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Implementation of a regional reference center in pancreatic surgery. Experience after 631 procedures. Cir Esp 2021; 99:745-756. [PMID: 34794902 DOI: 10.1016/j.cireng.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 09/23/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The main objective of this study is to determine whether our unit meets the quality standards required by the scientific community from the reference centers for pancreatic surgery in terms of peri-operative results. The secondary objectives are to compare the different pancreatic surgery techniques performed in terms of early post-operative morbidity and mortality and to analyze the impact of the resections added in these terms. METHOD Descriptive, retrospective and single-center study, corresponding to the period 2006-2019. The results obtained were compared with the proposed quality standards, by Bassi et al. and Sabater et al., required from the reference centers in pancreatic surgery. The sample was divided according to surgical technique and compared in terms of early post-operative morbidity and mortality, studying the impact of extended vascular and visceral resections. All patients undergoing pancreatic surgery in our unit due to pancreatic, malignant and benign pathology were included, since it was implemented as a reference center. Emergency procedures were excluded. RESULTS 631 patients were analyzed. The values obtained in the quality standards are in range. The most frequent surgery was pancreaticoduodenectomy, which associated higher peri-operative morbidity and mortality rates (P ≤ .05). The extended vascular resections impacted the pancreaticoduodenectomy group, associating a longer mean stay (P = .01) and a higher rate of re-interventions (P = .02). CONCLUSIONS The experience accumulated allows to meet the required quality standards, as well as perform extended resections to pancreatectomy with good results in terms of post-operative morbidity and mortality.
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Castillo Tuñón JM, Valle Rodas ME, Botello Martínez F, Rojas Holguín A, López Guerra D, Santos Naharro J, Jaén Torrejímeno I, Blanco Fernández G. Implementation of a regional reference center in pancreatic surgery. Experience after 631 procedures. Cir Esp 2020; 99:S0009-739X(20)30313-4. [PMID: 33342520 DOI: 10.1016/j.ciresp.2020.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 09/14/2020] [Accepted: 09/23/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION The main objective of this study is to determine if our unit meets the quality standards required by the scientific community from the reference centers for pancreatic surgery in terms of peri-operative results. The secondary objectives are to compare the different pancreatic surgery techniques performed in terms of early post-operative morbidity and mortality and to analyze the impact of the resections added in these terms. METHOD Descriptive, retrospective and single-center study, corresponding to the period 2006-2019. The results obtained were compared with the proposed quality standards, by Bassi et al. and Sabater et al., required from the reference centers in pancreatic surgery. The sample was divided according to surgical technique and compared in terms of early post-operative morbidity and mortality, studying the impact of extended vascular and visceral resections. All patients undergoing pancreatic surgery in our unit due to pancreatic, malignant and benign pathology were included, since it was implemented as a reference center. Emergency procedures were excluded. RESULTS 631 patients were analyzed. The values ??obtained in the quality standards are in range. The most frequent surgery was cephalic duodenopancreatectomy, which associated higher peri-operative morbidity and mortality rates (p ≤ 0.05). The extended vascular resections impacted the cephalic duodenopancreatectomy group, associating a longer mean stay (p = 0.01) and a higher rate of re-interventions (p = 0.02). CONCLUSIONS The experience accumulated allows to meet the required quality standards, as well as perform extended resections to pancreatectomy with good results in terms of post-operative morbi-mortality.
