Sixteen cases of laparoscopic central pancreatectomy for benign or low-grade malignant tumours in the pancreatic neck and proximal body

BACKGROUND

The purpose of this study is to examine and analyse the outcomes and patient experiences associated with laparoscopic central pancreatectomy.

METHODS

The perioperative data of 16 patients who underwent laparoscopic central pancreatectomy were retrospectively analysed at Ningbo Medical Center Lihuili Hospital (Xingning Branch and Eastern Branch) from September 2017 to July 2023.

RESULTS

All surgical procedures were completed without the need for intraoperative conversion to open surgery. In two cases, intraoperative cholangiography was performed, while in four cases, intraoperative fluoroscopic laparoscopic assistance was utilized. The duration of the operations varied from 160 to 360 min, with an average of 281.75 min. The estimated volume of intraoperative bleeding ranged from 50 to 300 mL, with an average of 113.75 mL. The postoperative pathology results revealed that there were two cases of intraductal papillary mucinous neoplasm, six cases of serous cystic neoplasms, one case of mucinous cystic neoplasm, five cases of solid pseudopapillary neoplasms, and two cases of neuroendocrine tumours. The maximum diameter of the tumours ranged from 3.0 to 5.0 cm, with an average of 3.67 cm. There were no instances of postoperative common bile duct stenosis or biliary leakage. Among the cases, five did not exhibit pancreatic fistula, six experienced biochemical leakage, three had grade B pancreatic fistula, and two had grade C pancreatic fistula.

CONCLUSION

Laparoscopic central pancreatectomy, as a method to preserve pancreatic function, entails specific surgical risks and a notable likelihood of postoperative pancreatic fistula, necessitating the expertise of seasoned surgeons for its execution.

No Drain, No Problem: Serum-Based Marker Prediction of Clinically Relevant Postoperative Pancreatic Fistula

BACKGROUND

Postoperative day (POD) 1 drain amylase concentration (DAC) is considered the most accurate predictor for the development of a clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD). Recent studies have associated drain placement with negative postoperative outcomes. This study aims to evaluate multiple biochemical markers and their associations with CR-POPF development in order to identify a reliable, non-drain dependent alternative to DAC.

METHODS

This is a review of 53 consecutive PD patients between 2021 and 2022. Albumin, C-reactive protein (CRP), C-reactive protein-to-albumin ratio (CAR), DAC, white blood cell count, and procalcitonin values were compared by CR-POPF status. The discriminatory abilities of CAR, CRP, and DAC for CR-POPF were compared using receiver operating characteristic (ROC) curves.

RESULTS

Six of 51 included patients developed a CR-POPF. Receiver operating characteristic curve analysis produced an area under the curve of .977 for POD 1 DAC (cut-off 5131.0 IU/L, sensitivity 100%, specificity 95.5%), .858 for POD 1 CRP (cut-off 52.5 mg/L, sensitivity 100%, specificity 72.7%), and 1.000 for POD 3 CAR (cut-off 99.2, sensitivity and specificity 100%). POD 3 CAR produced a positive and negative predictive value of 100%.

CONCLUSION

The CAR and CRP provide early and accurate identification of patients with post-PD CR-POPFs. These markers offer a method of safe CR-POPF detection, when the gold standard DAC is unavailable, ultimately allowing for early intervention and patient rescue.

Value of the surgical pancreatic duct anatomy and associated outcomes in pancreatic cancer

INTRODUCTION

Pancreatic cancer recurrence following surgery is a significant challenge, and personalized surgical care is crucial. Topographical variations in pancreatic duct anatomy are frequent but often underestimated. This study aimed to investigate the potential importance of these variations in outcomes and patient survival after Whipple's procedures.

METHODS

Data were collected from 105 patients with confirmed pancreatic head neoplasms who underwent surgery between 2008 and 2020. Radiological measurements of pancreatic duct location were performed, and statistical analysis was carried out using IBM SPSS.

RESULTS

Inferior pancreatic duct topography was associated with an increased rate of metastatic spread and tumour recurrence. Additionally, inferior duct topography was associated with reduced overall and recurrence-free survival. Posterior pancreatic duct topography was associated with decreased incidence of perineural sheet infiltration and improved overall survival.

DISCUSSION

These findings suggest that topographical diversity of pancreatic duct location can impact outcomes in Whipple's procedures. Intraoperative review of pancreatic duct location could help surgeons define areas of risk or safety and deliver a personalized surgical approach for patients with beneficial or deleterious anatomical profiles. This study provides valuable information to improve surgical management by identifying high-risk patients and delivering a personalized surgical approach with prognosis stratification.

Efficacy of the 'Five-Needle' method for pancreatojejunostomy in laparoscopic pancreaticoduodenectomy: an observational study

Objective

The five-needle pancreato-intestinal anastomosis method is used in laparoscopic pancreaticoduodenectomy (LPD). The aim of this study was to explore the clinical efficacy and adverse reactions of this new surgical method and to provide a scientific reference for promoting this new surgical method in the future.

Methods

A single-centre observational study was conducted to evaluate the safety and practicality of the five-needle method for pancreatojejunostomy in LPD surgeries. The clinical data of 78 patients who were diagnosed with periampullary malignancies and underwent LPD were collected from the 1st of August 2020 to the 31st of June 2023 at Lanzhou University First Hospital. Forty-three patients were treated with the 'Five-Needle' method (test groups), and 35 patients were treated with the 'Duct-to-Mucosa' method (control group) for pancreatojejunostomy. These two methods are the most commonly used and highly preferred pancreatointestinal anastomosis methods worldwide. The primary outcome was pancreatic fistula, and the incidence of which was compared between the two groups.

Results

The incidence of pancreatic fistula in the five-needle method group and the duct-to-mucosa method group was not significantly different (25.6% vs. 28.6%, p=0.767). Additionally, there were no significant differences between the two groups in terms of intraoperative blood loss (Z=-1.330, p=0.183), postoperative haemorrhage rates (p=0.998), length of postoperative hospital stay (Z=-0.714, p=0.475), bile leakage rate (p=0.745), or perioperative mortality rate (p=0.999). However, the operative time in the 'Five-Needle' method group was significantly shorter than that in the 'Duct-to-Mucosa' method group (270 ± 170 mins vs. 300 ± 210 mins, Z=-2.336, p=0.019). Further analysis revealed that in patients with pancreatic ducts smaller than 3 mm, the incidence of pancreatic fistula was lower for the 'Five-Needle' method than for the 'Duct-to-Mucosa' method (12.5% vs. 53.8%, p=0.007).

Conclusion

The five-needle method is safe and efficient for pancreatojejunostomy in LPD, and is particularly suitable for anastomosis in nondilated pancreatic ducts. It is a promising, valuable, and recommendable surgical method worthy of wider adoption.

Impact of endoscopic ultrasound-guided transmural drainage for postoperative pancreatic fistula after pancreatic surgery

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.

Proposal of the novel predictive model for postoperative pancreatic fistula in distal pancreatectomy for pancreatic tumor based on preoperative imaging parameters and stapler handling

BACKGROUND

Distal pancreatectomy (DP) using linear staplers is widely performed; however, postoperative pancreatic fistulas (POPF) remain an issue. This study aimed to analyze preoperative risk factors for POPF and assess stapler handling.

METHODS

We retrospectively analyzed consecutive patients who underwent DP for pancreatic tumors using a linear stapler between 2014 and 2022. Preoperative measurements included pancreas-to-muscle signal intensity ratio (SIR) on fat-suppressed T1-weighted magnetic resonance imaging (MRI). The main outcome was clinically relevant POPF of the 2016 International Study Group of Pancreatic Fistulas definition. The predictive ability of the model was compared with the distal fistula risk score (D-FRS) by using the area under the receiver operating characteristic curve (AUROC).

RESULTS

Among the 81 patients, POPF occurred in 31 (38.2%). Multivariate analysis identified computed tomography-measured pancreatic thickness (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.05-1.61, p = 0.009) and SIR on T1-weighted MRI (OR 6.85, 95% CI 1.71-27.4, p = 0.002) as preoperative predictors. A novel preoperative model, "Thickness × MRI (TM)"-index, was established by multiplying these two variables. The TM-index exhibited the highest predictability preoperatively (AUROC 0.757, 95% CI 0.649-0.867). In the intraoperative variable analyses, TM-index (p < 0.001), thin cartridge application (p = 0.032), and short pre-firing compression (p = 0.047) were identified as significant risk factors for POPF. The model's AUROC combined with these two stapler handling methods was higher than D-FRS (0.851 vs. 0.660, p = 0.006).

