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Imamura M, Kimura Y, Kukita K, Murakami T, Kato T, Kyuno D, Takemasa I. Powered stapler and polyglycolic acid sheet for pancreatic fistula after distal pancreatectomy. J Gastrointest Surg 2024; 28:2008-2014. [PMID: 39326510 DOI: 10.1016/j.gassur.2024.09.020] [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: 07/02/2024] [Revised: 08/20/2024] [Accepted: 09/21/2024] [Indexed: 09/28/2024]
Abstract
BACKGROUND Although distal pancreatectomy (DP) is crucial for the treatment of pancreatic diseases, it often leads to postoperative pancreatic fistula (POPF), a complication with significant management challenges and health effects. Despite the use of various techniques, including suturing methods, staplers, and biodegradable materials, the optimal strategy to reduce POPF remains unclear. This study investigated the combined use of powered staplers and polyglycolic acid (PGA) sheets to mitigate POPF. METHODS This study retrospectively analyzed the data of 165 patients who underwent DP at Sapporo Medical University Hospital between January 2013 and August 2023. This study compared the incidence of clinically relevant POPF (CR-POPF) between patients treated without (group O, n = 50) and with powered staplers and PGA sheets (group P, n = 115). In addition, the surgical techniques, patient demographics, and postoperative outcomes were examined. RESULTS This study found no significant difference in the overall incidence of POPF between the groups. However, group P had a significantly lower incidence of CR-POPF than group O (20.9% vs 40.0%, respectively; P = .011). Multivariate analysis demonstrated that male sex (odds ratio [OR], 2.81; 95% CI, 1.26-6.26; P = .012) and pancreatic thickness of more than 14 mm (OR, 2.85; 95% CI, 1.17-6.95; P = .021) were independent risk factors for CR-POPF. The use of powered staplers and PGA sheets (OR, 0.38; 95% CI, 0.17-0.85; P = .017) was associated with reduced CR-POPF risk. CONCLUSION The combined use of powered staplers and PGA sheets can significantly decrease the incidence of CR-POPF in patients with DP.
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Affiliation(s)
- Masafumi Imamura
- Department of Surgery, Surgical Oncology, and Science, Sapporo Medical University, Sapporo, Japan.
| | - Yasutoshi Kimura
- Department of Surgery, Surgical Oncology, and Science, Sapporo Medical University, Sapporo, Japan
| | - Kazuharu Kukita
- Department of Surgery, Surgical Oncology, and Science, Sapporo Medical University, Sapporo, Japan
| | - Takeshi Murakami
- Department of Surgery, Surgical Oncology, and Science, Sapporo Medical University, Sapporo, Japan
| | - Toru Kato
- Department of Surgery, Surgical Oncology, and Science, Sapporo Medical University, Sapporo, Japan
| | - Daisuke Kyuno
- Department of Surgery, Surgical Oncology, and Science, Sapporo Medical University, Sapporo, Japan
| | - Ichiro Takemasa
- Department of Surgery, Surgical Oncology, and Science, Sapporo Medical University, Sapporo, Japan
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Baba H, Oba A, Tanaka K, Miura T, Ban D, Edanami M, Ishikawa Y, Ohgi K, Tanaka H, Shintakuya R, Ikenaga N, Ijichi T, Kiya Y, Muranushi R, Yamaki S, Miyazaki N, Takeuchi S, Aoki S, Mizui T, Tanaka M, Ueda H, Dei H, Takami H, Okada K, Nakata K, Mataki Y, Osakabe H, Shibuya K, Hashimoto D, Inoue Y, Hirano S, Unno M, Esaki M, Kitago M, Akahoshi K, Sugiura T, Ebata T, Uemura K, Nakamura M, Otsuka T, Nagakawa Y, Fujii T, Satoi S, Takahashi Y. The efficacy of wrapping with polyglycolic acid mesh and fibrin glue in preventing clinically relevant pancreatic fistula after minimally invasive distal pancreatectomy (WRAP Study): study protocol for a multicenter randomized controlled trial in Japan. BMC Surg 2024; 24:314. [PMID: 39415231 PMCID: PMC11481437 DOI: 10.1186/s12893-024-02610-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2024] [Accepted: 10/03/2024] [Indexed: 10/18/2024] Open
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) continues to be the most common complication after distal pancreatectomy (DP). Recent advancements in surgical techniques have established minimally invasive distal pancreatectomy (MIDP) as the standard treatment for various conditions, including pancreatic cancer. However, MIDP has not demonstrated a clear advantage over open DP in terms of POPF rates, indicating the need for additional strategies to prevent POPF in MIDP. This trial (WRAP study) aims to evaluate the efficacy of wrapping the pancreatic stump with polyglycolic acid (PGA) mesh and fibrin glue in preventing clinically relevant (CR-) POPF following MIDP. METHODS This multicenter, randomized controlled trial will include patients scheduled for laparoscopic or robotic DP for tumors in the pancreatic body and/or tail. Eligible participants will be centrally randomized into either the control group (Group A) or the intervention group (Group B), where the pancreatic stump will be reinforced by PGA mesh and fibrin glue. In both groups, pancreatic transection will be performed using a bioabsorbable reinforcement-attached stapler. A total of 172 patients will be enrolled across 14 high-volume centers in Japan. The primary endpoint is the incidence of CR-POPF (International Study Group of Pancreatic Surgery grade B/C). DISCUSSION The WRAP study will determine whether the reinforcement of the pancreatic stump with PGA mesh and fibrin glue, a technique whose utility has been previously debated, could become the best practice in the era of MIDP, thereby enhancing its safety. TRIAL REGISTRATION This trial was registered with the Japan Registry of Clinical Trials on June 15, 2024 (jRCTs032240120).
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Affiliation(s)
- Hayato Baba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Kimitaka Tanaka
- Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, North 15, West 7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Takayuki Miura
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-Ku, Sendai, Miyagi, 980-8575, Japan
| | - Daisuke Ban
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-Ku, Tokyo, 104-0045, Japan
| | - Motonori Edanami
- Departments of Surgery, Keio University School of Medicine, Japan. 35 Shinanomachi, Shinjuku-Ku, TokyoTokyo, 162-8666, Japan
| | - Yoshiya Ishikawa
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Katsuhisa Ohgi
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007 , Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777, Japan
| | - Haruyoshi Tanaka
- Department of Surgery, Nagoya University Hospital, 65 Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
| | - Ryuta Shintakuya
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-Ku, Hiroshima, Hiroshima, 734-8551, Japan
| | - Naoki Ikenaga
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, Fukuoka, 812-8582, Japan
| | - Tetsuya Ijichi
- Department of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1, Sakuragaoka, Kagoshima, Kagoshima, Japan
| | - Yoshitaka Kiya
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishi-Shinjuku, Shinjuku-Ku, Tokyo, 160-0023, Japan
| | - Ryo Muranushi
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 , Sugitani, Toyama, Toyama, 930-0194, Japan
| | - So Yamaki
- Department of Pancreatobiliary Surgery, Kansai Medical University, 2-5-1 Shin-Machi, Hirakata, Osaka, 573-1010, Japan
| | - Naoki Miyazaki
- Division of Clinical Research Planning and Strategy, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Shintaro Takeuchi
- Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, North 15, West 7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Shuichi Aoki
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-Ku, Sendai, Miyagi, 980-8575, Japan
| | - Takahiro Mizui
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-Ku, Tokyo, 104-0045, Japan
| | - Masayuki Tanaka
- Departments of Surgery, Keio University School of Medicine, Japan. 35 Shinanomachi, Shinjuku-Ku, TokyoTokyo, 162-8666, Japan
| | - Hiroki Ueda
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Hideyuki Dei
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007 , Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777, Japan
| | - Hideki Takami
- Department of Surgery, Nagoya University Hospital, 65 Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
| | - Kenjiro Okada
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-Ku, Hiroshima, Hiroshima, 734-8551, Japan
| | - Kohei Nakata
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, Fukuoka, 812-8582, Japan
| | - Yuko Mataki
- Department of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1, Sakuragaoka, Kagoshima, Kagoshima, Japan
| | - Hiroaki Osakabe
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishi-Shinjuku, Shinjuku-Ku, Tokyo, 160-0023, Japan
| | - Kazuto Shibuya
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 , Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Daisuke Hashimoto
- Department of Pancreatobiliary Surgery, Kansai Medical University, 2-5-1 Shin-Machi, Hirakata, Osaka, 573-1010, Japan
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, North 15, West 7, Kita-Ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-Machi, Aoba-Ku, Sendai, Miyagi, 980-8575, Japan
| | - Minoru Esaki
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-Ku, Tokyo, 104-0045, Japan
| | - Minoru Kitago
- Departments of Surgery, Keio University School of Medicine, Japan. 35 Shinanomachi, Shinjuku-Ku, TokyoTokyo, 162-8666, Japan
| | - Keiichi Akahoshi
- Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, 1007 , Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777, Japan
| | - Tomoki Ebata
- Department of Surgery, Nagoya University Hospital, 65 Tsurumai-Cho, Showa-Ku, Nagoya, Aichi, 466-8560, Japan
| | - Kenichiro Uemura
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Kasumi 1-2-3, Minami-Ku, Hiroshima, Hiroshima, 734-8551, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, Fukuoka, 812-8582, Japan
| | - Takao Otsuka
- Department of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1, Sakuragaoka, Kagoshima, Kagoshima, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishi-Shinjuku, Shinjuku-Ku, Tokyo, 160-0023, Japan
| | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 , Sugitani, Toyama, Toyama, 930-0194, Japan
| | - Sohei Satoi
- Department of Pancreatobiliary Surgery, Kansai Medical University, 2-5-1 Shin-Machi, Hirakata, Osaka, 573-1010, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-Ku, Tokyo, 135-8550, Japan.