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Andrianello S, Landoni L, Bortolato C, Iudici L, Tuveri M, Pea A, De Pastena M, Malleo G, Bonamini D, Manzini G, Bassi C, Salvia R. Negative pressure wound therapy for prevention of surgical site infection in patients at high risk after clean-contaminated major pancreatic resections: A single-center, phase 3, randomized clinical trial. Surgery 2020; 169:1069-1075. [PMID: 33257037 DOI: 10.1016/j.surg.2020.10.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/13/2020] [Accepted: 10/26/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgical site infections are an important burden of pancreatic surgery, prolonging hospitalization and delaying adjuvant treatment. The aim of this study was to compare negative pressure wound therapy with standard sterile dressing in terms of the prevention of non-organ-space surgical site infection (superficial and deep surgical site infection) in the high-risk setting. METHODS The trial was conducted at the University of Verona Hospital Trust, Verona, Italy, from July 25, 2018, through October 10, 2019, among adults undergoing surgery for periampullary neoplasms. Only patients at high-risk for surgical site infection based on body mass index, diabetes, steroids, neoadjuvant therapy, American Society of Anesthesiologists score, Charlson comorbidity index, duration of surgery, and blood loss were included and randomized. RESULTS A total of 351 patients were screened, 100 met the inclusion criteria and were 1:1 allocated in the 2 arms. The difference in terms of non-organ-space surgical site infection comparing negative pressure wound therapy with standard sterile dressing was not significant (10.9 vs 12.2%, risk ratio [RR] 1.144, confidence interval [CI] 95% 0.324-4.040, P = 1.000). Hematomas (4.3 vs 2%, RR 1.565, CI 95% 0.312-7.848, P = .609) and organ-space infections (46.7 vs 43.8%, RR 1.059, CI 95% 0.711-1.576, P = .836) were similar. Negative pressure wound therapy prevented the development of seromas (0 vs 12.2%, RR 0.483, CI 95% 0.390-0.599, P = .027). The aesthetic result assessed on postoperative day 7 was better in the negative pressure wound therapy group (visual analogue scale, 8 vs 7, P = .029; Stony Brook Scar Evaluation Scale, 3.2 vs 2.5, P = .009), but it was no more evident on postoperative day 30 after a total number of 23 dropouts. CONCLUSION Compared with standard sterile dressing, negative pressure wound therapy is not associated with an improved rate of non-organ-space surgical site infection after surgery for periampullary neoplasms in patients at high risk for surgical site infection. Additional studies will help identify the population that could benefit most from this intervention.
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Affiliation(s)
- Stefano Andrianello
- Department of General and Pancreatic Surgery- The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Luca Landoni
- Department of General and Pancreatic Surgery- The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Cecilia Bortolato
- Department of General and Pancreatic Surgery- The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Livio Iudici
- Department of General and Pancreatic Surgery- The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Massimiliano Tuveri
- Department of General and Pancreatic Surgery- The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Antonio Pea
- Department of General and Pancreatic Surgery- The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Matteo De Pastena
- Department of General and Pancreatic Surgery- The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery- The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Deborah Bonamini
- Department of General and Pancreatic Surgery- The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Gessica Manzini
- Department of General and Pancreatic Surgery- The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery- The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
| | - Roberto Salvia
- Department of General and Pancreatic Surgery- The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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Giuliani T, Marchegiani G, Girgis MD, Crinò SF, Muthusamy VR, Bernardoni L, Pea A, Ramera M, Paiella S, Landoni L, Gabbrielli A, Salvia R, Donahue TR, Bassi C. Endoscopic placement of pancreatic stent for "Deep" pancreatic enucleations operative technique and preliminary experience at two high-volume centers. Surg Endosc 2020; 34:2796-2802. [PMID: 32180000 DOI: 10.1007/s00464-020-07501-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 03/02/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pancreatic enucleation (PE) is a viable option for the removal of non-malignant pancreatic masses leading to complete preservation of organ function. Nevertheless, PE is associated with substantial rates of post-operative pancreatic fistula (POPF), particularly when the mass is close to the main pancreatic duct (MPD). Preoperative stenting of the MPD may prevent its injury when performing PE. This paper describes a novel technique of "deep" PE preceded by endoscopic stenting of the MPD. METHODS From January 2017 to May 2019, patients with small pancreatic neuroendocrine tumors proximal to the MPD were candidates for PE with previous stenting of the MPD at the University of Verona, Italy, and at the UCLA Medical Center, Los Angeles, California. The endoscopic stenting was scheduled either the day before or 3 weeks before surgery, depending on the participating institute. RESULTS Ten patients were included in this pilot study. The endoscopic procedure was successful and well tolerated in all cases. Open, laparoscopic and robotic PE were performed. Seven patients had surgical complications. Among these, six developed a post-operative pancreatic fistula (POPF), but neither grade C fistulas nor disruptions of the MPD were detected. At pathology, a low grade pancreatic neuroendocrine tumor was confirmed in all cases. CONCLUSION In the setting of high-volume centers, this procedure is safe, and it is associated with acceptable short-term surgical morbidity. The preoperative stenting of the MPD might extend the surgical indications for PE.
