate after protocol implementation (p = 0.39; p = 0.76). On subgroup analysis, median length of stay was significantly shorter following OPDA implementation for patients who underwent DP and did not develop a postoperative pancreatic fistula (POPF) (6 vs 10 days, p = 0.03). Although the incidence of both surgical site infection and POPF were reduced following the intervention, neither reached statistical significance (38.1 to 28.3%, p = 0.31; and 38.1 to 28.3%, p = 0.31 respectively).

Conclusions

Implementing the OPDA was associated with earlier drain removal and decreased length of stay in patients undergoing distal pancreatectomy who did not develop POPF, without increased morbidity. Standardizing drain removal may help facilitate early drain removal after pancreatic resection at other institutions.

The Effect of Pancreaticojejunostomy Technique on Fistula Formation Following Pancreaticoduodenectomy in the Soft Pancreas

INTRODUCTION

A soft pancreas has been associated with an increased risk of post-operative pancreatic fistula formation. Few studies have evaluated the effect of anastomotic technique (duct to mucosa vs invagination) on fistula formation. This study aims to compare the effect of anastomotic technique on fistula formation among patients with a soft pancreas in a large multiinstitutional database.

METHODS

The targeted pancreas module of the American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) Database was used. All patients with a soft pancreas who underwent pancreaticoduodenectomy from 2014 to 2015 were identified. Demographic data, comorbid conditions, operative variables, and 30-day outcomes were compared using univariate and multivariable analyses.

RESULTS

A total of 975 patients met inclusion criteria. Eight-hundred fifty four (88%) underwent a duct to mucosa pancreaticojejunostomy technique and 121 (12%) underwent invagination. Patients who underwent invagination had higher 30-day mortality (5.8% vs 1.4%, p < 0.01), higher fistula formation (38% vs 25%, p < 0.01), and more often had percutaneous drain placement post-operatively (27% vs 14%, p < 0.01). Following multivariable analysis, invagination remained associated with pancreatic fistula formation (OR 2.5, CI 1.4-4.3) and post-operative percutaneous drain placement (OR 1.8, CI 1.1-2.9).

CONCLUSION

Invagination technique for pancreaticojejunostomy in patients with a soft pancreas is associated with increased rates of pancreatic fistula. Surgeons should consider utilizing a duct to mucosa technique when feasible to decrease morbidity following pancreaticoduodenectomy in this patient population.

Neoadjuvant Radiation Is Associated with Fistula Formation Following Pancreaticoduodenectomy

BACKGROUND

Post-operative pancreatic fistulas remain a significant source of morbidity following pancreatic surgery. Few studies have evaluated the effect of neoadjuvant chemotherapy and radiation on this adverse outcome. This study aims to evaluate the effects of neoadjuvant therapy on 30-day morbidity and mortality following pancreaticoduodenectomy.

STUDY DESIGN

A retrospective analysis was performed utilizing the targeted pancreas module of the National Surgical Quality Improvement Project (NSQIP) from 2014 to 2015 for patients undergoing pancreaticoduodenectomy with pancreaticojejunal reconstruction. A fistula was defined according to the NSQIP definition. Patient demographics, operative variables, and 30-day outcomes were compared between those who received no neoadjuvant therapy, chemoradiation, chemotherapy alone, and radiation alone. Univariate analysis was completed using chi-square, Fisher exact test, Student's t test, and Mann-Whitney U test where appropriate. Independent predictors of fistula formation were established using multivariable regression. A P value < 0.05 was considered significant.

RESULTS

Three thousand one hundred fourteen patients were included of which 559 patients (18%) developed a pancreatic fistula. Two thousand six hundred thirty-five (85%) patients did not undergo neoadjuvant therapy, 207 (6.6%) had chemoradiation, 256 (8.2%) had chemotherapy alone, and 16 (0.5%) had radiation alone. Patients who developed a fistula had increased 30-day mortality (4.9 vs. 1.7%, P < .001) and major morbidities. Following multivariable analysis, neoadjuvant radiation (OR 2.1, 95% CI 1.0-4.5) was associated with increased fistula formation while neoadjuvant chemotherapy (OR 0.5, 95% CI 0.3-0.9) was protective.

CONCLUSION

Neoadjuvant chemotherapy provides protection against the development of pancreatic fistulas while neoadjuvant radiation potentiates formation likely due to their effects on the texture of the pancreatic gland. Given the morbidity of pancreatic fistula formation, these factors should be considered in neoadjuvant regimens.

Comparison of Outcomes with Hand-sewn Versus Stapler Closure of Pancreatic Stump in Distal Pancreatectomy

AIM

The optimal method for pancreatic stump closure to prevent postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP), remains controversial though DP is still the only curative treatment for pancreatic cancer and other malignancies located on pancreatic body or tail.

PATIENTS AND METHODS

A total of 44 patients who consecutively underwent open DP were retrospectively analyzed, dividing them into two groups: group H (hand-sewn; n=24) and group S (stapler closure; n=20).