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Naito K, Shinmura K, Suzuki T, Maeda S, Kuboki S, Ohtsuka M. Appropriate linear stapler selection for avoiding postoperative pancreatic fistula after distal pancreatectomy: A retrospective cohort study. Medicine (Baltimore) 2024; 103:e39954. [PMID: 39465759 PMCID: PMC11460885 DOI: 10.1097/md.0000000000039954] [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: 12/22/2023] [Indexed: 10/29/2024] Open
Abstract
BACKGROUND Despite the progress in surgical techniques and perioperative managements, the incidence of postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) remains high. Recently, pancreatic dissection using a linear stapler has been widely performed; however, risk factors influencing the occurrence of POPF after DP using a liner stapler is not fully understood. The purpose of this paper was to evaluate whether the relations between staple height and pancreatic thickness or main pancreatic duct (MPD) diameter influenced the incidence of POPF. METHODS Patients who underwent DP without other organ resections between 2015 and 2022 were retrospectively reviewed. Compression Index (CI) was defined as staple height/pancreatic thickness, and Suturing Index (SI) was defined as staple height/ MPD diameter. RESULTS In 51 patients undergoing DP, 16 patients (31.4%) developed POPF. ROC analyses revealed that lower CI and higher SI significantly increased the incidence of POPF, and the cutoff values were 0.186 and 0.821, respectively. Univariate and multivariate analyses revealed that CI ≤ 0.186 and SI ≥ 0.821 were independent risk factors for POPF after DP. Moreover, the incidence of POPF in patients fulfilling both CI > 0.186 and SI < 0.821 was 5.9%, which was extremely lower than in those without fulfilling the criteria (44.1%), suggesting that this new criteria in combination with CI and SI was an excellent predictor of POPF. CONCLUSIONS It is possible that stapler cartridge selection using our new criteria in combination with CI and SI may reduce the incidence of POPF.
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Affiliation(s)
- Kei Naito
- Department of Surgery, Saitama Red Cross Hospital, Japanese Red Cross Society, Saitama, Japan
| | - Kazuyasu Shinmura
- Department of Surgery, Saitama Red Cross Hospital, Japanese Red Cross Society, Saitama, Japan
| | - Takayuki Suzuki
- Department of Surgery, Saitama Red Cross Hospital, Japanese Red Cross Society, Saitama, Japan
| | - Shintaro Maeda
- Department of Surgery, Saitama Red Cross Hospital, Japanese Red Cross Society, Saitama, Japan
| | - Satoshi Kuboki
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Masayuki Ohtsuka
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
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Hajibandeh S, Hajibandeh S, Hablus MA, Bari H, Pathanki AM, Ali M, Ahmad J, Marangoni G, Khan S, Lam FT. Meta-analysis and trial sequential analysis of pancreatic stump closure using a hand-sewn or stapler technique in distal pancreatectomy. Ann Hepatobiliary Pancreat Surg 2024; 28:302-314. [PMID: 38522846 PMCID: PMC11341886 DOI: 10.14701/ahbps.24-015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 02/20/2024] [Accepted: 02/20/2024] [Indexed: 03/26/2024] Open
Abstract
This study aimed to compare outcomes of hand-sewn and stapler closure techniques of pancreatic stump in patients undergoing distal pancreatectomy (DP). Impact of stapler closure reinforcement using mesh on outcomes was also evaluated. Literature search was carried out using multiple data sources to identify studies that compared hand-sewn and stapler closure techniques in management of pancreatic stump following DP. Odds ratio (OR) was determined for clinically relevant postoperative pancreatic fistula (POPF) via random-effects modelling. Subsequently, trial sequential analysis was performed. Thirty-two studies with a total of 4,022 patients undergoing DP with hand-sewn (n = 1,184) or stapler (n = 2,838) closure technique of pancreatic stump were analyzed. Hand-sewn closure significantly increased the risk of clinically relevant POPF compared to stapler closure (OR: 1.56, p = 0.02). When stapler closure was considered, staple line reinforcement significantly reduced formation of such POPF (OR: 0.54, p = 0.002). When only randomized controlled trials were considered, there was no significant difference in clinically relevant POPF between hand-sewn and stapler closure techniques (OR: 1.20, p = 0.64) or between reinforced and standard stapler closure techniques (OR: 0.50, p = 0.08). When observational studies were considered, hand-sewn closure was associated with a significantly higher rate of clinically relevant POPF compared to stapler closure (OR: 1.59, p = 0.03). Moreover, when stapler closure was considered, staple line reinforcement significantly reduced formation of such POPF (OR: 0.55, p = 0.02). Trial sequential analysis detected risk of type 2 error. In conclusion, reinforced stapler closure in DP may reduce risk of clinically relevant POPF compared to hand-sewn closure or stapler closure without reinforcement. Future randomized research is needed to provide stronger evidence.
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Affiliation(s)
- Shahin Hajibandeh
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Shahab Hajibandeh
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital of Wales, Cardiff, UK
| | - Mohammed Abdallah Hablus
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
- Department of General Surgery, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Hassaan Bari
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Adithya Malolan Pathanki
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Majid Ali
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Jawad Ahmad
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Gabriele Marangoni
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Saboor Khan
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
| | - For Tai Lam
- Department of Hepatobiliary and Pancreatic Surgery, University Hospital Coventry & Warwickshire, Coventry, UK
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Kelemen D, Kerbeche A, Farkas N, Vereczkei A. New method of remnant closure during distal pancreatectomy. Langenbecks Arch Surg 2023; 408:176. [PMID: 37140674 PMCID: PMC10160139 DOI: 10.1007/s00423-023-02916-2] [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: 09/29/2022] [Accepted: 04/28/2023] [Indexed: 05/05/2023]
Abstract
PURPOSE Pancreatic fistula following distal pancreatectomies still remains a relevant problem. The present study describes our first series with a new method of pancreatic remnant closure. METHODS A free fascia-peritoneum graft - harvested from the internal rectus sheet - was fixed onto the pancreatic stump by one circular stitch. The method was applied in 18 cases. RESULTS The postoperative hospital stay was 8 days in average. No clinically relevant postoperative pancreatic fistula (CR-POPF) developed. The morbidity rate was 39%, mostly Clavien-Dindo Grade II types. There was no reoperation or mortality. CONCLUSION The first series showed advantageous results with our method. Certainly, further studies are needed for the evaluation of this new and promising technique.
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Affiliation(s)
- D Kelemen
- Department of Surgery, Medical Faculty, Clinical Center, University of Pécs, Ifjúság u. 13., 7624, Pécs, Hungary.
| | - A Kerbeche
- Department of Surgery, Medical Faculty, Clinical Center, University of Pécs, Ifjúság u. 13., 7624, Pécs, Hungary
| | - N Farkas
- Institute of Bioanalysis, Medical Faculty, University of Pécs, Honvéd u. 1., 7624, Pécs, Hungary
| | - A Vereczkei
- Department of Surgery, Medical Faculty, Clinical Center, University of Pécs, Ifjúság u. 13., 7624, Pécs, Hungary
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De Pastena M, van Bodegraven EA, Mungroop TH, Vissers FL, Jones LR, Marchegiani G, Balduzzi A, Klompmaker S, Paiella S, Tavakoli Rad S, Groot Koerkamp B, van Eijck C, Busch OR, de Hingh I, Luyer M, Barnhill C, Seykora T, Maxwell T T, de Rooij T, Tuveri M, Malleo G, Esposito A, Landoni L, Casetti L, Alseidi A, Salvia R, Steyerberg EW, Abu Hilal M, Vollmer CM, Besselink MG, Bassi C. Distal Pancreatectomy Fistula Risk Score (D-FRS): Development and International Validation. Ann Surg 2023; 277:e1099-e1105. [PMID: 35797608 DOI: 10.1097/sla.0000000000005497] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop 2 distinct preoperative and intraoperative risk scores to predict postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) to improve preventive and mitigation strategies, respectively. BACKGROUND POPF remains the most common complication after DP. Despite several known risk factors, an adequate risk model has not been developed yet. METHODS Two prediction risk scores were designed using data of patients undergoing DP in 2 Italian centers (2014-2016) utilizing multivariable logistic regression. The preoperative score (calculated before surgery) aims to facilitate preventive strategies and the intraoperative score (calculated at the end of surgery) aims to facilitate mitigation strategies. Internal validation was achieved using bootstrapping. These data were pooled with data from 5 centers from the United States and the Netherlands (2007-2016) to assess discrimination and calibration in an internal-external validation procedure. RESULTS Overall, 1336 patients after DP were included, of whom 291 (22%) developed POPF. The preoperative distal fistula risk score (preoperative D-FRS) included 2 variables: pancreatic neck thickness [odds ratio: 1.14; 95% confidence interval (CI): 1.11-1.17 per mm increase] and pancreatic duct diameter (OR: 1.46; 95% CI: 1.32-1.65 per mm increase). The model performed well with an area under the receiver operating characteristic curve of 0.83 (95% CI: 0.78-0.88) and 0.73 (95% CI: 0.70-0.76) upon internal-external validation. Three risk groups were identified: low risk (<10%), intermediate risk (10%-25%), and high risk (>25%) for POPF with 238 (18%), 684 (51%), and 414 (31%) patients, respectively. The intraoperative risk score (intraoperative D-FRS) added body mass index, pancreatic texture, and operative time as variables with an area under the receiver operating characteristic curve of 0.80 (95% CI: 0.74-0.85). CONCLUSIONS The preoperative and the intraoperative D-FRS are the first validated risk scores for POPF after DP and are readily available at: http://www.pancreascalculator.com . The 3 distinct risk groups allow for personalized treatment and benchmarking.
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Affiliation(s)
- Matteo De Pastena
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Eduard A van Bodegraven
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Timothy H Mungroop
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Frederique L Vissers
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Leia R Jones
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Poliambulanza Institute Hospital Foundation, Brescia, Italy
| | - Giovanni Marchegiani
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Alberto Balduzzi
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Sjors Klompmaker
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Salvatore Paiella
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Shazad Tavakoli Rad
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Casper van Eijck
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Ignace de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Misha Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Caleb Barnhill
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA
| | - Thomas Seykora
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | | | - Thijs de Rooij
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Massimiliano Tuveri
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Giuseppe Malleo
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Alessandro Esposito
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Luca Landoni
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Luca Casetti
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Adnan Alseidi
- Department of Surgery, Virginia Mason Medical Center, Seattle, WA
- Department of Surgery, University of California, San Francisco, CA
| | - Roberto Salvia
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Mohammad Abu Hilal
- Department of Surgery, Poliambulanza Institute Hospital Foundation, Brescia, Italy
- Department of Surgery, Southampton University, Southampton, UK
| | | | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Claudio Bassi
- General and Pancreatic Surgery Department, Pancreas Institute, University and Hospital Trust of Verona, Verona, Italy
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7
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Kouladouros K, Kähler G. [Endoscopic management of complications in the hepatobiliary and pancreatic system and the tracheobronchial tree]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:469-484. [PMID: 36269350 DOI: 10.1007/s00104-022-01735-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/13/2022] [Indexed: 05/04/2023]
Abstract
Endoscopic methods are nowadays a priceless tool for the treatment of postoperative complications after hepatobiliary, pancreatic and thoracic surgery. Endoscopic decompression of the biliary tract is the treatment of choice for biliary duct leakage after cholecystectomy, hepatic resection or liver transplantation. Postoperative biliary duct stenosis can also be successfully treated by endoscopic balloon dilatation and implantation of various endoprostheses in most of the patients. In the case of pancreatic fistulas, especially those occurring after central or distal pancreatic resections, endoscopic decompression of the pancreatic duct can significantly contribute to rapid healing. Additionally, interventional endosonography provides a valuable treatment option for transgastric drainage of postoperative fluid collections, which often accompany a pancreatic fistula. Various treatment alternatives have been described for the bronchoscopic treatment of bronchopleural and tracheoesophageal fistulas, which often lead to the rapid alleviation of symptoms and often to the definitive closure of the fistula.