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Affiliation(s)
- Tommaso Giuliani
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona Hospital Trust, P.le L.A. Scuro n° 10, 37134, Verona, Italy
| | - Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona Hospital Trust, P.le L.A. Scuro n° 10, 37134, Verona, Italy
| | - Mark D Girgis
- Division of Surgical Oncology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Stefano Francesco Crinò
- Unit of Gastroenterology and Digestive Endoscopy, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | | | - Laura Bernardoni
- Unit of Gastroenterology and Digestive Endoscopy, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Antonio Pea
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona Hospital Trust, P.le L.A. Scuro n° 10, 37134, Verona, Italy
| | - Marco Ramera
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona Hospital Trust, P.le L.A. Scuro n° 10, 37134, Verona, Italy
| | - Salvatore Paiella
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona Hospital Trust, P.le L.A. Scuro n° 10, 37134, Verona, Italy
| | - Luca Landoni
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona Hospital Trust, P.le L.A. Scuro n° 10, 37134, Verona, Italy.
| | - Armando Gabbrielli
- Unit of Gastroenterology and Digestive Endoscopy, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona Hospital Trust, P.le L.A. Scuro n° 10, 37134, Verona, Italy
| | - Timothy R Donahue
- Division of Surgical Oncology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona Hospital Trust, P.le L.A. Scuro n° 10, 37134, Verona, Italy
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Esposito A, Balduzzi A, De Pastena M, Fontana M, Casetti L, Ramera M, Bassi C, Salvia R. Minimally invasive surgery for pancreatic cancer. Expert Rev Anticancer Ther 2019; 19:947-958. [DOI: 10.1080/14737140.2019.1685878] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Alessandro Esposito
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alberto Balduzzi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Matteo De Pastena
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Martina Fontana
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Luca Casetti
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Marco Ramera
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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Zhu J, Li X, Li H, Liu Z, Ma J, Kou J, He Q. Enhanced recovery after surgery pathways benefit patients with soft pancreatic texture following pancreaticoduodenectomy. Am J Surg 2019; 219:1019-1023. [PMID: 31409454 DOI: 10.1016/j.amjsurg.2019.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 07/21/2019] [Accepted: 08/03/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND We aimed to compare the enhanced recovery after surgery pathway with the standard perioperative care protocol concerning complications, postoperative length of stay and 1-year survival rate. METHODS Using a before-after cohort study design, data from patients with pancreatic head cancer, who consecutively underwent pancreaticoduodenectomy, were retrospectively collected. RESULTS Compared to the control group, patients with soft pancreas in the enhanced recovery after surgery group had a lower incidence of delayed gastric emptying (36.7% vs 13.3%, P = 0.026) and respiratory complications (46.7% vs 20.0%, P = 0.028), and shorter postoperative length of stay (All: 10.9 ± 3.4 d vs13.5 ± 3.8 d, P = 0.002; Soft: 11.2 ± 3.8 d vs14.0 ± 4.5 d, P = 0.001). The 1-year survival rates were similar between the groups. CONCLUSION The enhanced recovery after surgery pathways can significantly reduce the incidence of certain surgical complications and decrease the postoperative length of stay. It does not affect 1-year survival.
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Affiliation(s)
- Jiqiao Zhu
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xianliang Li
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Han Li
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Zixi Liu
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jun Ma
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jiantao Kou
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Qiang He
- Department of Hepatobiliary and Pancreaticosplenic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China.