CONCLUSIONS

The novel preoperative model exhibited excellent predictability. Thick cartridge use and long pre-firing compression were protective factors against POPF. This model may facilitate preventive surgical strategy development to reduce POPF.

Assessing Intra-abdominal status for clinically relevant postoperative pancreatic fistula based on postoperative fluid collection and drain amylase levels after distal pancreatectomy

Aim

The aim of this study was to evaluate the intra-abdominal status related to postoperative pancreatic fistula by combining postoperative fluid collection and drain amylase levels.

Methods

We retrospectively reviewed the data of 203 patients who underwent distal pancreatectomy and classified their postoperative abdominal status into four groups based on postoperative fluid collection size and drain amylase levels. We also evaluated the incidence of clinically relevant postoperative pancreatic fistula in each group according to C-reactive protein values.

Results

The incidence of clinically relevant postoperative pancreatic fistula in the entire cohort (n = 203) was 28.1%. Multivariate analysis revealed that postoperative fluid collection, drain amylase levels, and C-reactive protein levels are considerable risk factors for clinically relevant postoperative pancreatic fistula. In the subgroup with large postoperative fluid collection and high drain amylase levels, 65.9% of patients developed clinically relevant postoperative pancreatic fistula. However, no significant difference was observed in C-reactive protein levels between patients with clinically relevant postoperative pancreatic fistula and those without it. In contrast, in the subgroup with a large postoperative fluid collection size or a high amylase level alone, a significant difference was observed in C-reactive protein values between the patients with clinically relevant postoperative pancreatic fistula and those without it.

Conclusion

Postoperative fluid collection status and the C-reactive protein value provide a more precise assessment of intra=abdominal status related to postoperative pancreatic fistula after distal pancreatectomy. This detailed analysis may be a clinically reasonable approach to individual drain management.

Tomoelastography and Pancreatic Extracellular Volume Fraction Derived From MRI for Predicting Clinically Relevant Postoperative Pancreatic Fistula

BACKGROUND

Pancreatic stiffness and extracellular volume fraction (ECV) are potential imaging biomarkers for pancreatic fibrosis. Clinically relevant postoperative fistula (CR-POPF) is one of the most severe complications after pancreaticoduodenectomy. Which imaging biomarker performs better for predicting the risk of CR-POPF remains unknown.

PURPOSE

To evaluate the diagnostic performance of ECV and tomoelastography-derived pancreatic stiffness for predicting the risk of CR-POPF in patients undergoing pancreaticoduodenectomy.

STUDY TYPE

Prospective.

POPULATION

Eighty patients who underwent multiparametric pancreatic MRI before pancreaticoduodenectomy, among whom 16 developed CR-POPF and 64 did not.

FIELD STRENGTH/SEQUENCE

3 T/tomoelastography and precontrast and postcontrast T1 mapping of the pancreas.

ASSESSMENT

Pancreatic stiffness was measured on the tomographic c-map, and pancreatic ECV was calculated from precontrast and postcontrast T1 maps. Pancreatic stiffness and ECV were compared with histological fibrosis grading (F0-F3). The optimal cutoff values for predicting CR-POPF were determined, and the correlation between CR-POPF and imaging parameters was evaluated.

STATISTICAL TESTS

The Spearman's rank correlation and multivariate linear regression analysis was conducted. The receiver operating characteristic curve analysis and logistic regression analysis was performed. A double-sided P < 0.05 indicated a statistically significant difference.

RESULTS

Pancreatic stiffness and ECV both showed a significantly positive correlation with histological pancreatic fibrosis (r = 0.73 and 0.56, respectively). Patients with advanced pancreatic fibrosis had significantly higher pancreatic stiffness and ECV compared to those with no/mild fibrosis. Pancreatic stiffness and ECV were also correlated with each other (r = 0.58). Lower pancreatic stiffness (<1.38 m/sec), lower ECV (<0.28), nondilated main pancreatic duct (<3 mm) and pathological diagnosis other than pancreatic ductal adenocarcinoma were associated with higher risk of CR-POPF at univariate analysis, and pancreatic stiffness was independently associated with CR-POPF at multivariate analysis (odds ratio: 18.59, 95% confidence interval: 4.45, 77.69).

DATA CONCLUSION

Pancreatic stiffness and ECV were associated with histological fibrosis grading, and pancreatic stiffness was an independent predictor for CR-POPF.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY STAGE: 5.

Application of Neo-Pancreaticogastrostomy in Total Laparoscopic Pancreaticoduodenectomy

Objective: To introduce laparoscopic neo-pancreaticogastrostomy (neo-PG) and investigate its application potential in total laparoscopic pancreaticoduodenectomy (TLPD). Materials and Methods: We performed a single-center prospective single-arm trial to evaluate the feasibility and safety of neo-PG for its initial application in TLPD. The first 50 patients who were operated by a single surgeon and who underwent TLPD with neo-PG at our institution were recruited. The pre/intra/postoperation data were collected and analyzed. Results: Twenty-nine male patients and 21 female patients from May 2022 to March 2023 were included. The mean operation time was 272.60 ± 47.30 minutes. The median PG time was 16 (15, 23) minutes. Six patients had delayed gastric emptying (DGE), and all underwent standard LPD. None of the patients had Grade B/C postoperative pancreatic fistula (POPF) or postoperative hemorrhage, or underwent reoperation. The median length of post-LPD hospital stay was 6 (6, 8) days. None of the patients died within 90 days after surgery. Nineteen cases were pathologically classified as pancreatic lesion, 6 cases as bile duct lesion, 18 cases as duodenal lesion, and 7 cases as ampullary lesion. Conclusion: The laparoscopic neo-PG is a simple, safe, and feasible pancreatic anastomosis that can be applied in TLPD. Pylorus-preserving LPD may decrease DGE rate. Further studies involving more surgeons are warranted to prove that our new technique may terminate POPF in TLPD.

Endoscopic Nasopancreatic Drainage Contributes to Early Resolution of Postgastrectomy Gastropancreatic Fistula

A 76-year-old man experienced abdominal pain 43 days after gastric cancer resection. Computed tomography revealed a gastric wall defect extending to the pancreas, and endoscopic retrograde pancreatography revealed a gastropancreatic fistula. Afterward, a nasopancreatic duct drainage tube was inserted. Seven days later, no leakage of the contrast medium from the duct was observed, and the patient was discharged 22 days after endoscopic nasopancreatic duct drainage. Endoscopic nasopancreatic duct drainage prevents pancreatic juice leakage and promotes gastric ulcer healing.

Preoperative zinc status predicts the occurrence and healing time of pancreatic fistula after distal pancreatectomy

BACKGROUND

There are few studies that examined the relationship between preoperative zinc (Zn) concentrations and postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP).

METHODS

Data from 98 patients who underwent DP between January 2016 and April 2022 were retrospectively reviewed. Patients' clinicopathological and surgical outcomes were analyzed, and we examined the relationship between Zn and clinically relevant POPF (CR-POPF) after DP.

RESULTS

In this series, 41 (41.8%) patients had POPF and 31 (31.8%) patients had CR-POPF. The cut-off value for the preoperative Zn concentration was 74 μg/dL for POPF and CR-POPF. Patients with low Zn concentrations were significantly related with high age, low albumin concentrations, higher CRP concentrations, higher NLR, lower PNI, higher rates of POPF and CR-POPF, longer POPF healing time, longer hospital stay, and postoperative complications than patients with high Zn concentrations. The healing time of POPF after DP was significantly negatively correlated with serum Zn concentrations. A multivariate logistic regression analysis showed that preoperative lower Zn concentrations and a prolonged operation time were independent predictors of CR-POPF and the healing time of POPF after DP. The POPF healing time in patients with high Zn was significantly shorter than that in patients with low Zn concentrations.

CONCLUSIONS

This retrospective study showed the association between the preoperative Zn concentrations and the occurrence of POPF and the healing time after DP. Zn is a simple biomarker for malnutrition, which may lead to POPF after DP.

Recent trends in organ-preserving pancreatectomy: Its problems and clinical advantages compared with other standard pancreatectomies

In this review article, we focus on recent papers on organ-preserving pancreatectomy procedures published since 2010. When comparing central pancreatectomy (CP) and distal pancreatectomy (DP), most studies have concluded that the CP group exhibited significantly lower incidence of new-onset diabetes or diabetes exacerbation than the DP group postoperatively. However, because of increased incidence of morbidities such as pancreatic fistula, the surgeon faces a considerable trade-off between increased short-term morbidity and long-term preservation of endocrine function. When the outcomes of two types of spleen-preserving DP (Kimura and Warshaw procedures) are compared, most studies mentioned the low incidence of postoperative gastric varices and splenic infarction with the Kimura procedure. Although there are several reports regarding the effect of spleen preservation on prevention of postoperative infections, no report on the contribution of spleen preservation to the prevention of overwhelming post-splenectomy infection is seen. The advantages of duodenum-preserving pancreatic head resection (DPPHR) concerning endocrine and exocrine functions continue to be subjects of discussion, mainly due to the limited number of institutions that have adopted this approach; however, DPPHR should be presented as an option for patients due to its low incidence of postoperative cholangitis. Organ-preserving pancreatectomy requires meticulous surgical techniques, and postoperative complications may increase with this surgery compared with standard pancreatectomy, which may be influenced by the surgeon's skill and the surgical facility where the procedure is performed. Nonetheless, this technique has significant long-term advantages in terms of endocrine and exocrine functions and its wider adoption in the future is expected.