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Affiliation(s)
- Konstantinos Kouladouros
- Zentrale Interdisziplinäre Endoskopie, Chirurgische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
| | - Georg Kähler
- Zentrale Interdisziplinäre Endoskopie, Chirurgische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
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8
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Hedges EA, Khan TM, Babic B, Nilubol N. Predictors of post-operative pancreatic fistula formation in pancreatic neuroendocrine tumors: A national surgical quality improvement program analysis. Am J Surg 2022; 224:1256-1261. [PMID: 35999087 PMCID: PMC9700260 DOI: 10.1016/j.amjsurg.2022.07.007] [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: 02/08/2022] [Revised: 06/04/2022] [Accepted: 07/14/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Post-operative pancreatic fistula (POPF) is a serious complication following pancreas surgery. We aimed to establish factors associated with POPF specifically in patients with pancreatic neuroendocrine tumors (PNET). METHODS The 2014-2018 American College of Surgeons National Surgical Quality Improvement Program database was querried for patients undergoing resection for PNET. The impact of patient, tumor, and operative factors on POPF formation was evaluated. RESULTS 3532 patient underwent resections for PNET. The POPF rate was significantly higher in patients with PNET (24.8%) versus non-PNET (16.4%) (p < 0.0001). Male sex (OR 1.45, 95% CI 1.11-1.89), enucleation (OR 3.14, 95% CI 1.10-8.98), pancreaticoduodenectomy (OR 1.51, 95% CI 1.13-2.03), small duct size <3 mm (OR 3.24, 95% CI 1.62-6.48), and soft gland texture (OR 1.81, 95% CI 1.18-2.77) were independently associated with POPF in PNET patients on multivariable analysis. CONCLUSIONS POPF is more common in patients undergoing resection for PNET and is dictated primarily by surgical approach and gland characteristics.
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Affiliation(s)
- Elizabeth A Hedges
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Tahsin M Khan
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Bruna Babic
- Division of Endocrine Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Naris Nilubol
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
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9
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Kawasaki K, Hayashi T, Takahashi M, Morita Y. Covering reinforced staples with polyethylene glycolic acid felt-covered fibrin sealant to prevent pancreatic fistula after distal pancreatomy: a retrospective comparative study. BMC Surg 2022; 22:349. [PMID: 36138405 PMCID: PMC9502575 DOI: 10.1186/s12893-022-01799-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 09/13/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND In accordance with previous reports on the utility of polyethylene glycolic acid (PGA) felt and fibrin glue for postoperative pancreatic fistula (POPF), we usually perform distal pancreatectomy (DP) with a PGA felt reinforcement stapler when dissecting the pancreas and cover the stump with PGA felt and fibrin glue (the PPF method). In this study, we retrospectively analyzed our DP cases to compare the risk factors for POPF and the postoperative course of patients receiving the PPF method of treatment versus that of those receiving conventional treatment. METHODS A total of 127 DP procedures performed in our department between January 2008 and June 2021 were retrospectively analysed. RESULTS In the PPF method, grade B/C POPF rate tended to decrease, and POPF rate showed a significant decrease. The duration of drainage and the length of postoperative hospitalisation were also significantly shorter with the PPF method. The risk of grade B/C POPF significantly decreased with the PPF method if the pancreas was thick (> 13.5 mm) or the patients were obese. CONCLUSIONS The PPF method is useful for POPF in DP and is particularly effective when a thick pancreas or obese patient is involved. Removing the drainage tube early in the PPF method may lead to early discharge.
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Affiliation(s)
- Keishi Kawasaki
- grid.417089.30000 0004 0378 2239Department of General Surgery, Tokyo Metropolitan Tama Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo 183-8524 Japan
| | - Tatsuya Hayashi
- grid.417089.30000 0004 0378 2239Department of General Surgery, Tokyo Metropolitan Tama Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo 183-8524 Japan
| | - Makoto Takahashi
- grid.417089.30000 0004 0378 2239Department of General Surgery, Tokyo Metropolitan Tama Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo 183-8524 Japan
| | - Yasuhiro Morita
- grid.417089.30000 0004 0378 2239Department of General Surgery, Tokyo Metropolitan Tama Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo 183-8524 Japan
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10
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Landoni L, De Pastena M, Fontana M, Malleo G, Esposito A, Casetti L, Marchegiani G, Tuveri M, Paiella S, Pea A, Ramera M, Borin A, Giardino A, Frigerio I, Girelli R, Bassi C, Butturini G, Salvia R. A randomized controlled trial of stapled versus ultrasonic transection in distal pancreatectomy. Surg Endosc 2022; 36:4033-4041. [PMID: 34518950 PMCID: PMC9085691 DOI: 10.1007/s00464-021-08724-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/30/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND The pancreatic transection method during distal pancreatectomy is thought to influence postoperative fistula rates. Yet, the optimal technique for minimizing fistula occurrence is still unclear. The present randomized controlled trial compared stapled versus ultrasonic transection in elective distal pancreatectomy. METHODS Patients undergoing distal pancreatectomy from July 2018 to July 2020 at two high-volume institutions were considered for inclusion. Exclusion criteria were contiguous organ resection and a parenchymal thickness > 17 mm on intraoperative ultrasound. Eligible patients were randomized in a 1:1 ratio to stapled transection (Endo GIA Reinforced Reload with Tri-Staple Technology®) or ultrasonic transection (Harmonic Focus® + or Harmonic Ace® + shears). The primary endpoint was postoperative pancreatic fistula. Secondary endpoints included overall complications, abdominal collections, and length of hospital stay. RESULTS Overall, 72 patients were randomized in the stapled transection arm and 73 patients in the ultrasonic transection arm. Postoperative pancreatic fistula occurred in 23 patients (16%), with a comparable incidence between groups (12% in stapled transection versus 19% in ultrasonic dissection arm, p = 0.191). Overall complications did not differ substantially (35% in stapled transection versus 44% in ultrasonic transection arm, p = 0.170). There was an increased incidence of abdominal collections in the ultrasonic dissection group (32% versus 14%, p = 0.009), yet the need for percutaneous drain did not differ between randomization arms (p = 0.169). The median length of stay was 8 days in both groups (p = 0.880). Intraoperative blood transfusion was the only factor independently associated with postoperative pancreatic fistula on logistic regression analysis (OR 4.8, 95% CI 1.2-20.0, p = 0.032). CONCLUSION The present randomized controlled trial of stapled versus ultrasonic transection in elective distal pancreatectomy demonstrated no significant difference in postoperative pancreatic fistula rates and no substantial clinical impact on other secondary endpoints.
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Affiliation(s)
- Luca Landoni
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Matteo De Pastena
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Martina Fontana
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Alessandro Esposito
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Luca Casetti
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Massimiliano Tuveri
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Antonio Pea
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Marco Ramera
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | - Alex Borin
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | | | | | - Roberto Girelli
- Unit of HPB Surgery, Pederzoli Hospital, Peschiera del Garda, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy
| | | | - Roberto Salvia
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Verona, Italy.
- Unit of General and Pancreatic Surgery, G.B. Rossi Hospital, University of Verona - DSCOMI, P.Le Scuro 10, 37134, Verona, Italy.
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11
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Kim JS, Rho SY, Shin DM, Choi M, Kang CM, Lee WJ, Hwang HK. Wrapping the pancreas with a polyglycolic acid sheet before stapling reduces the risk of fluid collection on the pancreatic stump after distal pancreatectomy. Surg Endosc 2021; 36:1191-1198. [PMID: 33620565 PMCID: PMC8758620 DOI: 10.1007/s00464-021-08387-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/09/2021] [Indexed: 11/30/2022]
Abstract
Background Postoperative pancreatic fistula (POPF) and postoperative fluid collection (POFC) are common complications after distal pancreatectomy (DP). The previous method of reducing the risk of POPF was the application of a polyglycolic acid (PGA) sheet to the pancreatic stump after cutting the pancreas with a stapler (After-stapling); the new method involves wrapping the pancreatic resection line with a PGA sheet before stapling (Before-stapling). The study aimed to compare the incidence of POPF and POFC between two methods. Methods Data of patients who underwent open or laparoscopic DPs by a single surgeon from October 2010 to February 2020 in a tertiary referral hospital were retrospectively analyzed. POPF was defined according to the updated International Study Group of Pancreatic Fistula criteria. POFC was measured by postoperative computed tomography (CT). Results Altogether, 182 patients were enrolled (After-stapling group, n = 138; Before-stapling group, n = 44). Clinicopathologic and intraoperative findings between the two groups were similar. Clinically relevant POPF rates were similar between both groups (4.3% vs. 4.5%, p = 0.989). POFC was significantly lesser in the Before-stapling group on postoperative day 7 (p < 0.001). Conclusions Wrapping the pancreas with PGA sheet before stapling was a simple and effective way to reduce POFC. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-021-08387-0.
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Affiliation(s)
- Ji Su Kim
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea.,Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Seoung Yoon Rho
- Department of Hepatobiliary and Pancreatic Surgery, Yongin Severance Hospital, Yongin, Korea.,Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Dong Min Shin
- Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Munseok Choi
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea.,Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Chang Moo Kang
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea.,Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Woo Jung Lee
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea.,Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Ho Kyoung Hwang
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea. .,Department of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea.
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12
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Risk Factors for Clinically Relevant Postoperative Pancreatic Fistula (CR-POPF) after Distal Pancreatectomy: A Single Center Retrospective Study. Can J Gastroenterol Hepatol 2021; 2021:8874504. [PMID: 33542910 PMCID: PMC7840268 DOI: 10.1155/2021/8874504] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 11/15/2020] [Accepted: 01/07/2021] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Clinically relevant postoperative pancreatic fistula (CR-POPF) is the considerable contributor to major complications after pancreatectomy. The purpose of this study was to evaluate the potential risk factor contributing to CR-POPF following distal pancreatectomy (DP) and discuss the risk factors of pancreatic fistula in order to interpret the clinical importance. METHODS In this retrospective study, 263 patients who underwent DP at Ningbo Medical Center Li Huili Hospital between January 2011 and January 2020 were reviewed in accordance with relevant guidelines and regulations. Patients' demographics and clinical parameters were evaluated using univariate and multivariate analyses to identify the risk factors contributing to CR-POPF. P < 0.05 was considered statistically significant. RESULTS In all of the 263 patients with DP, pancreatic fistula was the most common surgical complication (19.0%). The univariate analysis of 18 factors showed that the patients with a malignant tumor, soft pancreas, and patient without ligation of the main pancreatic duct were more likely to develop pancreatic fistula. However, on multivariate analysis, the soft texture of the pancreas (OR = 2.381, 95% CI = 1.271-4.460, P=0.001) and the ligation of the main pancreatic duct (OR = 0.388, 95% CI = 0.207-0.726, P=0.002) were only an independent influencing factor for CR-POPF. CONCLUSIONS As a conclusion, pancreatic fistula was the most common surgical complication after DP. The soft texture of the pancreas and the absence of ligation of the main pancreatic duct can increase the risk of CR-POPF.