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Marchegiani G, Ramera M, Viviani E, Lombardo F, Cybulski A, Chincarini M, Malleo G, Bassi C, Zamboni GA, Salvia R. Dislocation of intra-abdominal drains after pancreatic surgery: results of a prospective observational study. Langenbecks Arch Surg 2019; 404:213-222. [PMID: 30771076 DOI: 10.1007/s00423-019-01760-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 02/05/2019] [Indexed: 02/08/2023]
Abstract
PURPOSE The use of intra-abdominal drains after major surgical procedures represents a well-established but controversial practice. No data are available regarding both the occurrence and the potential impact of their postoperative accidental dislocation. The aim of this study is to assess the actual rate of dislocation of intra-abdominal drains postoperatively and to evaluate its clinical impact. METHODS This is a prospective observational study using major pancreatic surgery as a model. Ninety-one consecutive patients undergoing pancreatoduodenectomy (PD) or distal pancreatectomy (DP) underwent low-dose, non-enhanced computed tomography (LDCT) on postoperative days (POD) 1 and 3 in a blinded fashion to assess the position of drains. We compared the outcomes of patients with dislocated and correctly placed drains. RESULTS Overall, drains were dislocated in 30 patients (33%), without differences between PD and DP. Most of dislocations were already present on POD 1 (77%). Postoperative complications occurred in 57% of patients, and the rate of postoperative pancreatic fistula (POPF) was 27%. The dislocated cohort had lesser morbidity (40% vs. 66%; relative risk (RR), 0.35; 95% CI, 0.14-0.86; P = 0.020), and the rate of POPF (3% vs. 39%, respectively; RR, 0.05; 95% CI, 0.01-0.42; P < 0.001). After PD, patients with dislocated drains had a shorter hospital stay (12 vs. 20 days; P = 0.015). No significant differences in terms of need for percutaneous drainage procedures, abdominal collections, or grade C POPFs were found between the groups. CONCLUSIONS Dislocation of intra-abdominal drains is an early and frequent event after major pancreatic resection. Its occurrence might protect against the negative effects of maintaining drainage, eventually leading to better postoperative outcomes. This data reinforces the knowledge that surgical drains might be detrimental in selected cases.
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Affiliation(s)
- Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Marco Ramera
- Department of General and Pancreatic Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Elena Viviani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Fabio Lombardo
- Department of Radiology, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Adam Cybulski
- Department of Radiology, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Marco Chincarini
- Department of Radiology, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy. .,Department of General and Pancreatic Surgery, "GB Rossi" Hospital, University of Verona, Piazzale L.A. Scuro, 10, 37134, Verona, Italy.
| | - Giulia A Zamboni
- Department of Radiology, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
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Paiella S, De Pastena M, Casciani F, Pan TL, Bogoni S, Andrianello S, Marchegiani G, Malleo G, Bassi C, Salvia R. Chyle leak after pancreatic surgery: validation of the International Study Group of Pancreatic Surgery classification. Surgery 2018; 164:450-454. [PMID: 29958728 DOI: 10.1016/j.surg.2018.05.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 04/08/2018] [Accepted: 05/08/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chyle leak is an uncommon complication after pancreatic surgery. The chyle leak incidence, definition, diagnosis, and treatment had been reported heterogeneously so far. Recently a consensus definition and grading system was published by the International Study Group for Pancreatic Surgery. This study aims to evaluate the differences in the clinical and economic burden of chyle leak applying the new definition. METHODS All data from patients who underwent pancreatic surgery for any disease from January 2014 to December 2016 were retrieved from the institutional prospective database. The 2017 International Study Group for Pancreatic Surgery definition and classification were applied. The classification was validated analyzing the differences in major complications, length of stay, and hospitalization costs. RESULTS A total of 945 patients was the final population. A chyle leak was reported in 43 patients (4.5%). Grade A chyle leak occurred in 10 patients (23.3%), Grade B chyle leak in 31 patients (72.1%), and Grade C chyle leak in 2 patients (4.6%). Chyle leak occurred as unique postoperative complication in 29 cases (67.4%). The economic analysis showed that the average costs of the 3 grades were 2,806, 7,150 and 15,684 euros respectively (P < .001). Furthermore, the length of stay, the rates of septic events, and major complications were significantly different among the 3 grades (P = .008, P = .004, and P < .001, respectively). Of note, we did not find any intraoperative factor associated with chyle leak. CONCLUSION The present study confirms the validity of the International Study Group for Pancreatic Surgery classification of chyle leak. The 3 grades of chyle leak proposed identify reliably clinical and economical differences among the chyle leak cases.
