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Rennie O, Sharma M, Helwa N. Hepatobiliary anastomotic leakage: a narrative review of definitions, grading systems, and consequences of leaks. Transl Gastroenterol Hepatol 2024; 9:70. [PMID: 39503018 PMCID: PMC11535784 DOI: 10.21037/tgh-24-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 07/10/2024] [Indexed: 11/08/2024] Open
Abstract
Background and Objective Hepatobiliary diseases are a longstanding and significant medical challenge which, despite advances in surgical techniques, still carry risks for postoperative complications such as anastomotic leaks (ALs), which can include both postoperative pancreatic fistula (POPF) and bile leaks (BL). These complications incur significant human and economic costs on all those involved, including the patient, healthcare providers, and hospital systems. The aim of this study was to construct a narrative review of literature surrounding definitions and grading systems for ALs in the context of hepato-pancreato-biliary (HPB) procedures, and consequences of POPF and BL. Methods A literature review was conducted by examining databases including PubMed, Web of Science, OVID Embase, Google Scholar, and Cochrane library databases. Searches were performed with the following search criteria: (((((((anastomosis) OR (anastomotic leak*)) OR (postoperative pancreatic fistula)) OR (bile leak*)) OR (pancreaticoduodenectomy)) OR (whipple)) AND ((hepatobiliary) OR (hepato-pancreato-biliary)) AND ((definition) OR (grading system*) OR (consequences) OR (outcomes) OR (risk factor*) OR (morbidity) OR (mortality))). Publications that were retrieved underwent further assessment to ensure other relevant publications were identified and included. Key Content and Findings A universally accepted definition and grading system for POPF and BL continues to be lacking, leading to variability in reported incidence in the literature. Various groups have worked to publish guidelines for defining and grading POPF and BL, with the International Study Group in Pancreatic Surgery (ISGPS) and International Study Group for Liver Surgery (ISGLS) definitions the current most recommended definitions for POPF and BL, respectively. The burden of AL on patients, healthcare providers, and hospitals is well documented in evidence from leak consequences, such as increased morbidity and mortality, higher reoperation rates, and increased readmission rates, among others. Conclusions AL remains a significant challenge in HPB surgery, despite medical advancements. Understanding the progress made in defining and grading leaks, as well as the range of negative outcomes that arise from AL, is crucial in improving patient care, reduce surgical mortality, and drive further advancements in earlier detection and treatment of AL.
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Affiliation(s)
- Olivia Rennie
- FluidAI Medical (formerly NERv Technology Inc.), Kitchener, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Manaswi Sharma
- FluidAI Medical (formerly NERv Technology Inc.), Kitchener, ON, Canada
| | - Nour Helwa
- FluidAI Medical (formerly NERv Technology Inc.), Kitchener, ON, Canada
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2
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Yang W, Zeng H, Jin Y. Robotic pancreaticoduodenectomy in patients with overweight or obesity: a meta-analysis protocol. BMJ Open 2024; 14:e080605. [PMID: 39019640 PMCID: PMC11284876 DOI: 10.1136/bmjopen-2023-080605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 06/24/2024] [Indexed: 07/19/2024] Open
Abstract
INTRODUCTION The prevalence of overweight or obesity among patients undergoing pancreaticoduodenectomy is on the rise. The utilisation of robotic assistance has the potential to enhance the feasibility of performing minimally invasive pancreaticoduodenectomy in this particular group of patients who are at a higher risk. The objective of this meta-analysis is to assess the safety and effectiveness of robotic pancreaticoduodenectomy in individuals with overweight or obesity. METHODS AND ANALYSIS This investigation will systematically search for randomised controlled trials (RCTs) and non-randomised comparative studies that compare robotic pancreaticoduodenectomy with open or laparoscopic pancreaticoduodenectomy in patients with overweight or obesity, using PubMed, Embase and the Cochrane Library databases. The methodological quality of studies will be evaluated using the Cochrane risk of bias tool for RCTs and the Newcastle-Ottawa Scale for observational studies. RevMan software (V.5.4.1) will be used for statistical analysis. The OR and weighted mean differences will be calculated separately for dichotomous and continuous data. The selection of a fixed-effects or random-effects model will depend on the level of heterogeneity observed among the included studies. ETHICS AND DISSEMINATION This study will be conducted based on data in the published literature from publicly available databases. Therefore, ethics approval is not applicable. The results will be disseminated in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42023462321.
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Affiliation(s)
- Wenxiao Yang
- Business School, University of Shanghai for Science & Technology, Shanghai, China
| | - Hai Zeng
- The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Yueling Jin
- Shanghai Science and Technology Museum, Shanghai, China
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Alqarni A, Aljehaiman F, Almousa SA, Almarshad SA, Alrzouq FK. The Relationship Between BMI and Postoperative Complications Among Colorectal Cancer Patients Undergoing Surgery. Cureus 2023; 15:e48715. [PMID: 38094533 PMCID: PMC10716719 DOI: 10.7759/cureus.48715] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2023] [Indexed: 03/30/2025] Open
Abstract
INTRODUCTION Colorectal cancer (CRC) is common worldwide, and surgery is one of the main treatments. Postoperative complications are a concern. The primary objective of this study is to determine whether elevated body mass index (BMI), the presence of comorbidities, tumor characteristics, and the type of surgery are associated with an increased risk of postoperative complications such as wound infections, pulmonary complications, anastomotic leak, venous thromboembolism (VTE), bowel obstruction, and incisional hernia. The secondary objective is to describe the characteristics of colorectal cancer patients with different BMI groups. METHODOLOGY A retrospective cohort study was conducted using a non-probability sampling technique at a tertiary National Guard Hospital in Riyadh, Saudi Arabia. This study involved 122 patients aged 18 years or more who underwent elective or emergency surgery for colorectal cancer between the years 2015 and 2022. Data analysis was performed using Statistical Package for Social Sciences (SPSS) version 27 (IBM SPSS Statistics, Armonk, NY). Descriptive statistics (mean and standard deviation) were used for quantitative variables, while qualitative variables were presented as percentages and frequencies. Non-parametric tests were applied to compare qualitative variables. Quantitative variables were analyzed using the analysis of variance (ANOVA) test. Significance was established at a p-value of 0.05. Ethical considerations were followed throughout the study. Prior to conducting the study, ethical approval was obtained from the Institutional Review Board of King Abdullah International Medical Research Center (KAIMRC) (approval number: IRB/1598/23). RESULTS High BMI scores were observed in patients with postoperative complications. A statistically significant variation in BMI scores (p-value < 0.05) was found between patients with complications and without complications. This observation suggests that factors beyond excessive body weight might contribute to the onset of postoperative complications. Moreover, elevated BMI scores were more prevalent in males and were associated with reduced hemoglobin (Hgb) levels, underscoring the potential influence of physiological variables on the emergence of postoperative complications (p-value < 0.05). Tumors located in the rectum or rectosigmoid regions, as well as partial colectomy procedures, exhibited a higher risk of postoperative complications (p-value < 0.05). However, no significant connections were identified between the presence of comorbidities and the occurrence of postoperative complications (p-value > 0.05). CONCLUSION This study highlights the impact of BMI on postoperative outcomes in colorectal cancer patients. Higher BMI was associated with unfavorable postoperative outcomes, such as an increased risk of VTE and fluid collection. However, no significant differences in mortality rates or length of hospital stay (LOS) were observed across various BMI categories. Factors beyond BMI, including tumor characteristics, the type of surgical intervention, and preoperative care, play a significant role in determining postoperative outcomes. Therefore, it is essential to adopt a comprehensive approach that considers multiple factors when managing postoperative complications in colorectal cancer patients, particularly those with higher BMI.
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Affiliation(s)
- Ayyob Alqarni
- Department of General and Colorectal Surgery, King Abdulaziz Medical City, Riyadh, SAU
- Collage of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Fahad Aljehaiman
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
- Department of Research, King Abdullah International Medical Research Center, Riyadh, SAU
| | - Saad A Almousa
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
- Department of Research, King Abdullah International Medical Research Center, Riyadh, SAU
| | - Sundos A Almarshad
- Collage of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
- Department of Research, King Abdullah International Medical Research Center, Riyadh, SAU
| | - Fahad K Alrzouq
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
- Department of Research, King Abdullah International Medical Research Center, Riyadh, SAU
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Mohamed A, Nicolais L, Fitzgerald TL. Textbook outcome as a composite measure of quality in hepaticopancreatic surgery. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:1172-1179. [PMID: 37735865 DOI: 10.1002/jhbp.1351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 05/02/2023] [Accepted: 06/28/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Textbook outcome (TO) is a valuable metric to assess postoperative outcomes. The aim of this study was to assess TO in patients undergoing hepatopancreatic surgery. METHODS This was a retrospective cohort NSQIP study from 2015 to 2018. TOs are defined as no complication or mortality and length of stay within the 75th percentile. RESULTS This study included 44 235 patients. Of those patients, 61% underwent pancreatic surgery (PS) and 39% hepatic surgery (HS). The most common surgical procedure was pancreaticoduodenectomy (16 464), followed by partial hepatectomy (11 817), distal pancreatectomy (8292), hemihepatectomy (4247), hepatic trisegmentectomy (1366) and total pancreatectomy (706). TO was more common for HS than PS, 47% versus 40%, p < .001. TO was more common for younger (0-65, OR: 1.60; CI: 1.30-1.96, p < .001), female (OR: 1.23; CI: 1.17-1.29, p < .001), white (OR: 1.10; CI: 1.01-1.19, p = .022), and lower ASA class (OR: 2.11; CI: 1.54-2.90, p < .001) patients. For patients undergoing HS TO was more common after partial lobectomy than trisegmentectomy and lobectomy (OR: 1.36; CI: 1.18-1.57, p < .001). For those undergoing PS, there was a lower likelihood of TO for those who are obese/morbidly obese compared to normal-weight patients (OR: 0.73; CI: 0.67-0.79, p < .001). Unlike HS, TO for patients undergoing PS was not associated with the type of surgical procedure. CONCLUSIONS TO is a composite that can be applied to a national data set to analyze outcome quality. In HS, more complex surgical procedures are associated with a decreased likelihood of TO. In PS, TO are similar regardless of the procedure but less common in obese or morbidly obese patients.