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13
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Miao Y, Lu Z, Yeo CJ, Vollmer CM, Fernandez-Del Castillo C, Ghaneh P, Halloran CM, Kleeff J, de Rooij T, Werner J, Falconi M, Friess H, Zeh HJ, Izbicki JR, He J, Laukkarinen J, Dejong CH, Lillemoe KD, Conlon K, Takaori K, Gianotti L, Besselink MG, Del Chiaro M, Montorsi M, Tanaka M, Bockhorn M, Adham M, Oláh A, Salvia R, Shrikhande SV, Hackert T, Shimosegawa T, Zureikat AH, Ceyhan GO, Peng Y, Wang G, Huang X, Dervenis C, Bassi C, Neoptolemos JP, Büchler MW. Management of the pancreatic transection plane after left (distal) pancreatectomy: Expert consensus guidelines by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2020; 168:72-84. [PMID: 32249092 DOI: 10.1016/j.surg.2020.02.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 02/11/2020] [Accepted: 02/18/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The aim was to evaluate the various operative techniques and outcomes used to manage the pancreatic transection plane (or stump) during a left (distal) pancreatectomy and to develop expert consensus guidelines. METHODS Evidence-based, clinically relevant questions were discussed and then were circulated among members of the International Study Group of Pancreatic Surgery. After agreement on the questions and statements, voting in a 9-point Likert scale was used to gauge the level of objective support for each. RESULTS Studies using the International Study Group of Pancreatic Surgery definition of postoperative pancreatic fistula including 16 randomized trials were reviewed to generate a series of statements set into 14 domains. There was strong consensus in the following statements: there was no difference in the postoperative pancreatic fistula rate after left pancreatectomy between the handsewn and stapler techniques; a stapling technique could not be used in all cases of left pancreatectomy; the use of an energy-based tissue sealant or a chemical sealant device or combinations of these did not impact the postoperative pancreatic fistula rate; there was no difference in the postoperative pancreatic fistula rate between the open, laparoscopic, or robotic approaches; and there are 1 or more clinically important, patient-related risk factors associated with the postoperative pancreatic fistula rate. There was weak or conditional agreement on the use of prophylactic somatostatin analogs, stents, stump closure, stump anastomosis, and the role of abdominal drains. CONCLUSION Areas of strong consensus suggests a change in clinical practice and priority setting. Eight domains with lower agreement will require novel approaches and large multicenter studies to determine future key areas of practice.
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Affiliation(s)
- Yi Miao
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China.
| | - Zipeng Lu
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | - Charles J Yeo
- Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Paula Ghaneh
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Christopher M Halloran
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Jörg Kleeff
- Department of Surgery, Martin-Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Thijs de Rooij
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jens Werner
- Department of General, Visceral, and Transplantation Surgery, Ludwig Maximilians-University, Munich, Germany
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, "Vita-Salute" University, Milan, Italy
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Herbert J Zeh
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jin He
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
| | - Cees H Dejong
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Keith D Lillemoe
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kevin Conlon
- Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland
| | - Kyoichi Takaori
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Luca Gianotti
- School of Medicine and Surgery, Milano - Bicocca University, and Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Marco Montorsi
- Humanitas University and Research Hospital IRCCS, Milan, Italy
| | - Masao Tanaka
- Shimonoseki City Hospital, Kyushu University, Shimonoseki, Yamaguchi, Japan
| | - Maximilian Bockhorn
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mustapha Adham
- Department of Digestive & HPB Surgery, Hospital Edouard Herriot, HCL, UCBL1, Lyon, France
| | | | - Roberto Salvia
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - Shailesh V Shrikhande
- Department of Gastrointestinal and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Tooru Shimosegawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Amer H Zureikat
- Division of Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Güralp O Ceyhan
- Department of General Surgery, School of Medicine, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Yunpeng Peng
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | - Guangfu Wang
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | - Xumin Huang
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | | | - Claudio Bassi
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - John P Neoptolemos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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14
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Papoulas M, Kontis E, Hadjicosta O, Pinsker N, Heaton N, Menon KV. A Novel Technique for Pancreatic Stump Closure: Clip Ligation of the Duct and Associated Suturing of Pancreas. Cureus 2020; 12:e7414. [PMID: 32337138 PMCID: PMC7182156 DOI: 10.7759/cureus.7414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Pancreatic fistula (PF) remains the primary source of morbidity after distal pancreatectomy (DP). There is currently no optimal stump closure technique to reduce PF rates. We present a novel technique for pancreatic stump closure using Clip Ligation of the duct and Associated Suturing of Pancreas (CLASP). Five patients (three females) with a median age of 65 years underwent DP and splenectomy for pancreatic body or tail tumour using the CLASP technique. Four of those operations were done laparoscopically. Only one patient developed grade A PF. No other postoperative complications were noticed. The mean length of stay was 5.4 days. The CLASP technique was applicable in both laparoscopic and open distal pancreatectomy. The key points include mobilisation of the pancreatic body from the retroperitoneum and division of the parenchyma with energy device. The technique of pancreatic stump closure involves the isolation of the pancreatic duct (PD), application of a double ligaclip on the proximal duct, division of the PD and finally suturing of the pancreatic stump. The CLASP technique is an effective and safe alternative technique to the current traditional methods of pancreatic stump closure.
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Affiliation(s)
- Michail Papoulas
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, GBR
| | - Elissaios Kontis
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, GBR
| | - Olympia Hadjicosta
- Medical School, Barts and the London School of Medicine and Dentistry, London, GBR
| | - Nathaneal Pinsker
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, GBR
| | - Nigel Heaton
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, GBR
| | - Krishna V Menon
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, London, GBR
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15
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Watanabe N, Yamamoto Y, Sugiura T, Okamura Y, Ito T, Ashida R, Uesaka K. The Impact of Stump Closure Techniques on Pancreatic Fistula Stratified by the Thickness of the Pancreas in Distal Pancreatectomy. Dig Surg 2020; 37:340-347. [PMID: 31986517 DOI: 10.1159/000505061] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 11/26/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND The purpose of this retrospective study was to evaluate the impact of stump closure techniques on pancreatic fistula (PF) focusing on pancreatic thickness after distal pancreatectomy (DP). METHODS A total of 213 patients who underwent DP between 2007 and 2017 were retrospectively reviewed. The risk factors of PF were investigated. RESULTS In all patients, age ≥65 years (odds ratio [OR]: 3.60, p = 0.012), operation time ≥300 min (OR: 3.05, p = 0.013) and thickness of transected pancreas (OR: 1.37, p < 0.001) were identified as independent risk factors for clinically relevant PF. A receiver operating curve analysis revealed the optimum cut-off values of thickness to be 14 mm with stapler closure and 17 mm with the clamp-crushing method. There were no significant differences regarding PF between the stapler closure and clamp-crushing methods in the thin (<14 mm) and very thick pancreas (≥17 mm) groups (p = 0.822, p = 0.072). In contrast, stapler closure was the only independent risk factor for developing PF in the moderately thick (≥14, <17 mm) pancreas group (OR: 6.75 and p = 0.004, respectively). CONCLUSION The clamp-crushing method was superior to stapler closure for pancreatic transection, especially in patients with moderately thick pancreas.
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Affiliation(s)
- Nobuyuki Watanabe
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yusuke Yamamoto
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan,
| | - Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yukiyasu Okamura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Takaaki Ito
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Ryo Ashida
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Shizuoka, Japan
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Miyamoto R, Sano N, Maeda M, Inagawa S, Ohkohchi N. Modified Reinforced Staple Closure Technique Decreases Postoperative Pancreatic Fistula After Distal Pancreatectomy. Indian J Surg Oncol 2019; 10:587-593. [PMID: 31866728 DOI: 10.1007/s13193-019-00958-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 08/06/2019] [Indexed: 01/02/2023] Open
Abstract
Postoperative pancreatic fistula (POPF) is a serious complication that can occur following distal pancreatectomy (DP). Recent studies demonstrated that the use of reinforced staplers with bioabsorbable mesh significantly reduced the incidence of POPF, although the safety and efficacy of this approach remain controversial. Therefore, we originally developed a modified closure technique that combines the use of a reinforced stapler with bioabsorbable mesh with suture closure of the main pancreatic duct. The aim of this study was to determine whether our closure technique is predictive of POPF after DP. Fifty-nine consecutive patients who underwent DP were retrospectively enrolled. Based on the closure technique, we divided the cohort into a suture group (group A; n = 39) and a modified closure group (group B; n = 20). Using multivariate analysis, surgical closure techniques, including our method, and other well-known POPF risk factors were independently assessed. Multivariate logistic regression analysis identified no pathological fibrosis (odds ratio [OR], 5.41; p < 0.01), body mass index (> 25 kg/m2) (OR, 3.01; p = 0.02), and pancreatic stump closure technique (group A) (OR, 2.04; p = 0.01) as independent risk factors for POPF. The present study indicated that our modified closure technique is an additional useful technique to reduce POPF after DP.
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Affiliation(s)
- Ryoichi Miyamoto
- 1Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki 305-8558 Japan
- 2Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery and Organ Transplantation, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575 Japan
| | - Naoki Sano
- 1Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki 305-8558 Japan
| | - Michihiro Maeda
- 1Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki 305-8558 Japan
| | - Satoshi Inagawa
- 1Department of Gastroenterological Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba, Ibaraki 305-8558 Japan
| | - Nobuhiro Ohkohchi
- 2Department of Surgery, Division of Gastroenterological and Hepatobiliary Surgery and Organ Transplantation, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575 Japan
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Jiang L, Ning D, Chen X. Prevention and treatment of pancreatic fistula after pancreatic body and tail resection: current status and future directions. Front Med 2019; 14:251-261. [PMID: 31840199 DOI: 10.1007/s11684-019-0727-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 10/12/2019] [Indexed: 02/08/2023]
Abstract
Postoperative pancreatic fistula (POPF) is the most common and critical complication after pancreatic body and tail resection. How to effectively reduce the occurrence of pancreatic fistula and conduct timely treatment thereafter is an urgent clinical issue to be solved. Recent research standardized the definition of pancreatic fistula and stressed the correlation between POPF classification and patient prognosis. According to the literature, identification of the risk factors for pancreatic fistula contributed to lowering the rate of the complication. Appropriate management of the pancreatic stump and perioperative treatment are of great significance to reduce the rate of POPF in clinical practice. After the occurrence of POPF, the treatment of choice should be determined according to the classification of the pancreatic fistula. However, despite the progress and promising treatment approaches, POPF remains to be a clinical issue that warrants further studies in the future.