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Affiliation(s)
- Salvatore Paiella
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Verona, Italy.
| | - Matteo De Pastena
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Verona, Italy
| | - Fabio Casciani
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Verona, Italy
| | - Teresa Lucia Pan
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Verona, Italy
| | - Selene Bogoni
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Verona, Italy
| | - Stefano Andrianello
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Verona, Italy
| | - Giovanni Marchegiani
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Verona, Italy
| | - Giuseppe Malleo
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Verona, Italy
| | - Claudio Bassi
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Verona, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Verona, Italy
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Marchegiani G, Perri G, Pulvirenti A, Sereni E, Azzini AM, Malleo G, Salvia R, Bassi C. Non-inferiority of open passive drains compared with closed suction drains in pancreatic surgery outcomes: A prospective observational study. Surgery 2018; 164:443-449. [PMID: 29903511 DOI: 10.1016/j.surg.2018.04.025] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/07/2018] [Accepted: 04/23/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Policies concerning the management of operatively placed drains after pancreatic surgery are still under debate. Open passive drains and closed-suction drains are both used currently in clinical practice worldwide, but there are no reliable data regarding potential differences in the postoperative outcomes associated with each drain type. The aim of the present study was to compare open passive drains and closed-suction drains with regard to postoperative contamination of the drainage fluid and overall morbidity and mortality. METHODS This study was a prospective, observational analysis of 320 consecutive, standard, partial resections (pancreaticoduodenectomy and distal pancreatectomy at a single institution from April 2016 to April 2017. Either open passive drains (n = 189, 51%) or closed-suction drains (n = 131) were used according to the operating surgeon's choice. Postoperative outcomes, including samples of drainage fluid collected on postoperative day V and sent for microbiologic analysis, were registered. RESULTS The open passive drain and closed-suction drain cohorts did not differ in terms of their clinical features, use of neoadjuvant chemotherapy or preoperative biliary drainage, fistula risk zone, and type of operative procedure. The overall rate of postoperative day V drainage fluid contamination (27.5% vs. 20.6%, P = .1) was similar between the groups. The same results were obtained for each specific procedure. The postoperative outcomes, namely, overall 30-day morbidity, postoperative pancreatic fistula, intra-abdominal fluid collections, percutaneous drainage, wound infections, reintervention, mean duration of hospital stay, and mortality did not differ between the 2 groups. Qualitative microbiologic analysis revealed that after pancreaticoduodenectomy, 61.5% of the bacteria contaminating the drainage fluid were attributable to human gut flora, while after distal pancreatectomy, 84.8% of the bacteria belonged to skin and mucous flora (P < .01), however, the spectrum of bacterial contamination did not significantly differ between the open passive drain and closed-suction drain cohorts. CONCLUSION The use of open passive drains and closed-suction drains for major pancreatic resection does not significantly impact the postoperative outcome. The spectrum of drain contamination depends on the specific operative procedure rather than on the type of drain used.
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Affiliation(s)
- Giovanni Marchegiani
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Giampaolo Perri
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Alessandra Pulvirenti
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Elisabetta Sereni
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Anna Maria Azzini
- Microbiology and Virology Unit, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Claudio Bassi
- General and Pancreatic Surgery - The Pancreas Institute, University of Verona Hospital Trust, Italy.
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Marchegiani G, Ballarin R, Malleo G, Andrianello S, Allegrini V, Pulvirenti A, Paini M, Secchettin E, Boriero F, Di Benedetto F, Bassi C, Salvia R. Quantitative Assessment of Pancreatic Texture Using a Durometer: A New Tool to Predict the Risk of Developing a Postoperative Fistula. World J Surg 2017; 41:2876-2883. [DOI: 10.1007/s00268-017-4073-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Bassi C, Balzano G, Zerbi A, Ramera M. Pancreatic surgery in Italy. Criteria to identify the hospital units and the tertiary referral centers entitled to perform it. Updates Surg 2016; 68:117-22. [PMID: 27272682 DOI: 10.1007/s13304-016-0371-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 05/17/2016] [Indexed: 12/18/2022]
Abstract
Indicators of effectiveness and quality of care are urgently needed to improve the surgical outcomes. This is particularly felt in the field of complex surgical fields, such as the HPB one. International and national studies have documented an association between the large number of pancreatic surgical procedures and the outcome quality. The aim of this paper is to suggest reliable structural requirements and surgical volume to support pancreatic surgical accreditation, preserving patient's safety. Moreover, an accreditation program is outlined.