A modified single-needle continuous suture of duct-to-mucosa pancreaticojejunostomy in pancreaticoduodenectomy

Background

The pancreatic reconstruction technique decides the incidence of postoperative pancreatic fistulas (POPF) in pancreaticoduodenectomy (PD). This study aims to evaluate the safety of modified single-needle continuous suture (SNCS) of duct-to-mucosa and compare the efficacy with double-layer continuous suture (DLCS) of duct-mucosa pancreaticojejunostomy (PJ) in open PD (OPD).

Methods

A total of 266 patients that received PD between January 2019 and May 2023 were retrospectively analyzed. Among them, 130 patients underwent DLCS, and 136 patients underwent SNCS [73 OPD and 63 laparoscopic PD (LPD)]. The primary outcome was clinically relevant POPF (CR-POPF) according to the definition of the revised 2016 International Study Group of Pancreatic Fistula (ISGPF). Propensity score matching (PSM) was conducted to reduce confounding bias.

Results

A total of 66 pairs were successfully matched using PSM in OPD. No significant difference was observed in the occurrence of CR-POPF between the two groups (9.1% vs. 21.2%, P=0.052). However, the median duration of operation and PJ was shorter in the SNCS group. The incidence of CR-POPF in LPD was 9.5%. Furthermore, regarding the alternative fistula risk score (a-FRS), the CR-POPF rate were 2.1%, 10.5%, and 15.6% in low-, intermediate-, and high-risk groups (P=0.067).

Conclusions

The SNCS is a facile, safe, and effective PJ technique and does not increase the incidence of POPF, regardless of a-FRS stratification, pancreatic texture, and main pancreatic duct (MPD) size.

Intraoperative Fluorescence Imaging During Robotic Pancreatoduodenectomy to Detect Suture-Induced Hypoperfusion of the Pancreatic Stump as a Predictor of Postoperative Pancreatic Fistula (FLUOPAN): Prospective Proof-of-concept Study

Background

A potential downside of robotic pancreatoduodenectomy (RPD) is the lack of tactile feedback when tying sutures, which could be especially perilous during pancreatic anastomosis. Near-infrared fluorescence imaging with indocyanine green (NIRF-ICG) could detect transpancreatic-suture-induced hypoperfusion of the pancreatic stump during RPD, which may be related to postoperative pancreatic fistula (POPF) grade B/C, but studies are lacking.

Methods

This prospective study included 37 patients undergoing RPD to assess the relation between pancreatic stump hypoperfusion as objectified with NIRF-ICG using Firefly and the rate of POPF grade B/C. In 27 patients, NIRF-ICG was performed after tying down the transpancreatic U-sutures. In 10 'negative control' patients, NIRF-ICG was performed before tying these sutures.

Results

Pancreatic stump hypoperfusion was detected using NIRF-ICG in 9/27 patients (33%) during RPD. Hypoperfusion was associated with POPF grade B/C (67% [6/9 patients] versus 17% [3/18 patients], P = 0.026). No hypoperfusion was objectified in 10 'negative controls'.

Conclusions

Transpancreatic-suture-induced pancreatic stump hypoperfusion can be detected using NIRF-ICG during RPD and was associated with POPF grade B/C. Surgeons could use NIRF-ICG to adapt their suturing approach during robotic pancreatico-jejunostomy. Further larger prospective studies are needed to validate the association between transpancreatic-suture-induced hypoperfusion and POPF.

Complications of Whipple procedure in a pediatric patient with pseudopapillary tumor of the pancreas

Pancreatic neoplasms are rare in pediatrics; the pseudopapillary tumor (PPT) of the pancreas is the most common. PPTs of the pancreas are usually located in the head of the pancreas. A pancreaticoduodenectomy or Whipple procedure is the technique of choice for the treatment of benign or malignant pancreatic tumors. Although mortality for this cause has decreased in recent years, due to the greater experience of surgeons and improved pre- and postoperative care, morbidity has remained high secondary to associated complications. These include delayed gastric emptying, intra-abdominal collections, pancreatic fistula, surgical site restenosis, and post-pancreatectomy hemorrhage. Here we describe the clinical case of a 13-year-old girl diagnosed with PPT of the pancreas who underwent an effective surgery in terms of cancer treatment, but who required a prolonged hospitalization secondary to surgical complications.

Hyperglycemia and insulin infusion in pancreatoduodenectomy: a prospective cohort study on feasibility and impact on complications

BACKGROUND

Hyperglycemia is a risk factor for postoperative complications but its impact on outcome after pancreatoduodenectomy (PD) is scarcely studied. This prospective cohort study aimed to assess the effect of continuous insulin infusion on postoperative complications and blood glucose, as well as to evaluate the impact of hyperglycemia on complications, after PD.

MATERIALS AND METHODS

One hundred patients planned for PD at Skåne University Hospital, Sweden were prospectively included for perioperative continuous insulin infusion and a historic cohort of 100 patients was included retrospectively. Median blood glucose levels were calculated and data on complications were analyzed and compared between the historic cohort and the intervention group as well as between normo- and hyperglycemic patients.

RESULTS

Median glucose levels were significantly lower in the intervention group compared to the historic cohort up to 30 days postoperatively (median glucose 8.5 mmol/l (interquartile range 6.4-11) vs. 9.1 mmol/l (interquartile range 6.8-17) ( P =0.007)). No significant differences in complication rates were recorded between these two groups. The incidence of complications classified as Clavien ≥3 was higher in hyperglycemic patients (100 vs. 27%, P =0.024). Among hyperglycemic patients the prevalence of preoperative diabetes was higher compared to normoglycemic patients (52 vs.12%, P <0.001). In patients with a known diagnosis of diabetes, a trend, although not statistically significant, towards a lower incidence of postoperative pancreatic fistula grade B and C, as well as postpancreatectomy hemorrhage grade B and C, was seen compared to those without preoperative diabetes (6.8 vs. 14%, P =0.231 and 2.3 vs. 7.0%, P =0.238, respectively).

CONCLUSION

Insulin infusion in the early postoperative phase after PD is feasible in a non-ICU setting and significantly decreased blood glucose levels. The influence on complications was limited. Preoperative diabetes was a significant predictor of postoperative hyperglycemia and was associated with a lower incidence of clinically significant postoperative pancreatic fistula.

Hepatic artery protection using a polyglycolic acid sheet during pancreaticoduodenectomy: A multicenter study

BACKGROUND

Postpancreatectomy hemorrhage (PPH) is the most feared complication after pancreaticoduodenectomy (PD). The most common cause is erosion of the gastroduodenal artery stump. Preventive measures have been previously reported, but a consensus is lacking. The aim of this study was to analyze the preventive effect of reinforcing the hepatic artery using a polyglycolic acid (PGA) sheet during PD.

METHODS

A multicenter retrospective study was performed, collecting data from three tertiary hospitals in Korea. Patients receiving PD from January 2016 to December 2021 were included. The primary endpoint was rate of PPH from the hepatic artery. Arterial reinforcement (AR) was performed by wrapping the artery with Neoveil (Gunze Ltd) and applying fibrin glue. The perioperative data of patients who did not receive AR were compared with data of those who received AR.

RESULTS

A total of 904 patients were analyzed. The rate of PPH from the hepatic artery was significantly lower in the AR group. (3.5% vs 0.7%, p = .002) In patients with CR-POPF, the 90 day mortality rate of the AR group was less than half that of the non-AR group (7.2% vs 3.5%, p = .455) Risk factor analysis showed CR-POPF to be an independent risk factor for PPH. Arterial reinforcement was shown to be a strong protective factor for PPH (OR 0.20, 95% CI: 0.05-0.72, p = .014).

CONCLUSIONS

AR of the hepatic artery using Neoveil and fibrin glue is a simple method that greatly reduces the rate of PPH after PD.