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Affiliation(s)
- Abdimajid Mohamed
- Division of Surgical Oncology, Tufts University School of Medicine-Maine Medical Center, Portland, Maine, USA
| | - Laura Nicolais
- Division of Surgical Oncology, Tufts University School of Medicine-Maine Medical Center, Portland, Maine, USA
| | - Timothy L Fitzgerald
- Division of Surgical Oncology, Tufts University School of Medicine-Maine Medical Center, Portland, Maine, USA
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Li J, Qian L, Shi Y, Shen B, Peng C. Short-term outcomes between robot-assisted and open pancreaticoduodenectomy in patients with high body mass index: A propensity score matched study. Cancer Med 2023; 12:15141-15148. [PMID: 37255405 PMCID: PMC10417296 DOI: 10.1002/cam4.6186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/27/2023] [Accepted: 05/21/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND High body mass index was considered as a risk factor for minimally invasive surgery. The short-term outcomes of robot-assisted pancreaticoduodenectomy (RPD) remain controversial. This study aims to investigate the feasibility and advantage of RPD in patients with high body mass index compared to open pancreaticoduodenectomy (OPD). METHODS Clinical data of 304 patients who underwent pancreaticoduodenectomy from January 2016 to December 2019 in Ruijin Hospital, Shanghai Jiao Tong University School of Medicine was collected. Patients with BMI >25 kg/m2 were included and divided into RPD and OPD group. After PSM at a 1:1 ratio, 75 patients of OPD and 75 patients of RPD were recorded and analyzed. RESULTS The RPD group showed advantages in the estimated blood loss (EBL) (323.3 mL vs. 480.7 mL, p = 0.010), the postoperative abdominal infection rate (24% vs. 44%, p = 0.010), the incidence of Clavien-Dindo III-V complications (14.7% vs. 28.0%, p = 0.042) over OPD group. CONCLUSION RPD shows advantages in less EBL, lower incidence rate of Clavien-Dindo III-V complications over OPD in overweight and obese patients. RPD was confirmed as a safe and feasible surgical approach for overweight or obsess patients.
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Affiliation(s)
- Jingfeng Li
- Department of General SurgeryPancreatic Disease CenterRuijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Research Institute of Pancreatic DiseasesShanghai Jiao Tong University School of MedicineShanghaiChina
- State Key Laboratory of Oncogenes and Related Genes (Shanghai)ShanghaiChina
- Institute of Translational MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Lihan Qian
- Department of General SurgeryPancreatic Disease CenterRuijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Research Institute of Pancreatic DiseasesShanghai Jiao Tong University School of MedicineShanghaiChina
- State Key Laboratory of Oncogenes and Related Genes (Shanghai)ShanghaiChina
- Institute of Translational MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Yusheng Shi
- Department of General SurgeryPancreatic Disease CenterRuijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Research Institute of Pancreatic DiseasesShanghai Jiao Tong University School of MedicineShanghaiChina
- State Key Laboratory of Oncogenes and Related Genes (Shanghai)ShanghaiChina
- Institute of Translational MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Baiyong Shen
- Department of General SurgeryPancreatic Disease CenterRuijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Research Institute of Pancreatic DiseasesShanghai Jiao Tong University School of MedicineShanghaiChina
- State Key Laboratory of Oncogenes and Related Genes (Shanghai)ShanghaiChina
- Institute of Translational MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Chenghong Peng
- Department of General SurgeryPancreatic Disease CenterRuijin HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
- Research Institute of Pancreatic DiseasesShanghai Jiao Tong University School of MedicineShanghaiChina
- State Key Laboratory of Oncogenes and Related Genes (Shanghai)ShanghaiChina
- Institute of Translational MedicineShanghai Jiao Tong UniversityShanghaiChina
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Russell TB, Labib PLZ, Aroori S. Five-year follow-up after pancreatoduodenectomy performed for malignancy: A single-centre study. Ann Hepatobiliary Pancreat Surg 2023; 27:76-86. [PMID: 36168824 PMCID: PMC9947371 DOI: 10.14701/ahbps.22-039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/13/2022] [Accepted: 07/21/2022] [Indexed: 11/17/2022] Open
Abstract
Backgrounds/Aims The aim of this study was to describe short- and long-term outcomes of patients who underwent pancreatoduodenectomy (PD) at a typical United Kingdom hepatopancreatobiliary unit. Methods A retrospective analysis of all PD patients with histologically-confirmed pancreatic ductal adenocarcinoma (PDAC), ampullary adenocarcinoma (AA), or distal cholangiocarcinoma (CC) from September 1st, 2006 to May 31st, 2015 was carried out. The following information was obtained: demographics, comorbidities, preoperative investigations, neoadjuvant treatment, operative details, postoperative management, complications, adjuvant treatment, five-year recurrence, and five-year survival. Effects of selected preoperative variables on short- and long-term outcomes were investigated. Results Of 271 included patients, 57.9% had PDAC, 25.8% had AA, and 16.2% had CC. In total, 67.9% experienced morbidity and 17.3% developed a Clavien-Dindo grade ≥ III complication. The 90-day mortality was 3.3%. Clinically-relevant postoperative pancreatic fistula, bile leak, gastrojejunal leak, postpancreatectomy haemorrhage and delayed gastric emptying affected 8.1%, 4.1%, 0.0%, 9.2%, and 19.9% of patients, respectively. American Society of Anesthesiologists grade III-VI correlated with overall morbidity (p = 0.002) and major morbidity (p = 0.009), but not 90-day mortality or five-year survival. The same pattern was observed in patients with a preoperative serum bilirubin > 29 μmol/L and/or a neutrophil/lymphocyte ratio > 3.1. Five-year cancer recurrence and five-year survival were 68.3% and 22.5%, respectively. PDAC patients had higher five-year recurrence but lower five-year survival rates (both p = 0.001). Conclusions In our series, the majority of patients experienced a complication. However, few patients experienced major morbidity. Surgical risk factors did not affect five-year survival.
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Affiliation(s)
- Thomas Brendon Russell
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | | | - Somaiah Aroori
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom,Corresponding author: Somaiah Aroori, MD, FRCS Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Derriford Road, Plymouth PL6 8DH, United Kingdom Tel: +44-7837388342, E-mail: ORCID: https://orcid.org/0000-0002-5613-6463
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Enderes J, Pillny C, Matthaei H, Manekeller S, Kalff JC, Glowka TR. Obesity Does Not Influence Delayed Gastric Emptying Following Pancreatoduodenectomy. BIOLOGY 2022; 11:biology11050763. [PMID: 35625491 PMCID: PMC9138317 DOI: 10.3390/biology11050763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 05/10/2022] [Accepted: 05/15/2022] [Indexed: 12/20/2022]
Abstract
Background: The data about obesity on postoperative outcome after pancreatoduodenectomy (PD) are inconsistent, specifically in relation to gastric motility and delayed gastric emptying (DGE). Methods: Two hundred and eleven patients were included in the study and patients were retrospectively analyzed in respect to pre-existing obesity (obese patients having a body mass index (BMI) ≥ 30 kg/m2 vs. non-obese patients having a BMI < 30 kg/m2, n = 34, 16% vs. n = 177, 84%) in relation to demographic factors, comorbidities, intraoperative characteristics, mortality and postoperative complications with special emphasis on DGE. Results: Obese patients were more likely to develop clinically relevant pancreatic fistula grade B/C (p = 0.008) and intraabdominal abscess formations (p = 0.017). However, clinically relevant DGE grade B/C did not differ (p = 0.231) and, specifically, first day of solid food intake (p = 0.195), duration of intraoperative administered nasogastric tube (NGT) (p = 0.708), rate of re-insertion of NGT (0.123), total length of NGT (p = 0.471) or the need for parenteral nutrition (p = 0.815) were equally distributed. Moreover, mortality (p = 1.000) did not differ between the two groups. Conclusions: Obese patients do not show a higher mortality rate and are not at higher risk to develop DGE. We thus show that in our study, PD is feasible in the obese patient in regard to postoperative outcome with special emphasis on DGE.