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Affiliation(s)
- Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, P.Le L.A. Scuro 10, 37134, Verona, Italy.
| | - Giampaolo Balzano
- Pancreas Unit, Department of Surgery, San Raffaele Scientific Institute, Milano, Italy
| | - Alessandro Zerbi
- Section of Pancreatic Surgery, Humanitas Research Hospital, Milano, Rozzano, Italy
| | - Marco Ramera
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, P.Le L.A. Scuro 10, 37134, Verona, Italy
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Lermite E, Wu T, Sauvanet A, Mariette C, Paye F, Muscari F, Cunha AS, Sastre B, Arnaud JP, Pessaux P. Postoperative biological and clinical outcomes following uncomplicated pancreaticoduodenectomy. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2016; 20:23-31. [PMID: 26925147 PMCID: PMC4767268 DOI: 10.14701/kjhbps.2016.20.1.23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 10/21/2015] [Accepted: 10/23/2015] [Indexed: 01/04/2023]
Abstract
Backgrounds/Aims The aim of this study was to describe clinical and biological changes in a group of patients who underwent pancreaticoduodenectomy (PD) without any complication during the postoperative period. These changes reflect the "natural history" of PD, and a deviation should be considered as a warning sign. Methods Between January 2000 and December 2009, 131 patients underwent PD. We prospectively collected and retrospectively analyzed demographic data, pathological variables, associated pathological conditions, and preoperative, intraoperative, and postoperative variables. Postoperative variables were validated using an external prospective database of 158 patients. Results The mean postoperative length of hospital stay was 20.3±4 days. The mean number of days until removal of nasogastric tube was 6.3±1.6 days. The maximal fall in hemoglobin level occurred on day 3 and began to increase after postoperative day (POD) 5, in patients with or without transfusions. The white blood cell count increased on POD 1 and persisted until POD 7. There was a marked rise in aminotransferase levels at POD 3. The peak was significantly higher in patients with hepatic pedicle occlusion (866±236 IU/L versus 146±48 IU/L; p<0.001). For both γ-glutamyl transpeptidase and alkaline phosphatase, there was a fall on POD1, which persisted until POD 5, followed with a stabilization. Bilirubin decreased progressively from POD 1 onwards. Conclusions This study facilitates a standardized biological and clinical pathway of follow-up. Patients who do not follow this recovery indicator could be at risk of complications and additional exams should be made to prevent consequences of such complications.
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Affiliation(s)
- Emilie Lermite
- Service de Chirurgie digestive, Hôpital universitaire d'Angers - Université d'Angers, France
| | - Tao Wu
- Digestive surgery, Hospital of Kunming - Medical University - Kunming - China
| | - Alain Sauvanet
- Service de Chirurgie Hépatobiliopancréatique, Hôpital Beaujon - Université Paris VII, France
| | - Christophe Mariette
- Service de Chirurgie digestive et oncologique, Hôpital Claude Huriez - Université de Lille, France
| | - François Paye
- Service de Chirurgie générale et digestive, Hôpital Saint-antoine - UPMC Paris VI, France
| | - Fabrice Muscari
- Service de Chirurgie digestive et de transplantation, Hôpital Rangueil - Université de Toulouse, France
| | - Antonio Sa Cunha
- Service de Chirurgie digestive, Hôpital Haut Levêque - Université de Bordeaux, France
| | - Bernard Sastre
- Service de Chirurgie digestive, Hôpital de la Timone - Université de Marseille, France
| | - Jean-Pierre Arnaud
- Service de Chirurgie digestive, Hôpital universitaire d'Angers - Université d'Angers, France
| | - Patrick Pessaux
- Unité de Chirurgie Hépatobiliaire et Pancréatique, Nouvel Hôpital Civil, Université de Strasbourg, IHU MixSurg, IRCAD, France
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Morales Soriano R, Esteve Pérez N, Tejada Gavela S, Cuadrado García Á, Rodríguez Pino JC, Morón Canis JM, Molina Romero X, Muñoz Pérez J, González Argente X. Outcomes of an enhanced recovery after surgery programme for pancreaticoduodenectomy. Cir Esp 2015; 93:509-15. [PMID: 26072690 DOI: 10.1016/j.ciresp.2015.04.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 04/12/2015] [Accepted: 04/15/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) has demonstrated in colorectal surgery a reduction in morbidity and length of stay without compromising security. Experience with ERAS programs in pancreatoduodenectomy (PD) is still limited. The aims of this study were first to evaluate the applicability of an ERAS program for PD patients in our hospital, and second to analyze the postoperative results. METHODS A retrospective study using a prospectively maintained database identified 41 consecutive PD included in an ERAS program. Key elements studied were early removal of tubes and drainages, early oral feeding and early mobilization. Variables studied were mortality, morbidity, perioperative data, length of stay, re-interventions and inpatient readmission. This group of patients was compared with an historic control group of 44 PD patients with a standard postoperative management. RESULTS A total of 85 pancreatoduodenectomies were analyzed (41 patients in the ERAS group, and 44 patients in the control group. General mortality was 2.4% (2 patients) belonging to the control group. There were no statistical differences in mortality, length of stay in intensive care, reoperationss, and readmissions. ERAS group had a lower morbidity rate than the control group (32 vs. 48%; P=.072), as well as a lower length of stay (14.2 vs. 18.7 days). All the key ERAS proposed elements were achieved. CONCLUSIONS ERAS programs may be implemented safely in pancreaticoduodenectomy. They may reduce the length of stay, unifying perioperative care and diminishing clinical variability and hospital costs.