RESULTS

POPFs were encountered in 5 (21%) and 11 (55%) patients in groups H and S, respectively (p=0.02). POPFs of Clavien-Dindo grade IIIa or above were observed in two (8%) and seven (35%) patients in groups H and S, respectively (p=0.03).

CONCLUSION

When indicating stapler closure, caution should be exercised for pancreatic consistency and thickness, device and cartridge type, and pancreatic duct ligation to more effectively control POPF rates.

Delayed gastric emptying following pancreaticoduodenectomy: Incidence, risk factors, and healthcare utilization

AIM

To characterize incidence and risk factors for delayed gastric emptying (DGE) following pancreaticoduodenectomy and examine its implications on healthcare utilization.

METHODS

A prospectively-maintained database was reviewed. DGE was classified using International Study Group of Pancreatic Surgery criteria. Patients who developed DGE and those who did not were compared.

RESULTS

Two hundred and seventy-six patients underwent pancreaticoduodenectomy (PD) (> 80% pylorus-preserving, antecolic-reconstruction). DGE developed in 49 patients (17.8%): 5.1% grade B, 3.6% grade C. Demographic, clinical, and operative variables were similar between patients with DGE and those without. DGE patients were more likely to present multiple complications (32.6% vs 4.4%, ≥ 3 complications, P < 0.001), including postoperative pancreatic fistula (POPF) (42.9% vs 18.9%, P = 0.001) and intra-abdominal abscess (IAA) (16.3% vs 4.0%, P = 0.012). Patients with DGE had longer hospital stay (median, 12 d vs 7 d, P < 0.001) and were more likely to require transitional care upon discharge (24.5% vs 6.6%, P < 0.001). On multivariate analysis, predictors for DGE included POPF [OR = 3.39 (1.35-8.52), P = 0.009] and IAA [OR = 1.51 (1.03-2.22), P = 0.035].

CONCLUSION

Although DGE occurred in < 20% of patients after PD, it was associated with increased healthcare utilization. Patients with POPF and IAA were at risk for DGE. Anticipating DGE can help individualize care and allocate resources to high-risk patients.

A novel approach using liquid embolic agent for the treatment of pancreatic-cutaneous fistulas: Report of a case

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Novel approach for treating pancreatic-cutaneous fistulas developed post-pancreaticoduodenectomy.

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Use of liquid embolic agent to treat a high-output pancreatic-cutaneous fistula after a Whipple procedure, which to the best of our knowledge, has not been performed before.

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Minimally invasive treatment for a difficult problem that often results in additional surgery or prolonged drainage and TPN.

Pancreatic fistula formation remains one of the most dreadful complications after pancreaticoduodenectomies, resulting in extended hospital stays, increased healthcare costs, along with significantly increased morbidity and mortality. Little is mentioned in the literature about the use of percutaneous techniques to resolve this complication when conservative treatments fail. Thus, we developed a novel technique for treating pancreatic-cutaneous fistulas that develop post-pancreaticoduodenectomy. This work describes a novel approach of using a liquid embolic agent to treat a high-output pancreatic-cutaneous fistula after a Whipple procedure, which to the best of our knowledge after extensive literature searches, has not been performed before.

Prediction of post-operative pancreatic fistula in pancreaticoduodenectomy patients using pre-operative MRI: a pilot study

BACKGROUND

Post-operative pancreatic fistula (POPF) is one of the most fearful complications which may occur after pancreaticoduodenectomy (PD). The methods used to predict POPF pre-operatively have not been studied in great detail. We analyzed correlation between various parameters related to PD including pre-operative magnetic resonance imaging (MRI) signal intensity (SI), pathology of pancreatic fibrosis and occurrence rates of POPF, and verified that MRI SI results could be the determining values for pre-operative prediction of POPF.

METHODS

From January 2005 to August 2006, we retrospectively examined 43 cases of PDs by reviewing abdominal MRI findings, degree of fibrosis of remnant pancreatic stump, and other surgery-related parameters.

RESULTS

POPF encountered in PD were 11 cases (25.6%). Operation time and degree of fibrosis of remnant pancreatic cut surface were related to POPF (P= 0.030, P= 0.010). The pancreas-liver SI ratio (PLSI) between fistula group and no fistula group was -0.0009 +/- 0.2 and -0.1297 +/- 0.2, respectively (P= 0.0004). The pancreas-spleen SI ratio (PSSI) in each group was 0.423 +/- 0.25 and 0.288 +/- 0.32, respectively (P= 0.014). Using quantitative analysis, the SI ratios were 1.27 and 0.66 in each group (P= 0.013).

CONCLUSIONS

When analyzing the results of POPF in 43 patients who underwent PD, PLSI, PSSI and qualitative analysis, fistula group differed significantly from no fistula group. Using these results, it will be helpful for us to predict the occurrence of POPF pre-operatively using MRI in PD patients.