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Zorbas K, Wu J, Reddy S, Esnaola N, Karachristos A. Obesity affects outcomes of pancreatoduodenectomy. Pancreatology 2021; 21:824-832. [PMID: 33752975 DOI: 10.1016/j.pan.2021.02.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 02/22/2021] [Accepted: 02/23/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Obesity is a major global health problem, and it has reached epidemic proportions worldwide. Therefore, surgeons will confront an increasingly larger proportion of obese candidates for pancreatoduodenectomy (PD) in the future. Several small retrospective studies have been conducted to evaluate the role of Body Mass Index (BMI) in postoperative surgical complications after PD, with conflicting results. The aim of this study was to use a large multi-institutional database to clarify the impact of different levels of obesity after PD. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients who underwent PD from 2014 to 2016. Patients were categorized in the following six BMI groups: <18.5 (Underweight), 18.5-24.9 (Normal Weight), 25-29.9 (Overweight), 30-34.9 (Class I obesity), 35-39.9 (Class II Obesity) and >40 (Class III Obesity). The primary outcomes of interest were 30-day mortality and morbidity after PD among the six BMI groups. RESULTS The final population consists of 10,316 patients. Class III is associated with higher risk of 30-day mortality (OR 2.56, 95% CI 1.25-5.25, p = 0.011), major complications (OR 2.23, 95% CI 1.54-3.22, p < 0.001), clinically relevant postoperative pancreatic fistula (OR 2.48, 95% CI 1.89-3.24, p < 0.001), surgical site infections (OR 2.06, 95% CI 1.61-2.65, p < 0.001) and wound dehiscence (OR 3.47, 95% CI 1.7-7.1, p < 0.001) in multivariable analysis. CONCLUSIONS In conclusion, our study shows that obesity is significantly associated with higher risk of postoperative complications in patients undergoing PD and patients with BMI≥40 have increased risk of mortality after PD.
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Affiliation(s)
| | - Jingwei Wu
- Department of Epidemiology and Biostatistics at Temple University, Philadelphia, PA, USA
| | - SanjayS Reddy
- Department of Surgery, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - NestorF Esnaola
- Division of Surgical Oncology, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Andreas Karachristos
- Division of Surgical Oncology, Department of Surgery, University of South Florida, Tampa, FL, USA.
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Chao YJ, Liao TK, Su PJ, Wang CJ, Shan YS. Impact of body mass index on the early experience of robotic pancreaticoduodenectomy. Updates Surg 2021; 73:929-937. [PMID: 34009628 PMCID: PMC8184700 DOI: 10.1007/s13304-021-01065-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 04/20/2021] [Indexed: 12/16/2022]
Abstract
Obesity
increases surgical morbidity and mortality in open pancreaticoduodenectomy (OPD). Its influence on robotic pancreaticoduodenectomy (RPD) remains uncertain. This study aimed to investigate the impact of body mass index (BMI) on the early experience of RPD. Between June 2015 and April 2020, 68 consecutive RPDs were performed at the National Cheng Kung University Hospital. The patients were categorized as normal-weight (BMI < 23 kg/m2), overweight (BMI = 23–27.5 kg/m2), and obese (BMI > 27.5 kg/m2) according to the definition of obesity in Asian people from the World Health Organization expert consultation. Preoperative characteristics, operative details, and postoperative outcomes were prospectively collected. The cumulative sum was used to assess the learning curves. The average age of the patients was 64.8 ± 11.7 years with an average BMI of 24.6 ± 3.7 kg/m2 (23 normal-weight, 29 overweight, and 16 obese patients). Eighteen patients were required to overcome the learning curve. The overall complication rate was 51.5%, and the major complication rate (Clavien grade ≥ III) was 19.1%. The normal-weight group showed the most favorable outcomes. The blood loss, major complication rate, peripancreatic fluid collection rate, and conversion rate were higher in the obese group than in the non-obese group. There were no differences in the operative time, clinically relevant postoperative pancreatic fistula, postoperative hemorrhage, delayed gastric emptying, bile leak, wound infection, reoperation, hospital stay, and readmission rate between the obese and non-obese groups. Multivariate analysis showed obesity as the only independent factor for major complications (OR: 5.983, CI: 1.394–25.682, p = 0.001), indicating that obesity should be considered as a surgical risk factor during the implementation of RPD.
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Affiliation(s)
- Ying-Jui Chao
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, 138, Sheng-Li Road, Tainan, 70428, Taiwan.,Department of Surgery, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Ting-Kai Liao
- Department of Surgery, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Ping-Jui Su
- Department of Surgery, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chih-Jung Wang
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, 138, Sheng-Li Road, Tainan, 70428, Taiwan.,Department of Surgery, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Yan-Shen Shan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, 138, Sheng-Li Road, Tainan, 70428, Taiwan. .,Department of Surgery, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan.
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Obesity and Pancreatic Cancer: A Matched-Pair Survival Analysis. J Clin Med 2020; 9:jcm9113526. [PMID: 33142763 PMCID: PMC7693315 DOI: 10.3390/jcm9113526] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 10/20/2020] [Accepted: 10/28/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Morbid obesity is a risk factor for pancreatic ductal adenocarcinoma (PDAC). However, the impact of obesity on postoperative outcomes and overall survival in patients with PDAC remains a controversial topic. METHODS Patients who underwent pancreatic surgery for PDAC between 1997 and 2018 were included in this study. Matched pairs (1:1) were generated according to age, gender and American Society of Anesthesiologists status. Obesity was defined according to the WHO definition as BMI ≥ 30 kg/m2. The primary endpoint was the difference in overall survival between patients with and without obesity. RESULTS Out of 553 patients, a total of 76 fully matched pairs were generated. Obese patients had a mean BMI-level of 33 compared to 25 kg/m2 in patients without obesity (p = 0.001). The frequency of arterial hypertension (p = 0.002), intraoperative blood loss (p = 0.039), and perineural invasion (p = 0.033) were also higher in obese patients. Clinically relevant postoperative complications (p = 0.163) and overall survival rates (p = 0.885) were comparable in both study groups. Grade II and III obesity resulted in an impaired overall survival, although this was not statistically significant. Subgroup survival analyses revealed no significant differences for completion of adjuvant chemotherapy and curative-intent surgery. CONCLUSIONS Obesity did not affect overall survival and postoperative complications in these patients with PDAC. Therefore, pancreatic surgery should not be withheld from obese patients.
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van der Heijde N, Balduzzi A, Alseidi A, Dokmak S, Polanco PM, Sandford D, Shrikhande SV, Vollmer C, Wang SE, Besselink MG, Asbun H, Abu Hilal M. The role of older age and obesity in minimally invasive and open pancreatic surgery: A systematic review and meta-analysis. Pancreatology 2020; 20:1234-1242. [PMID: 32782197 DOI: 10.1016/j.pan.2020.06.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 06/14/2020] [Accepted: 06/18/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES The aim of this study was to assess the impact of older age (≥70 years) and obesity (BMI ≥30) on surgical outcomes of minimally invasive pancreatic resections (MIPR). Subsequently, open pancreatic resections or MIPR were compared for elderly and/or obese patients. METHODS A systematic review was conducted as part of the 2019 Miami International Evidence-Based Guidelines on MIPR (IG-MIPR). Study quality assessment was according to The Scottish Intercollegiate Guidelines Network (SIGN). A meta-analysis was performed to assess the impact of MIPR or open pancreatic resections in elderly patients. RESULTS After screening 682 studies, 13 observational studies with 4629 patients were included. Elderly patients undergoing laparoscopic distal pancreatectomy (LDP) had less blood loss (117 mL, p < 0.001) and a shorter hospital stay (3.5 days p < 0.001) than elderly patients undergoing open distal pancreatectomy (ODP). Postoperative pancreatic fistula (POPF) B/C, major complication and reoperation rate were not significantly different in elderly patients undergoing either laparoscopic or open pancreatoduodenectomy (OPD). One study compared robot PD with OPD in obese patients, indicating that patients with robotic surgery had less blood loss (mean 250 ml vs 500 ml, p = 0.001), shorter operative time (mean 381 min vs 428 min, p = 0.003), and lower rate of POPF B/C (13% vs 28%, p = 0.039). CONCLUSION The current available limited evidence does not suggest that MIPR is contraindicated in elderly or obese patients. Additionally, outcomes in MIPR are equal or more beneficial compared to the open approach when applied in these patient groups.
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Affiliation(s)
- N van der Heijde
- Department of Surgery, Southampton University Hospital, Southampton, United Kingdom; Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands.
| | - A Balduzzi
- Department of Surgery, University Hospital, Verona, Italy
| | - A Alseidi
- Department of Surgery, University of California, San Francisco, USA
| | - S Dokmak
- Department of Surgery, Beaujon Hospital, Paris, France
| | - P M Polanco
- Department of Surgery, UT Southwestern Medical Center, Dallas, USA
| | - D Sandford
- Department of Surgery, Washington University, St. Louis, USA
| | - S V Shrikhande
- Department of Surgery, Tata Memorial Hospital, Mumbai, India
| | - C Vollmer
- Department of Surgery, University of Pennsylvania, USA
| | - S E Wang
- Department of Surgery, Taipei Veterans General Hospital and National Yang Ming University, National Yang Ming University, Taipei, Taiwan
| | - M G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - H Asbun
- Miami Cancer Institute, Miami, FL, USA
| | - M Abu Hilal
- Department of Surgery, Southampton University Hospital, Southampton, United Kingdom.