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Affiliation(s)
- Li Jiang
- Department of Biliary and Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Deng Ning
- Department of Biliary and Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xiaoping Chen
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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18
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Nishikawa M, Yamamoto J, Hoshikawa M, Einama T, Noro T, Aosasa S, Tsujimoto H, Ueno H, Kishi Y. Stapler sizes optimized for pancreatic thickness can reduce pancreatic fistula incidence after distal pancreatectomy. Surg Today 2019; 50:623-631. [DOI: 10.1007/s00595-019-01929-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 11/18/2019] [Indexed: 12/19/2022]
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19
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Maggino L, Malleo G, Salvia R, Bassi C, Vollmer CM. Defining the practice of distal pancreatectomy around the world. HPB (Oxford) 2019; 21:1277-1287. [PMID: 30910318 DOI: 10.1016/j.hpb.2019.02.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/20/2019] [Accepted: 02/26/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Best management practices for distal pancreatectomy (DP) have not been conclusively defined. The aim of this study was to analyze the practice of DP worldwide and to compare surgeons' behavior with the best available evidence. METHODS A survey assessing management approaches for DP was distributed worldwide, in eight native-language translations. Regions were clustered: North-America, South/Central America, Asia/Australia, and Europe/Africa/Middle East. RESULTS Overall, 721/797 (91%) responding surgeons (median age = 48; years of experience = 14) indicated their region, representing six continents and 68 nations. Use of minimally-invasive (MI) techniques is diverse-highest in North-America (p < 0.001). Laparoscopy is the most common MI approach, while robotic techniques are rarely performed outside North-America. The preferred means of pancreatic remnant closure is via stapler - more commonly applied in North-America than in Europe/Africa/Middle East. Management techniques for the remnant and other fistula mitigation strategies display significant regional variability. The use of drains is also diverse, with the biggest disparity between North-American and Asian/Australian surgeons (selective and routine drainers, respectively). CONCLUSION There is wide heterogeneity in practices for DP worldwide, which is influenced by the surgeon's region of practice. Variability in practice reflects the lack of solid evidence on the benefit of any given strategy, underlining areas for improvement.
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Affiliation(s)
- Laura Maggino
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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Risk Factors of Pancreatic Fistula in Distal Pancreatectomy Patients. Surg Res Pract 2019; 2019:4940508. [PMID: 31396547 PMCID: PMC6664546 DOI: 10.1155/2019/4940508] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 05/08/2019] [Accepted: 06/18/2019] [Indexed: 12/23/2022] Open
Abstract
Introduction Benign and malignant lesions of the pancreas located at the body and tail of the pancreas are managed by the standard procedure of distal pancreatectomy (DP). The mortality associated with this procedure is reported as less than 5% in high-volume centers. The major proportion of morbidity is comprised of pancreatic fistula with a reported incidence of 5% to 60%. The most considered risk factors associated with pancreatic fistula formation are soft pancreatic texture, diameter of the pancreatic duct <3 mm, intraoperative blood loss >1000 ml and surgical techniques. Among all these factors, the modifiable factor is the surgical technique. Several surgical techniques have been developed and modified for closure of the pancreatic remnant in the recent past in order to minimize the risk of pancreatic fistula and other complications. The main objective of the study is to analyze the factors associated with formation of pancreatic fistula after distal pancreatectomy. Patients and Methods We performed a single-center retrospective study at Aga Khan University Hospital from January 2004 till December 2015. The perioperative and postoperative data of 131 patients who underwent pancreatic resection were recorded by using ICD 9 coding. 45 patients underwent distal pancreatectomy, out of which 38 were included in the study based on inclusion criteria. Variables were grouped into demographics, indications, operative details, and postoperative course. Statistical analysis software (SPSS) was used for analysis. Quantitative variables were presented as mean with standard deviation or median with interquartile range depending on the distribution of data. Study endpoints for the risk factor analysis were surgical morbidity and development of pancreatic fistula. Univariate logistic regressions were performed associated with study endpoints. P value less than 0.05 was considered significant. Results Postoperative pancreatic fistula was the most common perioperative morbidity. The significant associated risk factor for pancreatic fistula was multivisceral resection as compared to spleen-preserving distal pancreatectomy (P value 0.039). However, the technique of stump closure when opted for suture techniques was seen to be associated with a higher occurrence of postoperative pancreatic fistula. The mortality rate was 2.6%. Conclusion Postoperative pancreatic fistula is the most common complication seen after distal pancreatectomy in our series. Multivisceral resection is associated with a high incidence of pancreatic fistula and is a statistical significant predictor of pancreatic fistula.
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Abstract
INTRODUCTION Pancreatic trauma results in high morbidity and mortality, in part caused by the delay in diagnosis and subsequent organ dysfunction. Optimal operative management strategies remain unclear. We therefore sought to determine CT accuracy in diagnosing pancreatic injury and the morbidity and mortality associated with varying operative strategies. METHODS We created a multicenter, pancreatic trauma registry from 18 Level 1 and 2 trauma centers. Adult, blunt or penetrating injured patients from 2005 to 2012 were analyzed. Sensitivity and specificity of CT scan identification of main pancreatic duct injury was calculated against operative findings. Independent predictors for mortality, adult respiratory distress syndrome (ARDS), and pancreatic fistula and/or pseudocyst were identified through multivariate regression analysis. The association between outcomes and operative management was measured. RESULTS We identified 704 pancreatic injury patients of whom 584 (83%) underwent a pancreas-related procedure. CT grade modestly correlated with OR grade (r 0.39) missing 10 ductal injuries (9 grade III, 1 grade IV) providing 78.7% sensitivity and 61.6% specificity. Independent predictors of mortality were age, Injury Severity Score (ISS), lactate, and number of packed red blood cells transfused. Independent predictors of ARDS were ISS, Glasgow Coma Scale score, and pancreatic fistula (OR 5.2, 2.6-10.1). Among grade III injuries (n = 158, 22.4%), the risk of pancreatic fistula/pseudocyst was reduced when the end of the pancreas was stapled (OR 0.21, 95% CI 0.05-0.9) compared with sewn and was not affected by duct stitch placement. Drainage alone in grades IV (n = 25) and V (n = 24) injuries carried increased risk of pancreatic fistula/pseudocyst (OR 8.3, 95% CI 2.2-32.9). CONCLUSION CT is insufficiently sensitive to reliably identify pancreatic duct injury. Patients with grade III injuries should have their resection site stapled instead of sewn and a duct stitch is unnecessary. Further study is needed to determine if drainage alone should be employed in grades IV and V injuries. LEVEL OF EVIDENCE Epidemiologic/Diagnostic study, level III.
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Why Does Postoperative Pancreatic Fistula Occur After Hand-sewn Parenchymal Closure and Staple Closure in Distal Pancreatectomy? Surg Laparosc Endosc Percutan Tech 2019; 29:e15-e19. [DOI: 10.1097/sle.0000000000000604] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Dokmak S, Ftériche FS, Meniconi RL, Aussilhou B, Duquesne I, Perrone G, Romdhani C, Belghiti J, Lévy P, Soubrane O, Sauvanet A. Pancreatic fistula following laparoscopic distal pancreatectomy is probably unrelated to the stapler size but to the drainage modality and significantly decreased with a small suction drain. Langenbecks Arch Surg 2019; 404:203-212. [DOI: 10.1007/s00423-019-01756-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 01/21/2019] [Indexed: 01/02/2023]
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Daniel F, Tamim H, Hosni M, Ibrahim F, Mailhac A, Jamali F. Validation of day 1 drain fluid amylase level for prediction of clinically relevant fistula after distal pancreatectomy using the NSQIP database. Surgery 2019; 165:315-322. [DOI: 10.1016/j.surg.2018.07.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 07/11/2018] [Accepted: 07/25/2018] [Indexed: 12/19/2022]
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Dumitrascu T, Eftimie M, Aiordachioae A, Stroescu C, Dima S, Ionescu M, Popescu I. Male gender and increased body mass index independently predicts clinically relevant morbidity after spleen-preserving distal pancreatectomy. World J Gastrointest Surg 2018; 10:84-89. [PMID: 30510633 PMCID: PMC6259023 DOI: 10.4240/wjgs.v10.i8.84] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 09/24/2018] [Accepted: 11/04/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To identify risk factors for clinically relevant complications after spleen-preserving distal pancreatectomy (SPDP). No previous studies explored potential predictors of morbidity after SPDP. METHODS The data of 41 patients who underwent a SPDP in a single surgical center between 2000 and 2015 were retrospectively reviewed from a prospectively maintained electronic database established in our Department of Surgery. The database included demographic, clinical, bioumoral, pathological, intraoperative and postoperative parameters. Uni- and multivariate analyses were performed to assess potential predictors of clinically relevant morbidity. Postoperative morbidity was defined as in-hospital complications and mortality was assessed at 90 d. Clinically relevant morbidity was defined as complication ≥ grade 2 Dindo. RESULTS Overall morbidity rate was 34.1% (14 patients): grade I (6 patients, 14.6%), grade II (2 patients, 4.8%), grade IIIa (1 patient, 2.4%), and grade IIIb (5 patients, 12.2%). A number of 5 patients (12.2%) required re-laparotomy for postoperative complications. There was no postoperative mortality. Thus, at least one clinically relevant complication occurred in 8 patients (19.5%). Univariate analysis identified male gender (P = 0.034), increased body mass index (P = 0.002) and neuroendocrine pathology (P = 0.013) as statistically significant risk factors. Multivariate analysis identified male gender [odds ratio (OR): 1.29, 95%CI: 1.07-1.55, P = 0.005] and increased body mass index (OR: 23.18, 95%CI: 1.72-310.96, P = 0.018) as the only independent risk factors of clinically relevant morbidity after SPDP. CONCLUSION Male gender and increased body mass index are independently associated with increased risk of clinically relevant morbidity after SPDP. These findings may assist a surgeon in clinical decision-making to better select patients suitable for SPDP.