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Affiliation(s)
- Rafael Morales Soriano
- Unidad de Cirugía HBP, Servicio de Cirugía General y Digestivo, Hospital Son Espases, Palma de Mallorca, Baleares, España.
| | - Neus Esteve Pérez
- Unidad de Cirugía HBP, Servicio de Cirugía General y Digestivo, Hospital Son Espases, Palma de Mallorca, Baleares, España
| | - Silvia Tejada Gavela
- Departamento de Biología y Ciencias de la Salud, Universidad de las Islas Baleares, Palma de Mallorca, Baleares, España
| | | | - José Carlos Rodríguez Pino
- Unidad de Cirugía HBP, Servicio de Cirugía General y Digestivo, Hospital Son Espases, Palma de Mallorca, Baleares, España
| | - José Miguel Morón Canis
- Unidad de Cirugía HBP, Servicio de Cirugía General y Digestivo, Hospital Son Espases, Palma de Mallorca, Baleares, España
| | - Xavier Molina Romero
- Unidad de Cirugía HBP, Servicio de Cirugía General y Digestivo, Hospital Son Espases, Palma de Mallorca, Baleares, España
| | - José Muñoz Pérez
- Servicio de Cirugía General y Digestivo, Hospital Son Llátzer, Palma de Mallorca, Baleares, España
| | - Xavier González Argente
- Unidad de Cirugía HBP, Servicio de Cirugía General y Digestivo, Hospital Son Espases, Palma de Mallorca, Baleares, España
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Bozzetti F, Mariani L. Perioperative nutritional support of patients undergoing pancreatic surgery in the age of ERAS. Nutrition 2014; 30:1267-71. [PMID: 24973198 DOI: 10.1016/j.nut.2014.03.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 02/24/2014] [Accepted: 03/01/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The results achieved through the Enhanced Recovery After Surgery (ERAS) approach in gastrointestinal surgery have led to its enthusiastic acceptance in pancreatic surgery. However, the ERAS program also involves an early oral feeding that is not always feasible after pancreatoduodenectomy. The aim of this review was to investigate in the literature whether the difficulty with early oral feeding in these patients was adequately balanced by perioperative enteral or parenteral nutritional support as recommended by the European Society for Clinical Nutrition and Metabolism (ESPEN) guidelines or whether these recommendations have lost value in the "bundle" of the ERAS. METHODS We reanalyzed both ESPEN guidelines and literature regarding the ERAS program in surgical pancreatic patients. RESULTS There was a high prevalence of malnutrition (and consequently of postoperative complications) in patients with pancreatic cancer, and there is evidence that many of these patients should be candidates for perioperative nutritional support according to ESPEN guidelines. The start of oral fluid and solid feeding was quite variable in literature reporting the use of ERAS in pancreatic cancer surgery, with a consistent gap between the recommended and the effective start of both the feedings. The use of nasogastric/jejunal tube or of a needle-catheter jejunostomy was discouraged by the ERAS guidelines but their use could prove beneficial in patients who are recognized at high risk for postoperative complications according to the scores available in the literature. CONCLUSION The current practice of the ERAS program in these patients appears to neglect some ESPEN recommendations. On the other hand, both ESPEN and ERAS recommendations could be combined for a supplemental benefit for the patient.