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12
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Hiraki M, Miyoshi A, Sadashima E, Shinkai Y, Yasunami M, Manabe T, Kitahara K, Noshiro H. The novel early predictive marker presepsin for postoperative pancreatic fistula: A pilot study. Exp Ther Med 2020; 20:2298-2304. [PMID: 32765708 DOI: 10.3892/etm.2020.8919] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 03/26/2020] [Indexed: 12/13/2022] Open
Abstract
Postoperative pancreatic fistula (PF) is a major and serious complication that occurs after pancreaticoduodenectomy (PD). The aim of the current study was to evaluate the use of a novel biomarker, presepsin, for predicting clinically relevant postoperative pancreatic fistula (CR-POPF) after PD. A prospective pilot study was conducted using 30 consecutive patients who underwent PD. Risk factors and candidates for predictive biomarkers for CR-POPF were statistically analyzed. CR-POPF (grade B and C; determined according to the guidelines of the International Study Group of Pancreatic Fistula) occurred in 15 patients (50%). Univariate analysis revealed that certain underlying conditions, including non-pancreatic cancer, smaller pancreatic ducts and soft pancreas texture were significantly associated with CR-POPF (P=0.005, P=0.004 and P=0.014, respectively). Furthermore, on day 1 post surgery (POD1), white blood cell count (P=0.040), levels of serum amylase (P=0.002) and serum presepsin (P=0.012), and the concentration of presepsin in drainage fluid (P<0.001) were significantly increased in CR-POPF compared with non-CR-POPF cases. Receiver operating characteristic curve analyses revealed that, on POD1, serum amylase and the concentration of presepsin in drainage fluid had an area under the curve value exceeding 0.8. A multivariate logistic regression analysis revealed that a higher concentration of presepsin in the drainage fluid was an independent predictive marker for CR-POPF (odds ratio, 14.503; 95% confidence interval, 1.750-120.229; P=0.013). To the best of our knowledge, the present study demonstrated for the first time that presepsin concentration in drainage fluid is a useful marker of CR-POPF after PD.
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Affiliation(s)
- Masatsugu Hiraki
- Department of Surgery, Saga Medical Center Koseikan, Saga 840-8571, Japan
| | - Atsushi Miyoshi
- Department of Surgery, Saga Medical Center Koseikan, Saga 840-8571, Japan
| | - Eiji Sadashima
- Life Science Research Institution, Saga Medical Center Koseikan, Saga 840-8571, Japan
| | - Yukio Shinkai
- Clinical Laboratory, Saga Medical Center Koseikan, Saga 840-8571, Japan
| | - Michio Yasunami
- Clinical Laboratory, Saga Medical Center Koseikan, Saga 840-8571, Japan
| | - Tatsuya Manabe
- Department of Surgery, Saga University Faculty of Medicine, Saga 849-8501, Japan
| | - Kenji Kitahara
- Department of Surgery, Saga Medical Center Koseikan, Saga 840-8571, Japan
| | - Hirokazu Noshiro
- Department of Surgery, Saga University Faculty of Medicine, Saga 849-8501, Japan
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13
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Zeng ZL, Sun Y, Xue D, Liu PL, Chen WM, Zhang L. Effect of six-stitch pancreaticojejunostomy on pancreatic fistula: A propensity score-matched comparative cohort study. Hepatobiliary Pancreat Dis Int 2020; 19:277-283. [PMID: 32376235 DOI: 10.1016/j.hbpd.2020.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 04/16/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) is the most common and severe complication after pancreaticoduodenectomy (PD). Despite the development of numerous anastomotic surgical techniques to minimize CR-POPF, more than 30% of patients who undergo PD develop CR-POPF. Herein, we propose a novel pancreaticojejunostomy (PJ) technique and evaluate its efficacy and safety compared to traditional PJ. METHODS This retrospective study enrolled 164 consecutive patients who underwent PJ after PD between January 2012 and June 2017. Of them, 78 (47.6%) underwent traditional PJ and 86 (52.4%) underwent six-stitch PJ. The primary outcome was CR-POPF at 1-month follow-up defined according to the revised 2016 International Study Group on Pancreatic Fistula definition. To adjust for baseline differences and selection bias, patients were matched by propensity scores, which left 63 patients with traditional PJ and 63 with six-stitch PJ. RESULTS Compared to patients who underwent traditional PJ (mean age 56.2 ± 9.4 years), patients who underwent six-stitch PJ (mean age 57.4 ± 11.4 years) had a lower CR-POPF rate. The risk of CR-POPF among patients who underwent six-stitch PJ was decreased by 81.7% after adjustment for age, sex, body mass index, and disease severity compared to patients who underwent traditional PJ. Additionally, the surgery time was reduced from 29 min for traditional PJ to 15 min for six-stitch PJ (P <0.001). Adverse effects such as abdominal fluid collection, abdominal bleeding, and wound infection were similar between two groups. CONCLUSION Six-stitch PJ may be an effective and efficient PJ technique for patients who undergo PD surgery.
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Affiliation(s)
- Zhao-Lin Zeng
- Department of General Surgery, the Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Yan Sun
- Department of General Surgery, the Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Da Xue
- Department of General Surgery, the Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Pi-Li Liu
- Department of General Surgery, the Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Wang-Ming Chen
- Department of General Surgery, the Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China
| | - Lei Zhang
- Department of General Surgery, the Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China.
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14
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Zou SY, Wang WS, Zhan Q, Deng XX, Shen BY. Higher body mass index deteriorates postoperative outcomes of pancreaticoduodenectomy. Hepatobiliary Pancreat Dis Int 2020; 19:163-168. [PMID: 31862346 DOI: 10.1016/j.hbpd.2019.11.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 11/27/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Previous studies presented controversies in impact of body mass index (BMI) on perioperative complications in pancreatectomy, and mainly focused on Western population. This study aimed to explore the impact of BMI on perioperative outcomes in Chinese patients undergoing pancreaticoduodenectomy. METHODS Seven hundred and seven adult patients undergoing open pancreaticoduodenectomy between January 2005 and December 2016 at Ruijin Hospital were studied retrospectively and categorized as obese (BMI ≥25 kg/m2), overweight (BMI ≥23 kg/m2 and <25 kg/m2), or normal weight (BMI ≥18.5 kg/m2 and <23 kg/m2). Associations of these BMI groups with perioperative outcomes were evaluated. RESULTS The overweight and obese groups experienced higher risk of clinically related postoperative pancreatic fistula (CR-POPF) (7.6% vs. 9.9% vs. 17.6%, P = 0.002) and re-operation (1.1% vs. 2.5% vs. 5.1%, P = 0.017), and longer systemic inflammation response syndrome (SIRS) duration [2 (1-9) d vs. 2 (1-7) d vs. 3 (1-10) d, P = 0.003] and postoperative hospital stay [19 (2-84) d vs. 19 (7-158) d vs. 23 (8-121) d, P = 0.023] than the normal weight group did. The multiple logistic regression models showed obese as an independent risk factor for CR-POPF (P = 0.013). The multiple linear regression analysis confirmed BMI as a predictor for prolonged postoperative hospital stay (P = 0.005). CONCLUSIONS Higher BMI results in higher morbidity of Chinese patients undergoing open pancreaticoduodenectomy. Pancreaticoduodenectomy is still a safe surgery procedure for overweight and obese patients, with intensive perioperative management.
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Affiliation(s)
- Si-Yi Zou
- Pancreatic Disease Center, Research Institute of Pancreatic Disease, Shanghai Institute of Digestive Surgery, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200025, China
| | - Wei-Shen Wang
- Pancreatic Disease Center, Research Institute of Pancreatic Disease, Shanghai Institute of Digestive Surgery, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200025, China
| | - Qian Zhan
- Pancreatic Disease Center, Research Institute of Pancreatic Disease, Shanghai Institute of Digestive Surgery, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200025, China
| | - Xia-Xing Deng
- Pancreatic Disease Center, Research Institute of Pancreatic Disease, Shanghai Institute of Digestive Surgery, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200025, China
| | - Bai-Yong Shen
- Pancreatic Disease Center, Research Institute of Pancreatic Disease, Shanghai Institute of Digestive Surgery, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200025, China.