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Affiliation(s)
- Traian Dumitrascu
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Mihai Eftimie
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Andra Aiordachioae
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Cezar Stroescu
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Simona Dima
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Mihnea Ionescu
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Irinel Popescu
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
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26
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Lin BC, Chen RJ, Hwang TL. Spleen-preserving versus spleen-sacrificing distal pancreatectomy in adults with blunt major pancreatic injury. BJS Open 2018; 2:426-432. [PMID: 30511043 PMCID: PMC6253790 DOI: 10.1002/bjs5.89] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 05/30/2018] [Indexed: 12/26/2022] Open
Abstract
Background The aim of this study was to analyse outcomes of spleen‐preserving (SPDP) and spleen‐sacrificing (SSDP) distal pancreatectomy in adults with severe blunt pancreatic injuries. Methods This was an observational study of adult patients who underwent distal pancreatectomy for grade III or IV blunt pancreatic injury between 1991 and 2015. Outcomes of SPDP and SSDP were compared. Results Fifty‐one patients were included, of whom 23 underwent SPDP and 28 SSDP. The median Injury Severity Score (ISS) was 13·0 (i.q.r. 9·0–18·0). No significant differences were observed between the groups regarding sex, trauma mechanism, shock at triage, laboratory data, location, ISS, associated injury, length of stay, mortality or morbidity. Age (27·0 versus 36·5 years; P = 0·012) and time interval from injury to distal pancreatectomy (15·0 versus 44·0 h; P = 0·022) differed significantly between SPDP and SSDP groups respectively. The mortality rate was 4 per cent (1 of 23) versus 11 per cent (3 of 28) respectively (P = 0·617). Nine patients (39 per cent) developed abdominal morbidity after SPDP, compared with 17 (61 per cent) after SSPD (P = 0·125). In the SPDP group, eight patients had grade B postoperative pancreatic fistula (POPF), two of whom required further intervention. In the SSDP group, six of ten patients with grade B POPF required CT‐guided drainage, and a further five patients required reoperation for other causes. There were more reinterventions after SSDP: 11 of 28 (39 per cent) versus 3 of 23 (13 per cent) in the SPDP group (P = 0·037). Conclusion SPDP was performed more often in younger patients and at a shorter interval after severe blunt pancreatic injury. SPDP was associated with fewer reinterventions.
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Affiliation(s)
- B-C Lin
- Division of Trauma and Emergency Surgery, Department of Surgery Chang Gung University Tao-Yuan City Taiwan
| | - R-J Chen
- Department of Surgery Taipei Medical University Hospital Taipei Taiwan
| | - T-L Hwang
- Department of General Surgery, Chang Gung Memorial Hospital Chang Gung University Tao-Yuan City Taiwan
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27
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Pancreatic stump closure techniques and pancreatic fistula formation after distal pancreatectomy: Meta-analysis and single-center experience. PLoS One 2018; 13:e0197553. [PMID: 29897920 PMCID: PMC5999073 DOI: 10.1371/journal.pone.0197553] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Accepted: 05/04/2018] [Indexed: 12/18/2022] Open
Abstract
Background Pancreatic fistula/PF is the most frequent and feared complication after distal pancreatectomy/DP. However, the safest technique of pancreatic stump closure remains an ongoing debate. Here, we aimed to compare the safety of different pancreatic stump closure techniques for preventing PF during DP. Methods We performed a PRISMA-based meta-analysis of all relevant studies that compared at least two techniques of stump closure during DP with regard to PF rates/PFR. We further performed a retrospective analysis of our institutional PFR in correlation with stump closure techniques. Results 8301 studies were initially identified. From these, ten randomized controlled trials/RCTs, eleven prospective and 59 retrospective studies were eligible. Stapler closure (26%vs.31%, OR:0.73, p = 0.02), combination of stapler and suture (30%vs.33%, OR:0.70, p = 0.05), or stump anastomosis (14%vs.28%, OR:0.51, p = 0.02) were associated with lower PFR than suture closure alone. Spleen preservation/splenectomy, or laparoscopic/open DP, TachoSil®, fibrin-like glue-application, or bioabsorbable-stapler-reinforcements (Seamguard®) did not influence PFR after DP. In contrast, autologous patches (falciform ligament/seromuscular patches) resulted in lower PFR than no patch application (21.9%vs.25,8%, OR:0.60, p = 0.006). In our institution, the major three techniques of stump closure resulted in comparable PFR (suture:27%, stapler:29%, or combination:24%). However, selective suturing/clipping of the main pancreatic duct during pancreatic stump closure prevented severe PF (p = 0.02). Conclusion After DP, stapler closure, pancreatic anastomosis, or falciform/seromuscular patches lead to lower PFR than suture closure alone. However, the differences are rather small, and further RCTs are needed to test these effects. Selective closure of the main pancreatic duct during stump closure may prevent severe PF.
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Nahm CB, Connor SJ, Samra JS, Mittal A. Postoperative pancreatic fistula: a review of traditional and emerging concepts. Clin Exp Gastroenterol 2018; 11:105-118. [PMID: 29588609 PMCID: PMC5858541 DOI: 10.2147/ceg.s120217] [Citation(s) in RCA: 125] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Postoperative pancreatic fistula (POPF) remains the major cause of morbidity after pancreatic resection, affecting up to 41% of cases. With the recent development of a consensus definition of POPF, there has been a large number of reports examining various risk factors, prediction models, and mitigation strategies for this costly complication. Despite these strategies, the rates of POPF have not significantly diminished. Here, we review the literature and evidence regarding both traditional and emerging concepts in POPF prediction, prevention, and management. In particular, we review the evidence for the association between postoperative pancreatitis and POPF, and present a novel proposed mechanism for the development of POPF.
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Affiliation(s)
- Christopher B Nahm
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, Australia.,Northern Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia.,Bill Walsh Translational Cancer Research Laboratory, Kolling Institute, The University of Sydney, Sydney, Australia
| | - Saxon J Connor
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Jaswinder S Samra
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, Australia.,Northern Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia.,Australian Pancreatic Centre, Sydney, Australia
| | - Anubhav Mittal
- Upper Gastrointestinal Surgical Unit, Royal North Shore Hospital, Sydney, Australia.,Northern Clinical School, Sydney Medical School, The University of Sydney, Sydney, Australia.,Australian Pancreatic Centre, Sydney, Australia
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Dokmak S, Aussilhou B, Ftériche FS, Sauvanet A. Randomized Studies Are Ongoing: In Reply to Ramacciato and colleagues. J Am Coll Surg 2018; 226:204-205. [PMID: 29389380 DOI: 10.1016/j.jamcollsurg.2017.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 11/22/2017] [Indexed: 11/29/2022]
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Volk A, Distler M, Müssle B, Berning M, Hampe J, Brückner S, Weitz J, Welsch T. Reproducibility of preoperative endoscopic injection of botulinum toxin into the sphincter of Oddi to prevent postoperative pancreatic fistula. Innov Surg Sci 2018; 3:69-75. [PMID: 31579768 PMCID: PMC6754046 DOI: 10.1515/iss-2017-0040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 01/04/2018] [Indexed: 01/08/2023] Open
Abstract
Background A postoperative pancreatic fistula (POPF) is the most common and potentially life-threatening surgical complication in pancreatic surgery. One possible pharmacological treatment could be the endoscopic injection of botulinum toxin (BTX) into the sphincter of Oddi to prevent POPF. Promising data reported a significantly reduced rate of clinically relevant POPF. We analyzed the effect of BTX injection in our patients undergoing distal pancreatectomy (DP). Methods A retrospective analysis of patients undergoing DP was performed. Patients with preoperative endoscopic injection of BTX into the sphincter of Oddi were included. The end points were postoperative outcomes including POPF. BTX patients were compared with a historical cohort and matched in a 1:1 ratio using a propensity score analysis. Results A total of 19 patients were treated with endoscopic injection of BTX before open (n=8) or laparoscopic (n=11) DP. The median age of the patients was 67 years and the mean body mass index was 25.9 kg/m2. In median, the intervention was performed 1 day (range, 0–14 days) before the operation. There were no intervention-related complications. The incidence of POPF was not statistically different between the two groups: a clinically relevant POPF grade (B/C) occurred in 32% (BTX) and 42% (control; p=0.737). Likewise, there were no significant differences in postoperative drain fluid amylase levels, morbidity, and mortality. Conclusion The present study could not reproduce the published results of a significant lowering of grade B/C POPF. The explanations could be the timing of BTX injection before surgery and the endoscopic technique of BTX injection. However, the conflicting results after BTX injection in two high-volume centers prompt a randomized controlled multicenter trial with trained endoscopists.
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Affiliation(s)
- Andreas Volk
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Benjamin Müssle
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Marco Berning
- Department of Internal Medicine, Section of Gastroenterology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jochen Hampe
- Department of Internal Medicine, Section of Gastroenterology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Stefan Brückner
- Department of Internal Medicine, Section of Gastroenterology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Dresden, Fetscherstraße 74, 01307 Dresden, Germany
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Guilbaud T, Birnbaum DJ, Loubière S, Bonnet J, Chopinet S, Grégoire E, Berdah S, Hardwigsen J, Moutardier V. Comparison of different feeding regimes after pancreatoduodenectomy - a retrospective cohort analysis. Nutr J 2017; 16:42. [PMID: 28676052 PMCID: PMC5496601 DOI: 10.1186/s12937-017-0265-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 06/25/2017] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Delayed gastric emptying (DGE) is the most frequent pancreatic specific complication (PSC) after pancreaticoduodenectomy (PD). Several gastric decompression systems exist to manage DGE. Patients with a pancreatic tumor require prolonged nutrition; however, controversies exist concerning nutrition protocol after PD. The aim of the study was to assess the safety and efficacy of nasogastric (NG), gastrostomy (GT), and gastrojejunostomy (GJ) tubes with different feeding systems on postoperative courses. METHODS Between January 2013 and March 2016, 86 patients underwent PD with pancreaticogastrostomy. Patients were divided into three groups: GJ group with enteral nutrition (EN, n = 12, 14%), NG (n = 31, 36%) and GT groups (n = 43, 50%), both with total parenteral nutrition (TPN). RESULTS Patients in the GJ (n = 9, 75%) and GT (n = 18, 42%) groups had an American Society of Anesthesiologists (ASA) score of 3 more often than those in the NG group (n = 5, 16%, p ≤ 0.01). Multivariate analysis identified the GT tube with TPN as an independent risk factor of severe morbidity (p = 0.02) and DGE (p < 0.01). An ASA score of 3, jaundice, common pancreatic duct size ≤3 mm and soft pancreatic gland texture (p < 0.05) were found as independent risk factors of PSCs. Use of a GJ tube with EN, GT tube with TPN, jaundice, and PSCs were identified as independent risk factors for greater postoperative length of hospital stay (p < 0.01). Mean global hospitalization cost did not differ between groups. CONCLUSION GT tube insertion with TPN was associated with increased severe postoperative morbidity and DGE and should not be recommended. EN through a GJ tube after PD is feasible but does not have clear advantages on postoperative courses compared to an NG tube.