Percutaneous Trans-jejunum Pancreatojejunostomy Reconstruction for Intractable Pancreatic Fistula after Pancreatoduodenectomy

We present an interventional radiology technique for percutaneous trans-jejunal pancreatojejunostomy reconstruction for intractable pancreatic fistula. A 70-year-old man with pancreatic cancer who had undergone pancreatoduodenectomy underwent percutaneous drainage for leakage from the anastomosis of the pancreatic duct to the jejunum. The leakage continued and the hole at the anastomosis site in the jejunum closed completely after 5 months. We performed percutaneous jejunostomy; the previously placed drainage catheter was then replaced with a balloon catheter, which was punctured by a 19-gauge needle from inside the jejunum through the percutaneous jejunostomy tube. The seeking catheter was inserted into the pancreatic duct. Finally, a side-holed 6-Fr straight catheter was successfully placed in the pancreatic duct through the percutaneous jejunostomy route.

Pancreaticogastrostomy versus Pancreaticojejunostomy and the Proposal of a New Postoperative Pancreatic Fistula Risk Score

Despite the substantial decrease in mortality rates following a pancreaticoduodenectomy to less than 5%, morbidity rates remain significant, reaching even 73%. Postoperative pancreatic fistula is one of the most frequent major complications and is significantly associated with other complications, including patient death. Currently, there is no consensus regarding the ideal type of pancreatic anastomosis, as the question of the choice between a pancreaticogastrostomy and pancreaticojejunostomy is still open. Furthermore, worldwide implementation of an ideal pancreatic fistula risk prediction score is missing. Our study found several significant predictive factors for the postoperative occurrence of fistulas, such as the soft consistency of the pancreas, non-dilated Wirsung duct, important intraoperative blood loss, other perioperative complications, preoperative patient hypoalbuminemia, and patient weight loss. Our study also revealed that for patients who exhibit fistula risk factors, pancreaticogastrostomy demonstrates a significantly lower pancreatic fistula rate than pancreaticojejunostomy. The occurrence of pancreatic fistulas has been significantly associated with the development of other postoperative major complications, and patient death. As the current pancreatic fistula risk scores proposed by various authors have not been consensually validated, we propose a simple, easy-to-use, and sensitive score for the risk prediction of postoperative pancreatic fistula occurrence based on important predictors from statistical analyses that have also been found to be significant by most of the reported studies. The new pancreatic fistula risk score proposed by us could be extremely useful for improved therapeutic management of cephalic pancreaticoduodenectomy patients.

A Multicenter Randomized Phase II Trial Investigating the Effect of Polyglycolic Acid Sheet on the Prevention of Pancreatic Fistula After Gastrectomy with Prophylactic Lymph Node Dissection

Pancreatic fistula after gastrectomy with lymph node dissection is associated with prolonged hospital stay and critical complications such as intra-abdominal bleeding and sepsis. Polyglycolic acid (PGA) sheets are absorbable suture reinforcement materials. A randomized Phase II trial has been planned to evaluate the effect of PGA sheets on preventing postoperative pancreatic fistula. A total of 320 patients will be recruited from thirteen institutions. Patients who are scheduled to undergo distal or total gastrectomy will be randomly allocated into the PGA group or control group, and the dissected area around the pancreas will be covered by the PGA sheet in the PGA group. The primary endpoint will be the maximum value of drain amylase concentration up to 5 days after surgery. The secondary endpoints will be as follows: transition of value of amylases of drain discharge, incidence of pancreatic fistula, incidence of intra-abdominal abscess, white blood cell count, value of C-reactive protein, incidence of postoperative complication, duration of antibiotic agents administration, duration of abdominal drainage, usage of octreotide, duration of hospital stay, incidence of bleeding in abdominal cavity, mortality, and incidence of reoperation.

Evaluation of the Value of Intraoperative Peri-Pancreatic Fluid Amylase Concentration in Predicting a Postoperative Pancreatic Fistula After Pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is a common complication after pancreaticoduodenectomy (PD) and is a cause of significant morbidity and mortality. This study aimed to assess the predictive value of the amylase concentration of fluid accumulating in the peri-pancreatic region intraoperatively or intraoperative amylase concentration (IOAC) for the development of a clinically relevant POPF after PD.

METHODS

All consecutive patients who underwent PD between April 2018 and May 2021 were prospectively included in the study. IOAC and postoperative day-three drain fluid amylase values were measured, and the incidence of clinically relevant POPF (CR-POPF) was noted. Receiver operating characteristic analysis was used to evaluate the predictive capacity of the IOAC for a CR-POPF.

RESULTS

The study included 64 patients. A clinically relevant POPF was seen in 12 (18.8%) patients. On ROC analysis, the area under the curve (AUC) was 0.912 (with 95% CI of 0.822-1.001, p<0.001), which is highly significant. A cut-off IOAC value of 236 IU/L was derived, and an IOAC above this value was shown to predict the development of a CR-POPF in the postoperative period with a sensitivity of 91.7%. The highest positive predictive value (87.5%) was obtained with a cut-off of 772 IU/L.

CONCLUSION

An IOAC is an early, simple, and sensitive predictor for the development of a clinically relevant POPF after PD and can potentially aid in managing the resulting morbidity with intraoperative and postoperative measures.

Robotic-Assisted Splenectomy by a Modified Lateral Approach: Technique and Outcomes

Introduction The utilization of robot-assisted technique for splenectomy has recently gained popularity especially in patients undergoing splenectomy for hematological indications owing to its magnification of and easy manipulation of internal abdominal organs. Moreover, robotic splenectomy emerged as an essential teaching module before approaching more complex robotic procedures. Methods  A total of 43 elective splenectomies were performed for hematological indications in Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) between January 2018 to July 2023 of which 14 patients underwent robotic splenectomy. All patients underwent lateral approach of robotic splenectomy with a modification of avoiding the lesser sac dissection. Prospectively maintained data were retrospectively analyzed and results were recorded in terms of intra-operative time taken, blood loss, need for blood and blood product transfusion and postoperative morbidity and mortality. Results The indications for patients who underwent robotic splenectomy include idiopathic thrombocytopenic purpura in eight patients, autoimmune hemolytic anemia in three patients, Evans syndrome in one patient and hereditary spherocytosis in two patients. The median splenic diameter was 14.8cm and the median platelet count before the operation was 10,800 cells/cubic millimeter (7000-3,20,000). The mean operative time was 92 minutes and blood loss was 40ml. The median duration of hospital stay was 2.4 days. All 14 patients had therapeutic success and there was no procedure-related mortality or morbidity. Conclusion Robotic splenectomy using the modified lateral approach can safely be performed with comparable operative time, blood loss and overall morbidity. However further studies are mandatory to confirm the advantage of this modified technique of lateral approach of robotic splenectomy.

Application of Simplified Duct-to-Mucosa Pancreaticojejunostomy for Nondilated Pancreatic Duct in Laparoscopic Pancreatic Surgery

OBJECTIVE

The objective of this study was to investigate the feasibility of simplified duct-to-mucosa pancreaticojejunostomy in a nondilated pancreatic duct in laparoscopic surgery.

MATERIALS AND METHODS

The data of 19 patients who underwent laparoscopic pancreaticoduodenectomy (LPD) and 2 patients who underwent laparoscopic central pancreatectomy were retrospectively analyzed.

RESULTS

All patients underwent pure laparoscopic surgery successfully with simplified duct-to-mucosa pancreaticojejunostomy. The operation time of LPD was 365.11±41.56 minutes, the time of pancreaticojejunostomy was 28.39±12.58 minutes, and postoperative hospitalization time was 14.16±6.88 days on average. Postoperative complications occurred in 3 patients of LPD, including 2 cases of class B postoperative pancreatic fistula and 1 case of gastroparesis followed by gastrointestinal anastomotic perforation. The operative time of laparoscopic central pancreatectomy was 191.00±12.73 minutes, the time of pancreaticojejunostomy 36.00±5.66 minutes, and the postoperative hospitalization time 12.5±0.71 days on average.

CONCLUSIONS

The described technique is a simple and safe reconstruction procedure and suitable for patients with nondilated pancreatic duct.

Single Center, Propensity Score Matching Analysis of Different Reconstruction Techniques following Pancreatoduodenectomy

BACKGROUND

Pancreatoduodenectomy is still hampered by significant morbidity. So far, there is no universally accepted technique aimed at minimizing postoperative complications. Herein, we compare three different reconstruction techniques.

METHODS

This is a retrospective study of a prospectively maintained database including 283 patients operated between January 2010 and December 2020. Three reconstruction techniques were compared: (1) the Neuhaus-style telescope pancreatojejunostomy, (2) the pancreatogastrostomy, and (3) the modified Blumgart-style, duct-to-mucosa pancreatojejunostomy. The primary endpoint consisted in determining the rates of clinically relevant postoperative pancreatic fistulas (CR-POPF); the secondary endpoints included 90 days morbidity and mortality rates. A propensity score matching analysis was used.