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15
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He S, Ding D, Wright MJ, Groshek L, Javed AA, Ka-Wan Chu K, Burkhart RA, Cameron JL, Weiss MJ, Wolfgang CL, He J. The impact of high body mass index on patients undergoing robotic pancreatectomy: A propensity matched analysis. Surgery 2019; 167:556-559. [PMID: 31837833 DOI: 10.1016/j.surg.2019.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/01/2019] [Accepted: 11/05/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients with high body mass index are associated with a higher risk of complications after open pancreatectomy. We aimed to investigate the perioperative outcome for patients with high body mass index after robotic pancreatectomy. METHODS This is a retrospective, propensity-score matched cohort analysis. From our prospectively maintained database, we identified consecutive patients with body mass index >25 who underwent robotic pancreatectomy between January 2016 and December 2018. Propensity score matching with open pancreatectomy was applied in 1:2 fashion based on age, gender, American Society of Anesthesiologists classification, surgery type, histology, neoadjuvant therapy, and body mass index during the same study period. RESULTS A total of 127 patients were included. The mean age for all patients was 61.7 ± 12.8 years and 65 (51.2%) were male. Median body mass index was 29.9 (interquartile range, 27.0-31.8) for both groups. Propensity score matching provided equally distributed general demographic and clinicopathological factors. Robotic pancreatectomy was associated with decreased blood loss (100 mL vs 300 mL, P < .001) and shorter hospital stay (7 vs 9 days, P = .019). CONCLUSION Robotic pancreatectomy is associated with decreased blood loss and shorter length of hospital stay in overweight patients. Robotic approach may help alleviate morbidity in overweight patients undergoing pancreatectomy.
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Affiliation(s)
- Shengliang He
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ding Ding
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD; The Pancreatic Cancer Precision Medicine Center of Excellence Program, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael J Wright
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; The Pancreatic Cancer Precision Medicine Center of Excellence Program, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lara Groshek
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ammar A Javed
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kevin Ka-Wan Chu
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Surgery, Queen Mary Hospital, The University of Hong Kong, China
| | - Richard A Burkhart
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; The Pancreatic Cancer Precision Medicine Center of Excellence Program, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - John L Cameron
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; The Pancreatic Cancer Precision Medicine Center of Excellence Program, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Matthew J Weiss
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; The Pancreatic Cancer Precision Medicine Center of Excellence Program, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher L Wolfgang
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; The Pancreatic Cancer Precision Medicine Center of Excellence Program, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jin He
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; The Pancreatic Cancer Precision Medicine Center of Excellence Program, The Johns Hopkins University School of Medicine, Baltimore, MD.
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16
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Lovasik BP, Kron P, Clavien PA, Petrowsky H, Kooby DA. Pancreatectomy and body mass index: an international evaluation of cumulative postoperative complications using the comprehensive complications index. HPB (Oxford) 2019; 21:1761-1772. [PMID: 31153835 DOI: 10.1016/j.hpb.2019.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 03/03/2019] [Accepted: 04/12/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Overweight and obese patients undergoing pancreatectomy are at increased risk for postoperative complications and readmission. We examined the association between body mass index (BMI) and postoperative complications following major pancreatectomy using the novel Comprehensive Complications Index (CCI), which analyzes the impact of multiple surgical complications rather than just the most severe. METHODS We performed a retrospective dual institutional international review of 500 consecutive patients who underwent pancreatic resection and assessed the association of BMI with postoperative complications using the CCI and Clavien-Dindo Classification (CDC) with uni- and multivariable analyses. RESULTS Overweight and obese patients undergoing pancreatic resection demonstrated a higher incidence and severity of CCI-measured complications (29.3 vs. 21.1, P < 0.001), more pancreatic fistulae (15.4 vs. 8.8%, 95% CI 1.005 -1.902), and an increased 30-day readmission rate (21.1 vs. 12.1%, 95% CI 1.067 -1.852) (all p < 0.05) than normal-BMI patients. The CCI was a more sensitive marker of post-pancreatectomy complications relative to the CDC, with a higher multicomplication rate in overweight/obese patients (54.8% vs. 44.5%). CONCLUSION Patients with overweight and obese body mass index undergoing major pancreatectomy demonstrated higher rates of postoperative complications, pancreatic fistulae, and readmissions. The CCI is a more robust and sensitive tool to assess post-pancreatectomy complications than the CDC.
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Affiliation(s)
| | - Philipp Kron
- Swiss HPB and Transplantation Center Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, Switzerland; Hepatopancreatobiliary and Transplant Services, St. James University Hospital, Leeds, United Kingdom
| | - Pierre-Alain Clavien
- Swiss HPB and Transplantation Center Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Henrik Petrowsky
- Swiss HPB and Transplantation Center Swiss HPB and Transplantation Center, Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - David A Kooby
- Department of Surgery, Emory University, Atlanta, GA, USA; Winship Cancer Institute, Emory University, Atlanta, GA, USA.
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17
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Søreide K, Healey AJ, Mole DJ, Parks RW. Pre-, peri- and post-operative factors for the development of pancreatic fistula after pancreatic surgery. HPB (Oxford) 2019; 21:1621-1631. [PMID: 31362857 DOI: 10.1016/j.hpb.2019.06.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/03/2019] [Accepted: 06/09/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND The most hazardous complication to pancreatic surgery is the development of a post-operative pancreatic fistula (POPF). Appropriate understanding of the underlying pathophysiology, risk factors and perioperative mechanisms may allow for better management and use of preventive measures. METHODS Systematic literature search using the English PubMed literature up to April 2019, with emphasis on the past 5 years. RESULTS Several risk scores have been developed but none are perfect in predicting POPF risk. A conceptual framework of factors that contribute to the pathophysiology of pancreatic fistulae is still developing but incomplete. Recognized factors include those related to the patient, the pathology and the perioperative care. Interventions such as use of drains, stents and various drugs to mediate risk is still debated. Emerging data suggest that both the microbiome and the inflammation in the post-operative phase may play important roles in risk for POPF. Available risk scores allow for stratification of risk and mitigation strategies tailored to reduce this. However, accurate estimation of risk remains a challenge and mechanisms are only partially understood. CONCLUSIONS The pathophysiology of POPF remains poorly understood. Current models only partially explain risks or associated mechanisms. Novel areas of investigation need to be explored for better prediction.
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Affiliation(s)
- Kjetil Søreide
- Clinical Surgery, University of Edinburgh, UK; Hepatobiliary and Pancreatic Surgery, Royal Infirmary of Edinburgh, UK; Department of Gastrointestinal Surgery, HPB Unit, Stavanger University Hospital, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway; Gastrointestinal Translational Research Unit, Laboratory for Molecular Biology, Stavanger University Hospital, Stavanger, Norway.
| | - Andrew J Healey
- Hepatobiliary and Pancreatic Surgery, Royal Infirmary of Edinburgh, UK
| | - Damian J Mole
- Clinical Surgery, University of Edinburgh, UK; Hepatobiliary and Pancreatic Surgery, Royal Infirmary of Edinburgh, UK
| | - Rowan W Parks
- Clinical Surgery, University of Edinburgh, UK; Hepatobiliary and Pancreatic Surgery, Royal Infirmary of Edinburgh, UK
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18
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Chang EH, Sugiyama G, Smith MC, Nealon WH, Gross DJ, Apterbach G, Coppa GF, Alfonso AE, Chung PJ. Obesity and surgical complications of pancreaticoduodenectomy: An observation study utilizing ACS NSQIP. Am J Surg 2019; 220:135-139. [PMID: 31761298 DOI: 10.1016/j.amjsurg.2019.10.030] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 10/02/2019] [Accepted: 10/15/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND An estimated 38% of US adults are obese. Obesity is associated with socioeconomic disparities and increased rates of comorbidities, and is a known risk factor for development of pancreatic cancer. As a fourth leading cause of death in the United States, pancreatic cancer is commonly treated with a pancreatico-duodenectomy (PD), or Whipple procedure. Data regarding the effects of obesity on post-operative complication rate primarily comes from specialized centers, however the results are mixed. Our aim is to elucidate the effects that obesity has on outcomes after PD for pancreatic head cancer using a national prospectively maintained clinical database. METHOD The 2010-2015 American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) Participant Use Files (PUF) were used as the data source. We identified cases in which PD was performed (CPT code 48150) in the setting of a postoperative diagnosis of pancreatic cancer (ICD9 code 157.0). We excluded cases that had emergency admissions, BMI ≤18.5 kg/m2, intraoperative wound classification of III or IV, and disseminated cancer. Cases with missing BMI, preoperative albumin, operative time, LOS data were also excluded. Multiple imputation for missing sex, race, functional status, and ASA classification using chained equations was performed.16 Patients that had BMI ≥30 kg/m2 were considered obese, and patients with BMI <30 kg/m2 were used as control. RESULTS 3484 patients underwent pancreaticoduodenectomy for pancreatic cancer. 860 patients were identified as obese. Propensity score analysis was performed matching age, sex, race, functional status, presence of dyspnea, diabetes, hypertension, acute renal failure, dialysis dependence, ascites, steroid use, bleeding disorders, history of chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), weight loss, American Society of Anesthesiologists (ASA) classification, and preoperative albumin levels. After matching, obese patients had higher risk of 30-day postoperative complications compared to control, including organ space wound infections (OR 1.38, 95% CI 1.07-1.79, p = 0.0128), returning to the operating room (OR 1.39, 95% CI 1.01-1.91, p = 0.0461), failure to extubate for greater than 48 h (OR 1.60, 95% CI 1.09-2.34, p = 0.0153), death (OR 1.68, 95% CI 1.01-2.78, p = 0.0453), septic shock (OR 2.22, 95% CI 1.46-3.38, p = 0.0002), pulmonary embolism (OR 2.42, 95% CI 1.07-5.45, p = 0.0332), renal insufficiency (OR 2.67, 95% CI 1.33-5.38, p = 0.0058). Sensitivity analysis yielded similar results with the exception of risk for return to the operating room, death, and pulmonary embolism, P > .05. CONCLUSION In this large observational study using a national clinical database, obese patients undergoing PD for head of pancreas cancer had increased risk of postoperative complications and mortality in comparison to controls.