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Affiliation(s)
| | - Luigi Mariani
- Unit of Clinical Epidemiology and Trial Organization, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
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15
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Pietri LD, Montalti R, Begliomini B. Anaesthetic perioperative management of patients with pancreatic cancer. World J Gastroenterol 2014; 20:2304-20. [PMID: 24605028 PMCID: PMC3942834 DOI: 10.3748/wjg.v20.i9.2304] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 01/06/2014] [Accepted: 01/20/2014] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer remains a significant and unresolved therapeutic challenge. Currently, the only curative treatment for pancreatic cancer is surgical resection. Pancreatic surgery represents a technically demanding major abdominal procedure that can occasionally lead to a number of pathophysiological alterations resulting in increased morbidity and mortality. Systemic, rather than surgical complications, cause the majority of deaths. Because patients are increasingly referred to surgery with at advanced ages and because pancreatic surgery is extremely complex, anaesthesiologists and surgeons play a crucial role in preoperative evaluations and diagnoses for surgical intervention. The anaesthetist plays a key role in perioperative management and can significantly influence patient outcome. To optimise overall care, patients should be appropriately referred to tertiary centres, where multidisciplinary teams (surgical, medical, radiation oncologists, gastroenterologists, interventional radiologists and anaesthetists) work together and where close cooperation between surgeons and anaesthesiologists promotes the safe performance of major gastrointestinal surgeries with acceptable morbidity and mortality rates. In this review, we sought to provide simple daily recommendations to the clinicians who manage pancreatic surgery patients to make their work easier and suggest a joint approach between surgeons and anaesthesiologists in daily decision making.
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Bozzetti F. Perioperative nutritional support in the ERAS approach. Clin Nutr 2013; 32:872-3. [PMID: 23726982 DOI: 10.1016/j.clnu.2013.04.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 04/04/2013] [Accepted: 04/22/2013] [Indexed: 02/03/2023]
Affiliation(s)
- F Bozzetti
- Faculty of Medicine, University of Milan, Via Festa del Perdono 9, 20100 Milano, Italy.
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Sun RC, Button AM, Smith BJ, Leblond RF, Howe JR, Mezhir JJ. A comprehensive assessment of transfusion in elective pancreatectomy: risk factors and complications. J Gastrointest Surg 2013; 17:627-35. [PMID: 23423430 PMCID: PMC4388036 DOI: 10.1007/s11605-013-2169-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 02/08/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Specific data are needed regarding the impact of transfusion on operative complications in pancreatectomy. The objectives of this study were to determine risk factors for transfusion and to evaluate the potential association between transfusion and operative complications in elective pancreatectomy procedures. STUDY DESIGN We reviewed our institution's pancreatectomy and ACS-NSQIP databases. Multivariate analysis was used to determine clinicopathologic risk factors predictive of transfusion, and then a transfusion propensity score was developed to evaluate the impact of transfusion on post-pancreatectomy complications. RESULTS Of the 173 patients who were treated from September 2007 to September 2011, 78 patients (45 %) were transfused ≥ 1 unit of blood (median, 3.0 units; range, 1-55). Risk factors for transfusion included increasing Body Mass Index (BMI), smoking, increasing mortality risk score, preoperative anemia, intraoperative blood loss, and benign pathology. After controlling for these risk factors using a transfusion propensity score, transfusion was an independent predictor of increased complications, infectious complications, and hospital costs. CONCLUSIONS Multiple factors are predictive of transfusion in pancreatectomy, including increasing BMI and smoking. When controlling for transfusion propensity based on these risk factors, RBC transfusion is associated with worse operative outcomes including infectious complications. Development of protocols and strategies to minimize unnecessary transfusion in pancreatectomy are justified.
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Affiliation(s)
- Raphael C. Sun
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Anna M. Button
- Epidemiology and Biostatistics, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Brian J. Smith
- Epidemiology and Biostatistics, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Richard F. Leblond
- Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - James R. Howe
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - James J. Mezhir
- Department of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA, USA. Division of Surgical Oncology and Endocrine Surgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive; 4642 JCP, Iowa City, IA 52242, USA
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