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Affiliation(s)
- Théophile Guilbaud
- Department of Digestive Surgery, Hôpital Nord, Aix-Marseille University, Chemin des Bourrely 13915, cedex 20 Marseille, France
| | - David Jérémie Birnbaum
- Department of Digestive Surgery, Hôpital Nord, Aix-Marseille University, Chemin des Bourrely 13915, cedex 20 Marseille, France
| | - Sandrine Loubière
- Self perceived Health Assessment Research Unit and Department of Public health, Aix-Marseille University, 27 Boulevard Jean Moulin, 13005, cedex 20 Marseille, France
| | - Julien Bonnet
- Department of Digestive Surgery, Hôpital Nord, Aix-Marseille University, Chemin des Bourrely 13915, cedex 20 Marseille, France
| | - Sophie Chopinet
- Department of Digestive Surgery and Liver Transplantation, Hôpital La Timone, Aix-Marseille University, 264 Rue Saint-Pierre 13385, cedex 20 Marseille, France
| | - Emilie Grégoire
- Department of Digestive Surgery and Liver Transplantation, Hôpital La Timone, Aix-Marseille University, 264 Rue Saint-Pierre 13385, cedex 20 Marseille, France
| | - Stéphane Berdah
- Department of Digestive Surgery, Hôpital Nord, Aix-Marseille University, Chemin des Bourrely 13915, cedex 20 Marseille, France
| | - Jean Hardwigsen
- Department of Digestive Surgery and Liver Transplantation, Hôpital La Timone, Aix-Marseille University, 264 Rue Saint-Pierre 13385, cedex 20 Marseille, France
| | - Vincent Moutardier
- Department of Digestive Surgery, Hôpital Nord, Aix-Marseille University, Chemin des Bourrely 13915, cedex 20 Marseille, France
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Kawaida H, Kono H, Watanabe M, Hosomura N, Amemiya H, Fujii H. Risk factors of postoperative pancreatic fistula after distal pancreatectomy using a triple-row stapler. Surg Today 2017; 48:95-100. [PMID: 28600634 PMCID: PMC5711995 DOI: 10.1007/s00595-017-1554-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 05/29/2017] [Indexed: 12/11/2022]
Abstract
PURPOSE Postoperative pancreatic fistula (POPF) is one of the major complications in patients who undergo distal pancreatectomy (DP). Recently, dividing the pancreas by stapler is a commonly performed technique, however, POPF still occurs. Therefore, the purpose of this study was to investigate the risk factors for POPF after DP using a triple-row stapler. METHODS A total of 75 patients underwent DP using a triple-row stapler (Endo GIA™ Reloads with Tri-Staple™ Technology 60 mm; COVIDIEN, North Haven, CT, USA) at Yamanashi University from December 2012 to December 2016. The clinical risk factors for POPF after DP using a triple-row stapler were identified based on univariate and multivariate analyses. RESULTS Clinical POPF (ISGPF Grade B and C) was seen in 7 of 75 patients (9.3%). The body mass index (BMI) was significantly higher in the patients with POPF (26.8 ± 0.5 kg/m2) compared with the patients without POPF (21.4 ± 0.4 kg/m2; a cut-off value; 25.7 kg/m2). In addition, the patients with POPF were significantly younger than the patients without POPF (56.4 ± 5.6 vs 67.0 ± 1.5; a cut-off value was 57.0 years old). CONCLUSIONS BMI and age were found to be significant risk factors for POPF after DP using a triple-row stapler.
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Affiliation(s)
- Hiromichi Kawaida
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan.
| | - Hiroshi Kono
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Mitsuaki Watanabe
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Naohiro Hosomura
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Hidetake Amemiya
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Hideki Fujii
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
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Dokmak S, Ftériche FS, Aussilhou B, Lévy P, Ruszniewski P, Cros J, Vullierme MP, Khoy Ear L, Belghiti J, Sauvanet A. The Largest European Single-Center Experience: 300 Laparoscopic Pancreatic Resections. J Am Coll Surg 2017; 225:226-234.e2. [PMID: 28414116 DOI: 10.1016/j.jamcollsurg.2017.04.004] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 03/27/2017] [Accepted: 04/03/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Although laparoscopic pancreatic resection (LPR) has become routine, large single-center series are still lacking. Our aim was to analyze the results of a large European single-center series of LPR. STUDY DESIGN Between January 2008 and September 2015, 300 LPRs were performed and studied prospectively, including 165 (55%) distal pancreatectomies, 68 (23%) pancreaticoduodenectomies (PDs), 30 (10%) enucleations, 35 (11%) central pancreatectomies, and 2 (1%) total pancreatectomies. RESULTS Mean age was 54 ± 15.4 years old (range 17 to 87 years), and most patients were women (58%). Laparoscopic pancreatic resection was performed for malignancy (46%), low potential malignant (44%), or benign (10%) diseases. The mean operative durations were 211 ± 102 minutes (range 30 to 540 minutes) for the entire population and 351 ± 59 minutes (range 240 to 540 minutes) for PD, and decreased with the learning curve. Mean blood loss was 229 ± 269 mL (range 0 to 1,500 mL), and 13 patients (4%) received transfusions. Conversion to an open procedure was required in 12 patients (4%), and only 5 in the last 250 patients (14% vs 2%; p < 0.001). Mortality occurred in 4 (1.3%) patients and only after PD (5.8%). Common complications were pancreatic fistula (n = 124, 41%), bleeding (n = 35, 12%), and reoperation (n = 28, 9%). The postoperative outcomes were less favorable in procedures with a reconstruction phase (n = 105) than in those without (n = 195), with increased mortality (3.8% vs 0%; p = 0.04), overall morbidity (76% vs % 52%; p < 0.001), and mean hospital stay (26 ± 15 days vs 16 ± 10 days; p < 0.001). CONCLUSIONS Laparoscopic pancreatic resection without a reconstruction phase has excellent outcomes; LPR with a reconstruction phase, especially PD, has less favorable outcomes, and further randomized studies are required to draw conclusions on the safety and benefits of this approach.
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Affiliation(s)
- Safi Dokmak
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, University Paris VII, Clichy, France.
| | - Fadhel Samir Ftériche
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, University Paris VII, Clichy, France
| | - Béatrice Aussilhou
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, University Paris VII, Clichy, France
| | - Philippe Lévy
- Department of Gastroenterology, Beaujon Hospital, APHP, University Paris VII, Clichy, France
| | - Philippe Ruszniewski
- Department of Gastroenterology, Beaujon Hospital, APHP, University Paris VII, Clichy, France
| | - Jérome Cros
- Department of Pathology, Beaujon Hospital, APHP, University Paris VII, Clichy, France
| | | | - Linda Khoy Ear
- Department of Anesthesia and Intensive Care, Beaujon Hospital, APHP, University Paris VII, Clichy, France
| | - Jacques Belghiti
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, University Paris VII, Clichy, France
| | - Alain Sauvanet
- Department of HPB Surgery and Liver Transplantation, Beaujon Hospital, APHP, University Paris VII, Clichy, France
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Comparison of surgical outcomes of three different stump closure techniques during distal pancreatectomy. Pancreatology 2017; 17:497-503. [PMID: 28411019 DOI: 10.1016/j.pan.2017.04.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 02/11/2017] [Accepted: 04/07/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND To find the appropriate method of pancreatic transection during distal pancreatectomy (DP), we retrospectively compared post-operative complications including postoperative pancreatic fistula (POPF) according to the different types of pancreatic transection. METHODS This study included 169 patients who underwent pancreatic transection using an ultrasonic activated device (USAD) with transfixion of the pancreatic duct (DP-TF group, n = 89), USAD followed by pancreaticogastrostomy (DP-PG group, n = 44), and a reinforced linear tristapler (DP-ST, n = 36). RESULTS Overall and POPF-related complications in DP-PG group, and delayed gastric emptying (DGE) in DP-ST group were significantly lower than DP-TF group. There were no significant difference in overall complication, length of hospitalization and operative costs between DP-PG and DP-ST groups. Operative time was significantly longer in DP-PG group than others. CONCLUSION Both DP-PG and DP-ST are associated with better surgical outcomes. Regarding ease of surgical technique, shorter operative times, and similar medical costs, DP with a reinforced linear tristapler is a good choice during DP.