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Affiliation(s)
- E H Chang
- State University of New York Downstate Medical Center, Department of Surgery, Brooklyn, NY, USA.
| | - G Sugiyama
- Zucker School of Medicine at Hofstra Northwell, Department of Surgery, Hempstead, NY, USA
| | - M C Smith
- Vanderbilt University Medical Center, Division of Trauma and Critical Care, Nashville, TN, USA
| | - W H Nealon
- Zucker School of Medicine at Hofstra Northwell, Department of Surgery, Hempstead, NY, USA
| | - D J Gross
- State University of New York Downstate Medical Center, Department of Surgery, Brooklyn, NY, USA
| | - G Apterbach
- Hofstra University, Department of Psychology, Hempstead, NY, USA
| | - G F Coppa
- Zucker School of Medicine at Hofstra Northwell, Department of Surgery, Hempstead, NY, USA
| | - A E Alfonso
- Zucker School of Medicine at Hofstra Northwell, Department of Surgery, Hempstead, NY, USA
| | - P J Chung
- State University of New York Downstate Medical Center, Department of Surgery, Brooklyn, NY, USA; Zucker School of Medicine at Hofstra Northwell, Department of Surgery, Hempstead, NY, USA
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19
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Seika P, Klein F, Pelzer U, Pratschke J, Bahra M, Malinka T. Influence of the body mass index on postoperative outcome and long-term survival after pancreatic resections in patients with underlying malignancy. Hepatobiliary Surg Nutr 2019; 8:201-210. [PMID: 31245400 DOI: 10.21037/hbsn.2019.02.05] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background While the long-term survival rate among patients with pancreatic and periampullary carcinomas remains low, it can be influenced by various factors. The purpose of this retrospective study was to investigate the effects of body mass index (BMI) on postoperative complications and patient survival after pancreatic resections for underlying malignancy over a 20-year observation period. Methods We analyzed 1,384 patients, 918 patients with pancreatic ductal adenocarcinoma (PDAC) (66.3%), 229 patients with distal cholangiocarcinoma (16.5%), 206 ampullary carcinoma patients (14.8%), and 31 duodenal carcinoma patients (2.2%). Patients were classified into four groups (group 1 <18.5; group 2, 18.5-25.0; group 3, 25.1-30.0; group 4 >30.0) according to their BMI (kg/m2). We analyzed differences in postoperative complications, postoperative length of hospital stays, reoperations, postoperative mortality and survival rate among the groups. Results Within a mean observation period of 687.7 [2-8,500] days, 735 (53.1%) patients died. There were important differences in postoperative complications (group 1, 16.2%; group 2, 20.3%; group 3, 27.2%, group 4, 41.6%) with the type of postoperative complications also varying between the groups. Overall 1-, 5-, 10- and 15-year survival rates were 66.4%, 25.5%, 17.9%, and 12.1%, respectively, with survival rates varying amongst the four groups. Conclusions Patients with a BMI between 18.5 and 30 show better postoperative outcomes, regarding complications, hospitalization duration, and reoperation rates than underweight or obese patients. Short-term survival depends strongly on postoperative complications while patients with a higher BMI show better long-term survival rates.
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Affiliation(s)
- Philippa Seika
- Department of Surgery, Charité Campus Mitte and Charité Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Fritz Klein
- Department of Surgery, Charité Campus Mitte and Charité Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Uwe Pelzer
- Department of Hematology/Oncology/Tumorimmunology, Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Charité Campus Mitte and Charité Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Marcus Bahra
- Department of Surgery, Charité Campus Mitte and Charité Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Malinka
- Department of Surgery, Charité Campus Mitte and Charité Campus Virchow Klinikum, Charité-Universitätsmedizin Berlin, Berlin, Germany
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20
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Umegaki T, Kunisawa S, Kotsuka M, Yamaki S, Kamibayashi T, Imanaka Y. The impact of low body mass index on postoperative outcomes in pancreatectomy patients: a retrospective analysis of Japanese administrative data. J Anesth 2018; 32:624-631. [PMID: 29936599 DOI: 10.1007/s00540-018-2527-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 06/19/2018] [Indexed: 01/18/2023]
Abstract
PURPOSE To comparatively examine in-hospital mortality among different underweight body mass index (BMI) categories in pancreatic cancer patients after pancreatectomy in Japan. METHODS We conducted a large-scale multi-center retrospective cohort study of adult patients with pancreatic cancer who underwent pancreatectomy between April 1, 2010 and March 31, 2016. Patients were classified according to BMI as follows: normal BMI (18.50-24.99 kg/m2), mild thinness (17.00-18.49 kg/m2), moderate thinness (16.00-16.99 kg/m2), and severe thinness (< 16.00 kg/m2). A multivariable logistic regression analysis was performed with in-hospital mortality as the dependent variable and BMI groups as the main independent variable of interest. RESULTS We analyzed 6173 patients from 332 hospitals. The results showed that the severe thinness group had a longer postoperative hospital stay (34.4 ± 25.6 days) and higher incidence of postoperative pneumonia (5.5%) than the other groups. The generalized estimating equations accounted for patient demographics, surgical procedure, anesthetic technique, activities of daily living score, and Charlson comorbidity index as covariates. Relative to the normal BMI group, the odds ratios for in-hospital mortality were 0.57 (95% confidence interval: 0.26-1.24; P = 0.16) in the mild thinness group, 1.49 (0.64-3.48; P = 0.36) in the moderate thinness group, and 2.54 (1.05-6.08; P = 0.04) in the severe thinness group. CONCLUSION Severe thinness was significantly associated with a higher risk of mortality, and extremely low BMI should be considered a risk factor in pancreatectomy patients.
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Affiliation(s)
- Takeshi Umegaki
- Department of Anesthesiology, Kansai Medical University Hospital, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan.
| | - Susumu Kunisawa
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Masaya Kotsuka
- Department of Surgery, Kansai Medical University Hospital, Osaka, Japan
| | - So Yamaki
- Department of Surgery, Kansai Medical University Hospital, Osaka, Japan
| | - Takahiko Kamibayashi
- Department of Anesthesiology, Kansai Medical University Hospital, 2-3-1 Shin-machi, Hirakata, Osaka, 573-1191, Japan
| | - Yuichi Imanaka
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan.
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Wang X, Bai Y, Cui M, Zhang Q, Zhang W, Fang F, Song T. Modified Blumgart anastomosis without pancreatic duct-to-jejunum mucosa anastomosis for pancreatoduodenectomy: a feasible and safe novel technique. Cancer Biol Med 2018; 15:79-87. [PMID: 29545971 PMCID: PMC5842338 DOI: 10.20892/j.issn.2095-3941.2017.0153] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Objective This study proposed a modified Blumgart anastomosis (m-BA) that uses a firm ligation of the main pancreatic duct with a supporting tube to replace the pancreatic duct-to-jejunum mucosa anastomosis, with the aim of simplifying the complicated steps of the conventional BA (c-BA). Thus, we observe if a difference in the risk of postoperative pancreatic fistula (POPF) exists between the two methods. Methods The m-BA anastomosis method has been used since 2010. From October 2011 to October 2015, 147 patients who underwent pancreatoduodenectomy (PD) using BA in Tianjin Medical University Cancer Institute and Hospital were enrolled in this study. According to the type of pancreatojejunostomy (PJ), 50 patients underwent m-BA and 97 received c-BA. The two patient cohorts were compared prospectively to some extent but not randomized, and the evaluated variables were operation time, the incidence rate of POPF, and other perioperative complications. Results The operation time showed no significant difference (P > 0.05) between the two groups, but the time of duct-to-mucosa anastomosis in the m-BA group was much shorter than that in the c-BA group ( P < 0.001). The incidence rate of clinically relevant POPF was 12.0% (6/50) in the modified group and 10.3% (10/97) in the conventional group ( P > 0.05), which means that the modified anastomosis method did not cause additional pancreatic leakage. The mean length of postoperative hospital stay of the m-BA group was 23 days, and that of the c-BA group was 22 days ( P > 0.05). Conclusions Compared with the conventional BA, we suggest that the modified BA is a feasible, safe, and effective operation method for P J of PD with no sacrifice of surgical quality. In the multivariate analysis, we also found that body mass index (≥ 25 kg/m2) increased the risk of POPF.