RESULTS

Rates of CR-POPF did not differ significantly between the groups (Neuhaus-style pancreatojejunostomy 16%, pancreatogastrostomy 17%, modified Blumgart-style pancreatojejunostomy 15%), neither in the unmatched nor in the matched analysis (p = 0.993 and p = 0.901, respectively). Similarly, no significant differences could be observed with regard to major morbidity (unmatched p = 0.596, matched p = 0.188) and mortality rates (unmatched p = 0.371, matched p = 0.209) within the first 90 days following surgery. Propensity-score matching analyses revealed, however, a higher occurrence of post-pancreatectomy hemorrhage after pancreatogastrostomy (p = 0.015).

CONCLUSION

Similar CR-POPF rates suggest no crucial role of the applied reconstruction technique. Increased incidence of intraluminal post-pancreatectomy hemorrhages following pancreatogastrostomy demands awareness for meticulous hemostasis.

Dorsal Subcutaneous Fat Thickness as a Risk Factor for Pancreatic Fistula After Gastric Cancer Surgery

BACKGROUND/AIM

Recently, there have been many reports on the use of preoperative body composition analysis to predict postoperative complications in gastric cancer surgery, most of which used 3D image analysis software for the measurements. This study aimed to evaluate the risk of postoperative infectious complications (PICs), especially pancreatic fistulas, using a simple measurement method incorporating only preoperative computed tomography images.

PATIENTS AND METHODS

A total of 265 patients with gastric cancer underwent laparoscopic or robot-assisted gastrectomy with lymph node dissection at Osaka Metropolitan University Hospital between 2016 and 2020. To simplify the measurement method, we measured the length of each region of the subcutaneous fat area (SFA). Each area included a) umbilical depth, b) thickness of the longest ventral subcutaneous fat, c) thickness of the longest dorsal subcutaneous fat, and d) thickness of the median dorsal subcutaneous fat (MDSF) measurements.

RESULTS

PICs occurred in 27 of 265 cases, of which pancreatic fistula was present in 9. SFA for pancreatic fistulas showed high diagnostic accuracy (area under the curve=0.922). Among the subcutaneous fat lengths, the MDSF was the most useful, and the optimal cut-off value was 16 mm. MDSF and non-expert surgeons were found to be independent risk factors for pancreatic fistula.

CONCLUSION

Since the possibility of developing pancreatic fistula is high in cases with MDSF ≥16 mm, careful surgical strategies, such as having a skilled physician, are necessary.

Current Perioperative Care in Pancreatoduodenectomy: A Step-by-Step Surgical Roadmap from First Visit to Discharge

Pancreaticoduodenectomy (PD) is a mainstay in the management of periampullary tumors. Treatment algorithms increasingly employ a multimodal strategy, which includes neoadjuvant and adjuvant therapies. However, the successful treatment of a patient is contingent on the execution of a complex operation, whereby minimizing postoperative complications and optimizing a fast and complete recovery are crucial to the overall success. In this setting, risk reduction and benchmarking the quality of care are essential frameworks through which modern perioperative PD care must be delivered. The postoperative course is primarily influenced by pancreatic fistulas, but other patient- and hospital-associated factors, such as frailty and the ability to rescue from complications, also affect the outcomes. A comprehensive understanding of the factors influencing surgical outcomes allows the clinician to risk stratify the patient, thereby facilitating a frank discussion of the morbidity and mortality of PD. Further, such an understanding allows the clinician to practice based on the most up-to-date evidence. This review intends to provide clinicians with a roadmap to the perioperative PD pathway. We review key considerations in the pre-, intra-, and post-operative periods.

Comparison of the complications of passive drainage and active suction drainage after pancreatectomy: A meta-analysis

Objective

This study aimed to compare the effect of passive drainage and active suction drainage on complications after pancreatectomy.

Methods

The databases were searched and covered in this study on the comparison of passive and active suction drainage after pancreatectomy from the database establishment to Feb. 2023. A meta-analysis was conducted with the RevMan5.3 software.

Results

On the whole, 1,903 cases were included in eight studies, including 994 cases in the passive drainage group, 909 in the active suction drainage group, 1,224 in the pancreaticoduodenectomy group, as well as 679 in the distal pancreatectomy group. No statistically significant difference was identified between the two groups in the incidence of total complications, the rate of abdominal hemorrhage, the rate of abdominal effusion, the death rate and the length of stay after pancreatectomy (all P > 0.05), whereas the difference in the incidence of pancreatic fistula after distal pancreatectomy between the two groups was of statistical significance (OR = 3.35, 95% CI = 1.12-10.07, P = 0.03). No significant difference was reported in pancreatic fistula between the two groups after pancreaticoduodenectomy.

Conclusion

After distal pancreatectomy, active suction drainage might down-regulate the incidence of postoperative pancreatic fistula.

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

OBJECTIVE

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

SUMMARY BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSION

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

Preoperative pancreatic CT value is related to pancreatic fistula after pancreaticoduodenectomy: a retrospective study

Background

Pancreatic fistula (PF) is the main complication in patients undergoing pancreaticoduodenectomy. Computed tomography (CT) value can reflect pancreatic tissue characteristics which is related to PF. This study was designed to study the relationship between the preoperative CT value and pancreatic fistula.

Methods

We retrospectively reviewed the clinical and medical data of patients undergoing pancreaticoduodenectomy from 2017 to 2021. The pancreatic CT value and the CT value ratios of the pancreas and abdominal aorta (P_CT/A_CT) were measured and compared between the PF group and non-PF group. The values in different PF severity groups were compared using variance analysis. A cut-off value was selected by receiver operating characteristic (ROC) curve. Single-factor and multiple-factor analysis were performed to evaluate Correlation between PF and CT.

Results

One hundred and twenty-seven cases were included in this study. The P_CT/A_CT in the PF group was significantly lower than that in the non-PF group (P<0.001), and the P_CT/A_CT value was correlatively lower in the severe PF group than in the mild PF group (P=0.008). A cutoff value of 0.99 was selected by ROC curves analysis. Further multifactor analysis identified P_CT/A_CT <0.99 to be an independent preoperative predictor [odds ratio (OR): 11.3, P<0.01].

Conclusions

The preoperative pancreatic CT value can indirectly reflect the histological condition of the pancreas and thus may related to postoperative PF after pancreaticoduodenectomy and provide useful information for surgeons in deciding upon the pancreaticojejunostomy method.

[Enucleation of pancreatic tumors: a multiple-center study]

OBJECTIVE

To evaluate the immediate results of enucleation of pancreatic neuroendocrine tumors (pNETs).

MATERIAL AND METHODS

The results of enucleation of pancreatic neuroendocrine tumors (pNETs) were analyzed in 95 patients between 2016 and 2021. Functioning tumors (mean size 16.8 mm) were found in 70 patients, non-functioning (mean size 25 mm) - in 25 patients. Intraparenchymal tumors were found in 48 people, extraorganic lesion - in 47 patients.

RESULTS

There were 262 patients with pNETs who underwent various surgeries between 2016 and 2021. Various resections were performed in 167 (63.8%) cases, enucleations - in 95 (36.2%) patients. Traditional surgical approach was used in 65 patients. Pancreatic fistula occurred in 21 patients (type B - 17, type C - 4), while arrosive bleeding occurred in 6 patients with unfavorable outcomes in 2 cases. Minimally invasive surgeries were performed in 30 patients. Eight patients with intraparenchymal tumors required conversion to open surgery. Type B pancreatic fistula occurred in 5 patients that led to arrosive bleeding in 2 cases (hemostasis was provided by endovascular method). Comparison of intraparenchymal and extraorgan tumors regarding the incidence of pancreatic fistula revealed odds ratio 5.26 (95% CI 1.5355; 18.0323, p=0.0041). Postoperative mortality was 2.1%.

CONCLUSION

Enucleation is advisable for highly differentiated pancreatic neuroendocrine tumors up to 2 cm. Minimally invasive enucleation is indicated for extraorgan tumors. Intraparenchymal tumors significantly increase the risk of postoperative complications.