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Affiliation(s)
- Xiaoqing Wang
- Department of Hepatobiliary Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Yang Bai
- Department of Hepatobiliary Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Mangmang Cui
- Department of Hepatobiliary Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Qingxiang Zhang
- Department of Hepatobiliary Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Wei Zhang
- Department of Hepatobiliary Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Feng Fang
- Department of Hepatobiliary Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
| | - Tianqiang Song
- Department of Hepatobiliary Oncology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer; Key Laboratory of Cancer Prevention and Therapy, Tianjin; Tianjin's Clinical Research Center for Cancer, Tianjin 300060, China
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One hundred and forty five total laparoscopic pancreatoduodenectomies: A single centre experience. Pancreatology 2017; 17:936-942. [PMID: 28867529 DOI: 10.1016/j.pan.2017.08.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 07/25/2017] [Accepted: 08/18/2017] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Laparoscopic pancreatoduodenectomy (LPD) remains one of the most challenging minimal invasive operations today. PATIENTS AND METHODS Between January 2007 and December 2016, 197 patients were scheduled for LPD but 162 patients (from January 2007 to July 2016) were analysed in this cohort series. RESULTS Total LPD concerned for 162 patients (five patients did not undergo PD and 12 underwent conversion): standard LPD in 104 patients (66%), and laparoscopic pylorus-preserving PD in 41 patients (26%). Median operative time was 415 (240-765) min. Median blood loss was 200 (50-2100) ml. Twelve patients required blood transfusion. Clinically relevant pancreatic fistula (ISGPF grades B and C) occurred in 21 (13%) patients: 16 (10.0%) grade B, and 5 (3%) grade C. Grades B and C delayed gastric emptying occurred in five patients each. Grades B and C post-pancreatectomy bleeding occurred in 9 (5.7%) and 3 (1.9%) patients, respectively. LPD was performed for 18 (11.4%) benign and 139 (88.5%) malignant lesions. Superior mesenteric and/or portal vein involvement required major venous resection in eight patients. The 90-day mortality 5.0%. The median overall survival for pancreatic ductal adenocarcinoma was 22.5 months. CONCLUSION Morbidity and mortality for LPD are comparable to open procedures rates in the literature. Laparoscopic major venous resection is feasible and safe.
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Shamali A, Shelat V, Jaber B, Wardak A, Ahmed M, Fontana M, Armstrong T, Abu Hilal M. Impact of obesity on short and long term results following a pancreatico-duodenectomy. Int J Surg 2017; 42:191-196. [PMID: 28461146 DOI: 10.1016/j.ijsu.2017.04.058] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 04/03/2017] [Accepted: 04/27/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND The impact of obesity on short and long term outcomes following a pancreatico-duodenectomy (PD) is still unclear and needs further clarification. METHODS Demographic, operative and outcomes data in 524 patients undergoing PD were analysed. RESULTS Ninety-seven patients (18.5%) had BMI greater than or equal to 30 kg/m2 (group A) and 427 patients (81.5%) had BMI less than 30 kg/m2 (group B). Group A had a significantly greater operative duration, (375 vs 360 min, p = 0.024) and a higher intra-operative blood loss, (660 vs 500 ml, p = 0.005). Post-operative pancreatic fistula (POPF) were more common in Group A (28.9% vs 16.2%, p = 0.006), this difference was also observed when considering only major POPF (Grade B and C) (16.5% vs 8.0%, p = 0.020). Intra-abdominal collections were higher in Group A, 28.9% compared to 19.0% in Group B (p = 0.037). On multivariate analysis BMI (OR 2.006; 95% CI 1.147-4.985, p = 0.040), small pancreatic duct (OR 2.755; 95% CI 1.589-2.968, p = 0.026) and soft pancreas (OR 2.289; 95% CI 1.126-3.665, p = 0.040) were found to be independent factors for POPF. The median survival for adenocarcinomas was 20 months in Group A and 22 months in Group B, (p = 0.109). CONCLUSION Patients with BMI ≥ 30 are at an increased risk of developing pancreatic fistula following PD. Obesity does not appear to have an impact on long term outcomes in patients undergoing a PD for adenocarcinomas.
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Affiliation(s)
- Awad Shamali
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Vishal Shelat
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Bashar Jaber
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Aisha Wardak
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mohamed Ahmed
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Martina Fontana
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Thomas Armstrong
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
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The Effect of Body Mass Index on Surgical Outcomes in Patients Undergoing Pancreatic Resection: A Systematic Review and Meta-Analysis. Pancreas 2016; 45:796-805. [PMID: 27295531 DOI: 10.1097/mpa.0000000000000525] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Previous studies that investigated the association between body mass index (BMI) and pancreatectomy outcomes have produced conflicting conclusions. We conducted this meta-analysis to assess the association between them. METHODS We searched PubMed, EMBASE, and Cochrane Library databases up to December 28, 2014. Patients were divided into high-BMI group (BMI ≥ 25 kg/m) and normal-BMI group (BMI < 25 kg/m). Postoperative and intraoperative outcomes were evaluated. Meta-regression and subgroup analysis were performed to evaluate any factors accountable for the heterogeneity. Meta-analysis was performed using a random-effect model. RESULTS We included 22 studies involving 8994 patients. Patients in the high-BMI group had significantly increased postoperative pancreatic fistula rate (odds ratio [OR],1.96; 95% confidence interval [CI], 1.43-2.67), delayed gastric emptying rate (OR, 1.62; 95% CI, 1.15-2.29), wound infection rate (OR, 1.43; 95% CI, 1.07-1.93), operation time (mean difference [MD],15; 95% CI, 13.40-16.60), blood loss (MD, 270.71; 95% CI, 248.93-292.49), and length of hospital stay (MD, 2.87; 95% CI, 1.51-4.24). For modest heterogeneity in postoperative pancreatic fistula, regional distribution tended to be the contributor. CONCLUSIONS High BMI not only increased the surgical difficulty but also decreased the surgical safety for pancreatectomy.
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Sato N, Tamura T, Minagawa N, Hirata K. Preoperative body mass index-to-prognostic nutritional index ratio predicts pancreatic fistula after pancreaticoduodenectomy. Hepatobiliary Surg Nutr 2016; 5:256-62. [PMID: 27275468 DOI: 10.21037/hbsn.2015.12.08] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Estimating or scoring the risk of post-operative pancreatic fistula (POPF) may help with selection of high-risk patients and individualized patient consent. However, there are no simple and reliable preoperative predictors of POPF used in daily clinical practice. METHODS We investigated the utility of body mass index-to-prognostic nutritional index (BMI/PNI) ratio as a preoperative marker to predict the development of POPF in 87 patients undergoing pancreaticoduodenectomy. RESULTS The overall incidence of clinical (grade B/C) POPF was 17% (15 of 87 patients). Among various pre-, intra-, and post-operative variables analyzed, higher BMI and lower PNI were identified as independent predictors for POPF by multivariate analysis. We therefore investigated BMI/PNI ratio as a preoperative predictor for POPF. BMI/PNI ratio was significantly higher in patients with POPF than in those without POPF (0.54 vs. 0.45, P=0.0007). A receiver operating characteristic (ROC) curve analysis demonstrated a fair capability of BMI/PNI ratio to predict the occurrence of POPF (area under the ROC curve 0.781). With a cut-off value of 0.5, the sensitivity, specificity, and diagnostic accuracy of BMI/PNI ratio to predict POPF was 73%, 74%, and 74%, respectively. In particular, when restricted to a subgroup of elderly (≥75 years old) male patients, the sensitivity, specificity, and diagnostic accuracy of BMI/PNI ratio was 100%, 100%, and 100%, respectively. CONCLUSIONS The BMI/PNI ratio is a simple preoperative marker to predict the occurrence of POPF after pancreaticoduodenectomy.
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Affiliation(s)
- Norihiro Sato
- Department of Surgery 1, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Toshihisa Tamura
- Department of Surgery 1, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Noritaka Minagawa
- Department of Surgery 1, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Keiji Hirata
- Department of Surgery 1, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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Wang SE, Daskalaki D, Masrur MA, Patton K, Bianco FM, Giulianotti PC. Impact of Obesity on Robot-Assisted Distal Pancreatectomy. J Laparoendosc Adv Surg Tech A 2016; 26:551-6. [PMID: 27248765 DOI: 10.1089/lap.2016.0192] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Obesity has been steadily increasing in the United States. The effect of body mass index (BMI) on surgical outcomes in pancreatic surgery is still controversial. Currently, there is no report related to obesity and robotic pancreatic surgery. The purpose of this study was to evaluate the impact of BMI on the surgical outcomes of both nonobese and obese patients undergoing robot-assisted distal pancreatectomy (RADP). METHODS A prospectively collected database for RADP was retrieved for analysis. Patients were categorized as obese (BMI ≥30 kg/m(2)) and nonobese (BMI <30 kg/m(2)). Demographics, perioperative data, American Society of Anesthesiologists score, diagnosis, conversion rate, morbidity, surgical mortality, pancreatic fistula rate, and length of stay were compared. RESULTS A total for 85 RADP were included, with 57 (67%) in the nonobese group and 28 (33%) in the obese group. No differences were found between nonobese and obese patients regarding demographic, preoperative risk, and perioperative parameters and mortality. There was a trend in the obese group associated with a higher rate of postoperative complications, but it was statistically insignificant. Clinically significant pancreatic fistula (grade B) occurred in 28.5% of obese patients and in 7% of nonobese patients, but without statistical significance (P = .064). CONCLUSIONS Obesity does not have a significant impact on the perioperative outcomes and surgical risks for patients undergoing RADP, but high BMI may be a predictor for pancreatic fistula after RADP.
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Affiliation(s)
- Shin-E Wang
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Despoina Daskalaki
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Mario A Masrur
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Kristin Patton
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Franceso M Bianco
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Pier C Giulianotti
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois
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Shi YQ, Yang J, Du P, Xu T, Zhuang XH, Shen JQ, Xu CF. Effect of Body Mass Index on Overall Survival of Pancreatic Cancer: A Meta-Analysis. Medicine (Baltimore) 2016; 95:e3305. [PMID: 27057903 PMCID: PMC4998819 DOI: 10.1097/md.0000000000003305] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Although obesity has been identified as a risk factor for pancreatic cancer, the important question of whether obesity influences the prognosis of pancreatic cancer has not been explicated thoroughly. We therefore performed a meta-analysis to investigate the association between body mass index (BMI) and survival outcomes of patients with pancreatic cancer.Studies that described the relationship between BMI and overall survival (OS) of pancreatic cancer were searched in PubMed, Embase, Ovid, and Cochrane Library Databases from the earliest available date to May 12, 2015. Hazard ratios (HRs) for OS in each BMI category from individual studies were extracted and pooled by a random-effect model. Dose-response meta-analysis was also performed to estimate summary HR and 95% confidence interval (CI) for every 5-unit increment. Publication bias was evaluated by Begg funnel plot and Egger linear regression test.Ten relevant studies involving 6801 patients were finally included in the meta-analysis. Results showed that obesity in adulthood significantly shortened OS of pancreatic cancer patients (HR: 1.29, 95% CI: 1.17-1.41), whereas obesity at diagnosis was not associated with any increased risk of death (HR: 1.10, 95% CI: 0.78-1.42). For every 5-kg/m increment in adult BMI, the summary HR was 1.11 (95% CI: 1.05-1.18) for death risk of pancreatic cancer. However, no dose-response relationship was found in the BMI at diagnosis. Egger regression test and Begg funnel plot both revealed no obvious risk of publication bias.In conclusion, increased adult BMI is associated with increased risk of death for pancreatic cancer patients, which suggested that obesity in adulthood may be an important prognostic factor that indicates an abbreviated survival from pancreatic cancer. More studies are needed to validate this finding, and the mechanism behind the observation should be evaluated in further studies.
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Affiliation(s)
- Yu-Qi Shi
- From the Department of Gastroenterology (Y-QS, TX, X-HZ, J-QS, C-FX); Department of Clinical Nutrition (JY); and Department of Interventional Radiology (PD), the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
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Dalla Valle R, De Bellis M, Pedrazzi G, Lamecchi L, Bianchi G, Pellegrino C, Iaria M. Can early serum lipase measurement be routinely implemented to rule out clinically significant pancreatic fistula after pancreaticoduodenectomy? Int J Surg 2015; 21 Suppl 1:S50-4. [PMID: 26118616 DOI: 10.1016/j.ijsu.2015.04.090] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 03/24/2015] [Accepted: 04/10/2015] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Postoperative pancreatic fistula (POPF) is the most significant cause of morbidity and mortality after pancreaticoduodenectomy (PD). We evaluated the role of postoperative serum lipase concentration in ruling out POPF in the immediate post-operative period. MATERIALS AND METHODS We retrospectively analysed 98 consecutive PD performed between January 2009 and December 2014, investigating the correlation between postoperative day 1 (POD1) serum lipase concentration and POPF development. RESULTS 29 patients (29.5%) developed POPF [grade A, 17 (17.3%); grade B, 8 (8.1%); grade C, 4 (4%)]. A receiver operating characteristic (ROC) analysis was conducted to determine the threshold value of POD1 serum lipase associated with clinically significant POPF (AUC = 0.76, 95% CI 0.64-0.86, P = 0.01). Such threshold was ≤ 44.5 U/L and its sensitivity and specificity were 92% and 66%, respectively. The positive and negative predictive values (PPV, NPV) were 31% and 98%, respectively. CONCLUSION Early routinely measurement of serum lipase proved to be helpful in ruling out clinically relevant POPF (CR-POPF). In our cohort, a POD1 cut-off of ≤ 44.5 U/L allowed early and accurate identification of patients with low probability to develop clinically significant POPF, who can eventually be selected for enhanced post-operative recovery with significant clinical and economic benefits.
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Affiliation(s)
| | - Mario De Bellis
- Department of Surgery, Parma University Hospital, Parma, Italy.
| | - Giuseppe Pedrazzi
- Department of Neuroscience, Parma University Hospital, Parma, Italy.
| | - Laura Lamecchi
- Department of Surgery, Parma University Hospital, Parma, Italy.
| | - Giorgio Bianchi
- Department of Surgery, Parma University Hospital, Parma, Italy.
| | | | - Maurizio Iaria
- Department of Surgery, Parma University Hospital, Parma, Italy.
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Liu QY, Zhang WZ, Xia HT, Leng JJ, Wan T, Liang B, Yang T, Dong JH. Analysis of risk factors for postoperative pancreatic fistula following pancreaticoduodenectomy. World J Gastroenterol 2014; 20:17491-17497. [PMID: 25516663 PMCID: PMC4265610 DOI: 10.3748/wjg.v20.i46.17491] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 04/25/2014] [Accepted: 08/28/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To explore the morbidity and risk factors of postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy.
METHODS: The data from 196 consecutive patients who underwent pancreaticoduodenectomy, performed by different surgeons, in the General Hospital of the People’s Liberation Army between January 1st, 2013 and December 31st, 2013 were retrospectively collected for analysis. The diagnoses of POPF and clinically relevant (CR)-POPF following pancreaticoduodenectomy were judged strictly by the International Study Group on Pancreatic Fistula Definition. Univariate analysis was performed to analyze the following factors: patient age, sex, body mass index (BMI), hypertension, diabetes mellitus, serum CA19-9 level, history of jaundice, serum albumin level, blood loss volume, pancreatic duct diameter, pylorus preserving pancreaticoduodenectomy, pancreatic drainage and pancreaticojejunostomy. Multivariate logistic regression analysis was used to determine the main independent risk factors for POPF.
RESULTS: POPF occurred in 126 (64.3%) of the patients, and the incidence of CR-POPF was 32.7% (64/196). Patient characteristics of age, sex, BMI, hypertension, diabetes mellitus, serum CA19-9 level, history of jaundice, serum albumin level, blood loss volume, pylorus preserving pancreaticoduodenectomy and pancreaticojejunostomy showed no statistical difference related to the morbidity of POPF or CR-POPF. Pancreatic duct diameter was found to be significantly correlated with POPF rates by univariate analysis and multivariate regression analysis, with a pancreatic duct diameter ≤ 3 mm being an independent risk factor for POPF (OR = 0.291; P = 0.000) and CR-POPF (OR = 0.399; P = 0.004). The CR-POPF rate was higher in patients without external pancreatic stenting, which was found to be an independent risk factor for CR-POPF (OR = 0.394; P = 0.012). Among the entire patient series, there were three postoperative deaths, giving a total mortality rate of 1.5% (3/196), and the mortality associated with pancreatic fistula was 2.4% (3/126).
CONCLUSION: A pancreatic duct diameter ≤ 3 mm is an independent risk factor for POPF. External stent drainage of pancreatic secretion may reduce CR-POPF mortality and POPF severity.
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Casadei R, Ricci C, Taffurelli G, D'Ambra M, Pacilio CA, Ingaldi C, Minni F. Are there preoperative factors related to a "soft pancreas" and are they predictive of pancreatic fistulas after pancreatic resection? Surg Today 2014; 45:708-14. [PMID: 25331230 DOI: 10.1007/s00595-014-1045-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 05/14/2014] [Indexed: 02/07/2023]
Abstract
PURPOSE Soft pancreatic parenchyma is the most widely recognized risk factor for pancreatic fistula. We conducted this study to clarify if there are preoperative factors related to a soft pancreatic remnant and to establish if they are useful for predicting pancreatic fistula. METHODS This was a retrospective study of patients who underwent pancreatic resections at the Department of Surgical Sciences of the S. Orsola-Malpighi Hospital, Bologna, Italy. The factors considered were sex, age, co-morbidities, body mass index, American Society of Anesthesiologists score, characteristics of the pancreatic remnant, and preoperative diagnosis. RESULTS Data from 208 patients were recorded. The risk factors predictive of a soft pancreatic remnant were BMI >24 kg/m(2) (P = 0.011), a Wirsung duct size ≤3 mm (P < 0.001), and coexisting periampullary diseases (P < 0.001). Using these factors, we developed a risk score model that was validated by considering the pancreatic fistula rate. The overall and clinically relevant pancreatic fistula rate increased with increasing score values (P = 0.002 and P = 0.028, respectively). Using a score cut-off value of six points, patients with a score ≥6 were considered to be at high risk. CONCLUSIONS Body mass index >24 kg/m(2), a Wirsung duct size <3 mm, and preoperative diagnosis represented the preoperative factors related to a soft pancreas. These factors proved useful in the building of a risk score model to predict the incidence of pancreatic fistula.
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Affiliation(s)
- Riccardo Casadei
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Chirurgia Generale-Minni, Alma Mater Studiorum, Università di Bologna, Policlinico S. Orsola-Malpighi, Via Massarenti n.9, 40138, Bologna, Italy,
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