Clinically Relevant Pancreatic Fistula after Pancreaticoduodenectomy: How We Do It

(1) Background: This study's goals were to investigate possible risk factors for clinically relevant postoperative pancreatic fistula (POPF) grade B/C according to the updated definitions of the International Study Group of Pancreatic Surgery and to analyze possible treatment strategies; (2) Methods: Between 2017 and 2021, 200 patients were analyzed regarding the development of POPF grade B/C with an emphasis on postoperative outcome and treatment strategies; (3) Results: POPF grade B/C was observed in 39 patients (19.5%). These patients were younger, mainly male, had fewer comorbidities and showed a higher body mass index. Also, they had lower CA-19 levels, a smaller tumor size and softer pancreatic parenchyma. They experienced a worse outcome without affecting the overall mortality rate (10% vs. 6%, p = 0.481), however, this lead to a prolonged postoperative stay (28 (32-36) d vs. 20 (15-28) d, p ≤ 0.001). The majority of patients with POPF grade B/C were able to receive conservative treatment, followed by drainage placement, endoscopic vacuum-assisted therapy (EVT) and surgery. Conservative treatment resulted in a shorter length of the postoperative stay (24 (22-28) d vs. 34 (26-43) d, p = 0.012); (4) Conclusions: Patients developing POPF grade B/C had a worse outcome; however, this did not affect the overall mortality rate. The majority of the patients were able to receive conservative treatment, resulting in a shorter length of their hospital stay.

Selective use of pancreatic duct occlusion during pancreaticoduodenectomy in patients with a small-size duct and atrophic parenchyma in the distal pancreas: A retrospective study

Background

Despite the advancements in surgical techniques, postoperative pancreatic fistula (POPF) remains a potentially life-threatening complication of pancreaticoduodenectomy (PD). Pancreatic duct occlusion (PDO) without anastomosis has also been proposed to alleviate the clinical consequences of POPF in selected patients after PD.

Objectives

To assess the safety and effectiveness of PDO with mechanical closure after PD in patients with an atrophic pancreatic body-tail and a small pancreatic duct.

Methods

We retrospectively identified two female and two male patients from April 2019 to October 2020 through preoperative computed tomography of the abdomen. Among them, three patients underwent PDO with mechanical closure after PD, and one underwent PDO after pylorus-preserving PD. In addition, patients' medical records and medium-and long-term follow-up data were analyzed.

Results

Postoperative histological examination revealed a solid pseudopapillary tumor in two patients, pancreatic ductal adenocarcinoma in one patient, and chronic pancreatitis with pancreatic duct stones in one patient. However, none of the patients developed biochemical or clinically relevant POPF, with no postpancreatectomy hemorrhage, biliary leakage, delayed gastric emptying, intra-abdominal abscess, or chyle leakage. Among the four patients, three developed new-onset diabetes mellitus, and one had impaired glucose tolerance. Furthermore, three patients received pancreatic enzyme supplementation at a dose of 90,000 Ph. Eur. units/d, and one was prescribed a higher dose of 120,000 Ph. Eur. units/d.

Conclusions

PDO with mechanical closure is an alternative approach for patients with an atrophic pancreatic body-tail and a small pancreatic duct after PD. Therefore, further evidence should evaluate the potential benefits of selective PDO in these patients.

Novel end-to-side one-layer continuous pancreaticojejunostomy vs. end-to-end invaginated pancreaticojejunostomy in pancreatoduodenectomy: A single-center retrospective study

Background and Objective

Postoperative pancreatic fistula (POPF) is the most common critical complication after pancreatoduodenectomy (PD) and is the primary reason for increased mortality and morbidity after PD. We aim to investigate the clinical significance of a novel approach, i.e., end-to-side one-layer continuous pancreaticojejunostomy, for patients with PD.

Methods

The clinical data of 65 patients who underwent pancreatoduodenectomy at the Xiangya Hospital, Central South University, from September 2020 to December 2021 were retrospectively analyzed.

Results

Forty patients underwent end-to-end invaginated pancreaticojejunostomy, and 25 underwent the novel end-to-side one-layer continuous pancreaticojejunostomy. No significant differences were observed in pancreatic fistula, intraperitoneal infection, intraperitoneal bleeding, reoperation, postoperative hospital stay, or perioperative death between the two groups. However, the novel end-to-side one-layer continuous pancreaticojejunostomy group had significantly shorter operation duration (32.6 ± 5.1 min vs. 8.3 ± 2.2 min, p < 0.001). The incidence of pancreatic fistula in the novel pancreaticojejunostomy group was 12%, including two cases of grade A POPF and only one case of grade B POPF. No cases of grade C POPF occurred. No deaths were observed during the perioperative period.

Conclusions

The novel anastomosis method leads to a shorter operation duration than the traditional anastomosis method and does not increase postoperative complications. In conclusion, it is a simplified and feasible method for pancreatic anastomosis.

[Pancreaticoduodenectomy - results and prospects (two-center study)]

OBJECTIVE

To summarize the results of pancreaticoduodenectomy (PD) for pancreatic tumors and complications of chronic pancreatitis regarding prediction and prevention of postoperative complications.

MATERIAL AND METHODS

There were 336 PD procedures between 2016 and mid-2022 in two centers. We assessed the factors influencing specific postoperative complications (postoperative pancreatitis, pancreatic fistula, gastric stasis, arrosive bleeding). Several risk factors were distinguished: baseline pancreatic disease and tumor size, CT-signs of a «soft» gland, intraoperative assessment of the pancreas, number of functioning acinar structures. We assessed surgical prevention of pancreatic fistula via preserving adequate blood supply to the pancreatic stump. The last one is provided by extended pancreatic resection and reconstructive stage of surgery, i.e. Roux-en-Y hepatico- and duodenojejunostomy with isolation of pancreaticojejunostomy on the second loop.

RESULTS

Postoperative pancreatitis underlies specific complications after PD. The risk of pancreatic fistula in case of postoperative pancreatitis increases by 5.3 times compared to patients without pancreatitis. Postoperative pancreatic fistula is more common in patients with T1 and T2 tumors. According to univariate analysis, only pancreatic fistula significantly affects the risk of gastric stasis. Among 336 people who underwent PD, pancreatic fistula occurred in 69 patients (20.5%), gastric stasis - in 61 (18.2%), pancreatic fistula complicated by arrosive bleeding - in 45 (13.4%) patients. Mortality rate was 3.6% (n=15).

CONCLUSION

Modern prognostic criteria are valuable to predict specific complications after PD. A promising way to prevent postoperative pancreatitis can be extended pancreatic resection considering angioarchitectonics of the pancreatic stump. Roux-en-Y pancreaticojejunostomy is advisable to reduce aggressiveness of pancreatic fistula.

Preliminary experience in laparoscopic distal pancreatectomy using the AEON™ endovascular stapler

Background

The aim of this study is to investigate the effects of using a new innovative endovascular stapler, AEON™, on the pancreatic leak rates and other outcome measures.

Methods

In a retrospective review of prospectively collected data from a secure tertiary unit registry, patients undergoing distal or lateral pancreatectomy were analyzed for any differences on pancreatic fistula rates, length of stay, comprehensive complication index (CCI), and demographics after using AEON™ compared with other commonly used staplers. Statistical significance was defined as <0.05.

Results

There were no differences in the demographics between the two groups totaling 58 patients over 2 years from 2019 to 2021. A total of 43 and 15 patients underwent pancreatic transection using other staplers and AEON™ endovascular stapler, respectively. The comparison of the two groups revealed a significantly reduced rate of mean drain lipase at postoperative day 3 with AEON™ (446 U/L) versus the other staplers (4,208 U/L) (p = 0.018) and a subsequent reduction of postoperative pancreatic fistula (POPF) from 65% to 20%. A reduction in the mean CCI, from 13.80 when other staplers were used to 4.97 when AEON™ was used, was also observed (p = 0.087). Mean length of stay was shorter by 3 days in the AEON™ group compared with that in the other staplers (6 and 9 days, respectively; p = 0.018).

Conclusion

AEON™ stapler when used to transect the pancreas demonstrated a significantly reduced pancreatic fistula rate, length of stay in hospital, and a leaning towards a reduced CCI. Its use should be further evaluated in larger cohorts with the encouraging results to determine whether this is possibly related to the technology used in the design of the AEON™ stapler.

Pancreatic fistula and biliary fistula after laparoscopic pancreatoduodenectomy: 500 patients at a single institution

Background

Pancreatic fistula (PF) and biliary fistula (BF) are two major leakage complications after pancreatoduodenectomy (PD). The aim of this study is to investigate the risk factors of PF and BF after laparoscopic PD (LPD).

Materials and Methods

We conducted a retrospective analysis of 500 patients who underwent LPD from 1 April 2015 to 31 March 2020. Clinical data from patients were analysed using multivariate logistic regression analysis.

Results

PF occurred in 86 (17.2%) patients. Univariate and multivariate analysis indicated that the soft texture of the pancreas (P = 0.001) was the independent risk factor for PF. BF occurred in 32 (6.4%) patients. Univariate and multivariate analysis indicated that history of cardiovascular disease (P < 0.001), surgical time (P = 0.005), pre-operative CA125 (P = 0.036) and pre-operative total bilirubin (P = 0.044) were independent risk factors for BF.

Conclusion

The texture of the pancreas was an independent risk factor for PF after LPD, which was consistent with the literatures. In addition, history of cardiovascular disease, surgical time, pre-operative CA125 and pre-operative total bilirubin were new independent risk factors for BF after LPD. Therefore, patients with high-risk factors of BF should be informed that they are at a high risk for this complication.

Operative Re-Intervention following Pancreatoduodenectomy: What Has Changed over the Last Decades

Background: To investigate changes over the last decades in the management of postoperative complications following pancreatoduodenectomy (PD) with special emphasis on reoperations, their indications, and outcomes. Methods: 409 patients who underwent PD between 2008 and 2021 were retrospectively analyzed with respect to their need for reoperations (reoperation, n = 81, 19.8% vs. no reoperation, n = 328, 80.2%). The cohort was then compared to a second cohort comprising patients who underwent PD between 1989 and 2007 (n = 285). Results: 81 patients (19.8%) underwent reoperation. The main cause of reoperation was the dehiscence of pancreatogastrostomy (22.2%). Reoperation was associated with a longer duration of the index operation, more blood loss, and more erythrocyte concentrates being transfused. Patients who underwent reoperation showed more postoperative complications and a higher mortality rate (25% vs. 2%, p < 0.001). Compared to the earlier cohort, the observed increase in reoperations did not lead to increased mortality (5% vs. 6%, p = 353). Conclusions: The main cause for reoperation has changed over the last decades and was the dehiscence of pancreatogastrostomy. Associated with a leakage of pancreatic fluid and clinically relevant PF, it remains the most devastating complication following PD. Strategies for prevention and treatment, e.g., by endoscopic vacuum-assisted-closure therapy are of utmost importance.

Arterial reinforcement following pancreatoduodenectomy: The solution to prevent delayed hemorrhage caused by postoperative pancreatic fistula

PURPOSE

Delayed hemorrhage (DH) is a rare and yet well-known fatal complication associated with postoperative pancreatic fistula (POPF) in pancreatoduodenectomy (PD). The study aimed to investigate whether arterial reinforcement (AR) using polyglycolic acid sheets (PAS) followed by fibrin sealant (FS) to the hepatic artery could prevent DH in the setting of POPF after PD.

METHODS

A total of 345 patients underwent PD for periampullary tumors from March 2011 to March 2022. From March 2011 to March 2018, 225 patients underwent PD, and AR was not performed (non-AR group). From April 2018 to March 2022, 120 patients underwent PD, and AR was performed (AR group). AR was achieved by wrapping the proper hepatic artery all the way down to the celiac artery with PAS followed by coating with FS. Demographic profile and various outcomes including DH of these two groups were compared and analyzed retrospectively.

RESULTS

In non-AR group, 48 (21.3%) and 12 (5.3%) patients had grade B and C POPF, respectively. In AR group, 26 (21.7%) and four (3.3%) patients had grade B and C POPF, respectively. The incidence of POPF was not statistically significant (p = .702) between the groups. Among the patients with grade B or C POPF, DH occurred in 14 (23.3%) patients in non-AR group and only one patient in AR group (p = .016). Of the 15 patients with DH, four (26.7%) patients died.

CONCLUSION

AR using PAS and FS is effective in preventing DH in the setting of POPF.

Initial Experience with Robotic Gastrectomy in Patients with Gastric Cancer: An Assessment of Short-Term Surgical Outcomes

Robotic gastrectomy (RG) is an alternative minimally invasive surgical technique that has gradually come into use for the treatment of gastric cancer (GC). This study aimed to assess the feasibility and safety of RG for the treatment of GC. We retrospectively reviewed the use of RG in 47 patients with GC, and clinicopathological features and surgical outcomes were evaluated. The median age and body mass index of the patients were 68 years and 21.9 kg/m², respectively. Distal gastrectomy, total gastrectomy, and proximal gastrectomy were performed in 39 (83.0%), 5 (10.6%), and 3 (6.4%) patients, respectively. The median operative time was 354 (256- 603) min. None of the operations were converted to open or laparoscopic procedures. The median blood loss was 15 (2-350) ml. None of the patients required blood transfusion. The mean number of resected lymph nodes was 43 (7-93). The median duration of postoperative hospital stay was 13 (9-37) days. Approximately 4.3% and 2.1% of the patients had anastomotic leakage and pancreatic fistula, respectively. One (2.1%) patient had Clavien-Dindo classification grade IIIa surgical complication (anastomotic leakage). No treatment-related deaths were observed. These findings suggest that RG might be a safe and feasible procedure for the treatment of GC.

[Case Reports of Intravascular Treatment for Gastrointestinal Bleeding Associated with Pancreatitis: Hemosuccus Pancreaticus and Pancreaticocolic Fistula]

Elderly patients with a history of chronic alcoholism presented to our hospital with episodes of melena, abdominal pain, and anemia. During admission, hemorrhagic cystic lesion at the pancreas was observed on abdominal CT. Transcatheter angiography confirmed active bleeding foci and arterial embolization was performed. After the procedure, the bleeding was resolved. The authors report two cases of hemosuccus pancreaticus and pancreaticocolic fistula associated with pancreatitis, a rare cause of gastrointestinal bleeding, treated with vascular intervention.

Closure and anastomosis of the pancreas using a four-needle three-loop suture device

Pancreatic juice can leak not only from the main pancreatic duct but also from unclosed ductal branches appearing on the pancreatic stump. We have developed a suture device consisting of three loops of suture attached to four small-curvature needles with the aim to maximize the area of pancreatic parenchyma to be ligated and reduce the number of punctures made on the pancreas during pancreatic closure or anastomosis. In pancreatojejunostomy, the dorsal wall of the jejunum and then the pancreatic parenchyma are sutured using the four needles. Following duct-to-mucosa anastomosis, the ventral jejunal wall is sutured, and the three threads are finally tied sequentially to complete the reconstruction following the Blumgart method. In distal pancreatectomy, the pancreatic stump is sutured from the dorsal aspect sequentially using the four needles, before or after the pancreatic transection. The three threads are then respectively tied on the ventral surface of the pancreas. This device was used in six pancreatoduodenectomies (including two minimally invasive procedures) and five distal pancreatectomies. A postoperative pancreatic fistula requiring additional drainage or repositioning of abdominal drains developed in two patients. No adverse events associated with this device were encountered. The four-needle three-loop suture device can be an alternative to conventional staplers or sutures for closure and anastomosis of the pancreatic stump.

The outcome of bioabsorbable staple line reinforcement versus standard stapler for distal pancreatectomy: A systematic review and meta-analysis

Background and Aim:

In the era of minimally invasive procedures and as a way to decrease the incidence of post-operative pancreatic fistula (POPF), the use of staplers for distal pancreatectomy (DP) has increased dramatically. Our aim was to investigate whether reinforced staplers decrease the incidence of clinically relevant PF after DP compared with staplers without reinforcement.

Methods:

PubMed, Scopus, Web of Science and Cochrane Library were searched for eligible studies from inception to 1 November 2021, and a systematic review and a meta-analysis were done to detect the outcomes after using reinforced staplers versus standard stapler for DP.

Results:

Seven studies with a total of 681 patients were included. The overall incidence of POPF and the incidence of Grade A POPF after DP are similar for the two groups (overall POPF, risk ratio [RR] = 0.85, 95% confidence interval [CI] = 0.71–1.01, P = 0.06; I² = 38% and Grade A POPF, RR = 1.15, 95% CI = 0.78–1.69, P = 0.47; I² = 49%). However, the incidence of clinically significant POPF (Grades B and C) is significantly lower in DP with reinforced staplers than DP with bare staplers (Grades B and C, RR = 0.45, 95% CI = 0.29–0.71, P = 0.0005; I² = 17%). Nevertheless, the time of the operation, the blood loss during surgical procedure, the hospital stay after the surgery and the thickness of the pancreas are similar for both techniques.

Conclusion:

Although staple line reinforcement after DP failed to prevent biochemical PF, it significantly reduced the rate of clinically relevant POPF in comparison to standard stapling.

Postoperative Pancreatic Fistula: Is Minimally Invasive Surgery Better than Open? A Systematic Review and Meta-analysis

BACKGROUND/AIM

Minimally invasive pancreaticoduodenectomy (PD) is gaining popularity. The aim of this study was to compare the incidence of postoperative pancreatic fistula (POPF) after minimally invasive versus open procedures.

MATERIALS AND METHODS

Following the PRISMA statement, literature research was conducted focusing on papers comparing the incidence of POPF after open pancreaticoduodenectomy (OPD) versus minimally invasive pancreaticoduodenectomy (MIPD).

RESULTS

Twenty-one papers were included in this meta-analysis, for a total of 4,448 patients. A total of 2,456 patients (55.2%) underwent OPD, while 1,992 (44.8%) underwent MIPD. Age, ASA score III patients, incidence of pancreatic ductal adenocarcinoma and duct diameter were significantly lower in the MIPD group. No statistically significant differences were found between the OPD and MIPD regarding the incidence of major complications (15.6% vs. 17.0%, respectively, p=0.55), mortality (3.7% vs. 2.4%, p=0.81), and POPF rate (14.3% vs. 12.9%, p=0.25).

CONCLUSION

MIPD and OPD had comparable rates of postoperative complications, postoperative mortality, and POPF.

Severity of Pancreatic Leak in Relation to Gut Restoration After Pancreaticoduodenectomy: The Role of the Roux-en-Y Configuration

Background

Pancreatic leak after pancreaticoduodenectomy and gut restoration via a single jejunal loop remains the crucial predictor of patients' outcome. Our reasoning that active pancreatic enzymes may be more disruptive to the pancreatojejunostomy prompted us to explore a Roux-en-Y configuration for the gut restoration, anticipating diversion of bile salts away from the pancreatic stump. Our study aims at comparing two techniques regarding the severity of postoperative pancreatic fistula (POPF) and patients' outcome.

Methods

The files of 415 pancreaticoduodenectomy patients were retrospectively reviewed. Based on gut restoration, the patients were divided into: cohort A (n = 105), with gut restoration via a single jejunal loop, cohort B (n = 140) via a Roux-en-Y technique assigning the draining of pancreatic stump to the short limb and gastrojejunostomy and bile (hepaticojejunostomy) flow to long limb, and cohort C (n = 170) granting the short limb to the gastric and pancreatic anastomosis, whereas hepaticojejunostomy was performed to the long limp. The POPF-related morbidity and mortality were analyzed.

Results

Overall POPF in cohort A versus cohorts B and C was 19% versus 12.1% and 9.4%, respectively (P = 0.01 A vs B + C). POPF-related morbidity in cohort A versus cohorts B and C was 10.5% versus 7.3% and 6.3%, respectively (P = 0.03 A vs B+C). POPF-related total hospital mortality in cohorts A versus B and C was 1.9% versus 0.8% and 0.59%, respectively (P = 0.02 A vs B+C).

Conclusion

Roux-en-Y configuration showed lower incidence and severity of POPF. Irrespective of technical skill, creating a gastrojejunostomy close to pancreatojejunostomy renders the pancreatic enzymes less active by leaping the bile salts away from the pancreatic duct and providing a lower pH.

Robotic Distal Gastrectomy Reduces Drain Amylase Values in Patients With a Small Pancreas-left Gastric Artery Angle

PURPOSE

Pancreatic fistula is a severe complication after laparoscopic distal gastrectomy (LDG). We previously evaluated the pancreas-left gastric artery angle (PLA) as a risk indicator for developing a pancreatic fistula after LDG. This study evaluated the incidence of pancreatic fistula with robotic distal gastrectomy (RDG) in comparison to LDG from the view of the PLA.

MATERIALS AND METHODS

An association between the PLA and the incidence of pancreatic fistula in 165 patients who underwent either RDG (n=45) or LDG (n=120) was investigated retrospectively.

RESULTS

RDG patients had significantly lower drain amylase values (postoperative day 2) than LDG patients. As opposed to LDG patients, drain amylase values were similar for patients with small (PLA <62 degrees) and large (PLA ≥62 degrees) PLA in RDG patients.

CONCLUSION

Robotic surgery may reduce the risk of postoperative pancreatic fistula in patients with a small PLA.

Comparison of risk adjusted excess post-operative pancreatic fistula rates after pancreaticoduodenectomy using cumulative sum analysis

BACKGROUND

Post-operative pancreatic fistula (POPF) is a key outcome post pancreaticoduodenectomy. There are numerous POPF risk calculators but no agreed benchmark, a key component of meaningful audit. We compared observed versus predicted POPF for six risk adjusted POPF calculators, to ascertain how they differ and thus contribute to discussion around benchmarking.

METHODS

This was a retrospective single-arm cohort study at the Royal Melbourne Hospital of patients who underwent pancreaticoduodenectomy 1 November 2015 to 31 December 2021 with a primary outcome of a clinically relevant POPF. Cumulative sum (CUSUM) plots of observed versus predicted rate of POPF for sequential patients were constructed for six risk adjusted POPF calculators - Birmingham, updated Birmingham, fistula risk score (FRS), modified FRS (m-FRS), alternative FRS (a-FRS), and updated alternative FRS (ua-FRS).

RESULTS

The study included 77 patients. The actual rate of clinically relevant POPF was 14.3%. FRS calculated an excess of 1.3 POPF per 100 cases. All other calculators demonstrated prevention of POPF per 100 cases: Birmingham 3.4, updated Birmingham 14.0, m-FRS 0.3, a-FRS 1.2, ua-FRS 19.7.

CONCLUSION

The observed versus predicted rate of POPF was near zero for all risk calculators except ua-FRS and updated Birmingham, which predicted a higher POPF than observed (19.7, 14.0, respectively). These results indicate that, excepting ua-FRS and updated Birmingham, these calculators yield comparable results. Benchmarks for POPF should prescribe which risk calculators are used, and ideally a unified standard between centres should be the goal to provide consistency in outcome reporting and robust audit processes.

Effect of perioperative fluid volume restriction on the incidence of complications following pancreaticoduodenectomy

BACKGROUND

Perioperative fluid restriction has been suggested to reduce morbidity and length of stay. The purpose of this study was to compare the morbidity following pancreaticoduodenectomy (PD) between fluid restriction group and conventional management group.

METHODS

Seventy-two patients were enrolled for perioperative fluid restriction of PD. During the operation, main fluid was infused at a rate of less than 8 mL/kg/hr. Until POD#3, 10% dextrose and Hartmann's solution were administered at rates of 40 mL/h and {(1.5*body weight) - 42} mL/h, respectively. The historical control group consisted of 139 patients. We compared the rates of major complication (Clavien-Dindo grade III to V) and clinically relevant postoperative pancreatic fistula (CR-POPF), length of hospital stays (LOS), amount of urine output, and the rate of acute kidney injury (AKI).

RESULTS

The rates of major complication (19.0% versus 18.7%; p > 0.999), CR-POPF (15.5% versus 15.1%; p > 0.999), and LOS (19 days [range: 10-52] versus 19 days [range: 11-75]; p = 0.514) were comparable in the study and the control group, respectively. Amount of urine output during the operation and from POD#1 to POD#3 was more than minimal amount (0.5 mL/kg/hr) in the both groups. Incidence rate of AKI in the study group was not higher than the control group (Stage I: 1.7% versus 2.9%, p > 0.999; stage II: 0% versus 1.4%, p > 0.999).

CONCLUSION

There was no decrease in incidence of morbidity including POPF following PD with perioperative fluid restriction. Fluid restriction was feasible because it did not reduce urine output and did not increase incidence of AKI.

The net parenchymal thickness predicts pancreatic fistula after pancreaticoduodenectomy: a retrospective cohort study of objective data

BACKGROUND

The clinically relevant postoperative pancreatic fistula (CR-POPF) is still a challenging complication of pancreaticoduodenectomy (PD). This study aims to explore the predictors of CR-POPF after PD, including net parenchymal thickness (NPT) of pancreatic neck.

METHODS

The consecutive patients who underwent PD at a tertiary hospital were retrospectively reviewed. Univariate and multivariate analyses were conducted on the perioperative data, which was mainly extracted from the objective data, containing the results from the laboratory tests and the imaging examination. NPT refers to the total thickness of pancreatic gland excluding main pancreatic duct (MPD) at the CT film.

RESULTS

Univariate analyses showed that total serum bilirubin (TBiL) and albumin (ALB) levels, MPD size and NPT were significantly different between the patients with and without CR-POPF. The white blood cell count, the rate of intra-abdominal infection (IAI) and the postoperative length of hospital stay (LOS) were associated with the incidence of CR-POPF. The proportion of patients with pancreatic adenocarcinoma or chronic pancreatitis was significantly lower in the CR-POPF group than in the non-CR-POPF group. Multivariate analyses manifested that ALB ≤35 g/L and NPT >10 mm were two of the independent risk factors for CR-POPF.

CONCLUSION

Preoperative ALB ≤35 g/L and NPT > 10 mm were both the independent predictors of CR-POPF. CR-POPF was associated with the higher IAI rate and the extended LOS.