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Anchi P, Khurana A, Bale S, Godugu C. The Role of Plant-derived Products in Pancreatitis: Experimental and Clinical Evidence. Phytother Res 2017; 31:591-623. [DOI: 10.1002/ptr.5792] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 02/03/2017] [Accepted: 02/06/2017] [Indexed: 12/13/2022]
Affiliation(s)
- Pratibha Anchi
- Department of Regulatory Toxicology; National Institute of Pharmaceutical Education and Research (NIPER), Balanagar; Hyderabad Telangana India
| | - Amit Khurana
- Department of Regulatory Toxicology; National Institute of Pharmaceutical Education and Research (NIPER), Balanagar; Hyderabad Telangana India
| | - Swarna Bale
- Department of Regulatory Toxicology; National Institute of Pharmaceutical Education and Research (NIPER), Balanagar; Hyderabad Telangana India
| | - Chandraiah Godugu
- Department of Regulatory Toxicology; National Institute of Pharmaceutical Education and Research (NIPER), Balanagar; Hyderabad Telangana India
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Pendola F, Gadde R, Ripat C, Sharma R, Picado O, Lobo L, Sleeman D, Livingstone AS, Merchant N, Yakoub D. Distal pancreatectomy for benign and low grade malignant tumors: Short-term postoperative outcomes of spleen preservation-A systematic review and update meta-analysis. J Surg Oncol 2017; 115:137-143. [PMID: 28133818 DOI: 10.1002/jso.24507] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 10/21/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND The value of spleen preservation with distal pancreatectomy (DP) for benign and low grade malignant tumors remains unclear. The aim of this study was to evaluate the short-term postoperative clinical outcomes in patients undergoing DP with splenectomy (DPS) or spleen preservation (SPDP). METHODS Online database search was performed (2000 to present); key bibliographies were reviewed. Studies comparing patients undergoing DP with either DPS or SPDP, and assessing postoperative complications were included. RESULTS Meta-analysis of included data showed SPDP patients had significantly less operative blood loss, shorter duration of hospitalization, lower incidence of fluid collection and abscess, lower incidence of postoperative splenic and portal vein thrombosis, and lower incidence of new onset postoperative diabetes. For the whole group, there was no difference in incidence of postoperative pancreatic fistula (POPF) (RR = 0.95; 95%CI 0.65-1.40, P = 0.80), however, subgroup analysis of studies using ISGPF criteria showed that DPS patients had increased rates of Grade B/C POPF (RR = 1.35; 95%CI 1.08-1.70, P = 0.01). CONCLUSIONS SPDP for benign and low grade malignant tumors is associated with shorter hospital stay and decreased morbidity compared to DPS. J. Surg. Oncol. 2017;115:137-143. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Fiorella Pendola
- Division of Surgical Oncology, Department of Surgery, University of Miami - Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, Florida
| | - Rahul Gadde
- Division of Surgical Oncology, Department of Surgery, University of Miami - Miller School of Medicine, Miami, Florida
| | - Caroline Ripat
- Division of Surgical Oncology, Department of Surgery, University of Miami - Miller School of Medicine, Miami, Florida
| | - Rishika Sharma
- Division of Surgical Oncology, Department of Surgery, University of Miami - Miller School of Medicine, Miami, Florida
| | - Omar Picado
- Division of Surgical Oncology, Department of Surgery, University of Miami - Miller School of Medicine, Miami, Florida
| | - Laila Lobo
- Division of Surgical Oncology, Department of Surgery, University of Miami - Miller School of Medicine, Miami, Florida
| | - Danny Sleeman
- Division of Surgical Oncology, Department of Surgery, University of Miami - Miller School of Medicine, Miami, Florida
| | - Alan S Livingstone
- Division of Surgical Oncology, Department of Surgery, University of Miami - Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, Florida
| | - Nipun Merchant
- Division of Surgical Oncology, Department of Surgery, University of Miami - Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, Florida
| | - Danny Yakoub
- Division of Surgical Oncology, Department of Surgery, University of Miami - Miller School of Medicine, Miami, Florida.,Sylvester Comprehensive Cancer Center, University of Miami - Miller School of Medicine, Miami, Florida
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Pancreatic stump closure after pancreatoduodenectomy in elderly patients: a retrospective clinical study. Aging Clin Exp Res 2017; 29:35-40. [PMID: 27837458 PMCID: PMC5334406 DOI: 10.1007/s40520-016-0657-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 10/12/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND Pancreatic fistula (PF) after pancreatoduodenectomy (PD) represents the major source of morbidity. Derivative procedures are preferred by pancreatic surgeons, but the optimal management of remnant pancreatic stump remains controversial. AIMS The purpose of this retrospective study is to evaluate the efficacy and safety of pancreatic stump closure in selected elderly patients (>65 years). METHODS Clinical data of 44 PD undergone mechanical closure of the pancreatic stump performed between 2001 and 2014 in two department of general and oncologic surgery were retrospectively collected. Considering the age, patients were divided into two groups: 21 patients of less than 65 years (Group A) and 23 patients of more than 65 years (Group B). RESULTS A soft pancreatic parenchyma with a not-dilated duct (diameter <3 mm) was reported in all the 44 patients. A grade-A PF, which did not required further treatments, developed in 20 cases (45.4%; 13 in group A and 7 in group B; p < 0.05), grade-B in 5 patients (11.4%; 3 in group A and 2 in group B; statistically not significant) and a grade-C PF was observed only in one patient (2.2%; 1 in group A and 0 in group B). DISCUSSION In selected "high risk" elderly patients (>65 years) with soft pancreatic texture, the closure of the pancreatic stump can be a useful tool in the surgical armamentarium with the aim to reduce the incidence of age-related complications. CONCLUSIONS Prospective randomized controlled trial to better evaluate PF risk factors is needed.
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Uemura K, Satoi S, Motoi F, Kwon M, Unno M, Murakami Y. Randomized clinical trial of duct-to-mucosa pancreaticogastrostomy versus handsewn closure after distal pancreatectomy. Br J Surg 2017; 104:536-543. [PMID: 28112814 DOI: 10.1002/bjs.10458] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 10/08/2016] [Accepted: 11/14/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) remains a major cause of morbidity after distal pancreatectomy. The aim of this study was to investigate whether duct-to-mucosa pancreaticogastrostomy of the pancreatic stump decreased clinical POPF formation compared with handsewn closure after distal pancreatectomy. METHODS This multicentre RCT was performed between April 2012 and June 2014. Patients undergoing distal pancreatectomy were assigned randomly to either duct-to-mucosa pancreaticogastrostomy or handsewn closure. The primary endpoint was the incidence of clinical POPF. Secondary endpoints were rates of other complications and length of hospital stay. RESULTS Some 80 patients were randomized, and 73 patients were evaluated in an intention-to-treat analysis: 36 in the pancreaticogastrostomy group and 37 in the handsewn closure group. The duration of operation was significantly longer in the pancreaticogastrostomy group than in the handsewn closure group (mean 268 versus 197 min respectively; P < 0·001). The incidence of clinical POPF did not differ between groups (7 of 36 versus 7 of 37; odds ratio (OR) 1·03, 95 per cent c.i. 0·32 to 3·10; P = 1·000). The rate of intra-abdominal fluid collection was significantly lower in the pancreaticogastrostomy group (6 of 36 versus 21 of 37; OR 0·15, 0·05 to 0·45; P < 0·001). There were no statistically significant differences in the rates of other complications or length of hospital stay. CONCLUSION Duct-to-mucosa pancreaticogastrostomy did not reduce the incidence of clinical POPF compared with handsewn closure of the pancreatic stump after distal pancreatectomy. Registration number UMIN000007426 (http://www.umin.ac.jp).
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Affiliation(s)
- K Uemura
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - S Satoi
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - F Motoi
- Division of Gastroenterological Surgery, Department of Surgery, Tohoku University, Sendai, Japan
| | - M Kwon
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - M Unno
- Division of Gastroenterological Surgery, Department of Surgery, Tohoku University, Sendai, Japan
| | - Y Murakami
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Bovine Serum Albumin-Glutaraldehyde Sealed Fish-Mouth Closure of the Pancreatic Remnant during Distal Pancreatectomy. HPB SURGERY : A WORLD JOURNAL OF HEPATIC, PANCREATIC AND BILIARY SURGERY 2017; 2017:9747421. [PMID: 28194043 PMCID: PMC5282416 DOI: 10.1155/2017/9747421] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 12/28/2016] [Indexed: 12/11/2022]
Abstract
Introduction. Postoperative pancreatic fistula formation remains the major complication after distal pancreatectomy. At our institution, we have recently developed a novel bovine serum albumin-glutaraldehyde sealed hand sutured fish-mouth closure technique of the pancreatic remnant during distal pancreatectomy. The aim of this study was to analyze the impact of this approach with regard to technical feasibility and overall postoperative outcome. Patients and Methods. 32 patients who underwent a bovine serum albumin-glutaraldehyde sealed hand sutured fish-mouth closure of the pancreatic remnant during distal pancreatectomy between 2012 and 2014 at our institution were analyzed for clinically relevant postoperative pancreatic fistula formation (Grades B and C according to ISGPF definition) and overall postoperative morbidity. Results. Three out of 32 patients (9.4%) developed Grade B pancreatic fistula, which could be treated conservatively. No Grade C pancreatic fistulas were observed. Postpancreatectomy hemorrhage occurred in 1 patient (3.1%). Overall postoperative complications > Clavien II were observed in 5 patients (15.6%). There was no postoperative mortality. Conclusion. The performance of a bovine serum albumin-glutaraldehyde sealed hand sutured fish-mouth closure of the pancreatic remnant was shown to be technically feasible and may lead to a significant decrease of postoperative pancreatic fistula formation after distal pancreatectomy.
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Takaki H, Yamakado K, Kuriyama N, Nakatsuka A, Sakuma H, Isaji S. Percutaneous drainage of pancreatic fistula following pancreatectomy with CT-fluoroscopic guidance. Diagn Interv Imaging 2017; 98:43-50. [PMID: 27316574 DOI: 10.1016/j.diii.2016.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Revised: 05/07/2016] [Accepted: 05/13/2016] [Indexed: 12/26/2022]
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Hayashibe A, Ogino N. Clinical study for pancreatic fistula after distal pancreatectomy with mesh reinforcement. Asian J Surg 2016; 41:236-240. [PMID: 27964997 DOI: 10.1016/j.asjsur.2016.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 10/25/2016] [Accepted: 11/07/2016] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The purpose of this cohort study was to determine whether distal pancreatectomy with mesh reinforcement can reduce postoperative pancreatic fistula (POPF) rates compared with bare stapler. METHODS In total, 51 patients underwent stapled distal pancreatectomy. Out of these, 22 patients (no mesh group) underwent distal pancreatectomy with bare stapler and 29 patients (mesh group) underwent distal pancreatectomy with mesh reinforced stapler. The risk factor for clinically relevant POPF (grades B and C) after distal pancreatectomy was also evaluated. RESULTS Clinical characteristics were almost similar in both the groups. The days of the mean hospital stay and drainage tube insertion in the mesh group were significantly fewer than those in the no mesh group. The mean level of amylase in the discharge fluid in the mesh group was also significantly lower than that the in no mesh group. The rate of clinically relevant POPF (grades B and C ) in the mesh group was significantly lower than that in the no mesh group (p=0.016). Univariate analyses of risk factors for POPF (grades B and C) revealed that only mesh reinforcement was associated with POPF (grades B and C). Moreover, on multivariate analyses of POPF risk factors with p value<0.2 in univariate analyses by logistic regression, mesh reinforcement was regarded as a significant factor for POPF(grades B and C). CONCLUSIONS The distal pancreatectomy with mesh reinforced stapler was thought to be favorable for the prevention of clinically relevant POPF (grades B and C).
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Affiliation(s)
- Akira Hayashibe
- Department of Surgery, Osakafu Saiseikai Tondabayashi Hospital, Osaka, Japan.
| | - Nobuo Ogino
- Department of Surgery, Osakafu Saiseikai Tondabayashi Hospital, Osaka, Japan
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Modified Hand-Sewn Closure With Retroperitoneal Tissue-covering Method Prevents Pancreatic Fistula in Laparoscopic Distal Pancreatectomy. Surg Laparosc Endosc Percutan Tech 2016; 26:e95-e99. [PMID: 27579983 DOI: 10.1097/sle.0000000000000306] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In laparoscopic distal pancreatectomy, the stapler transection of the pancreas remains the preferred method; however, pancreatic fistula continues to be a critical unsolved problem. The aim of this study was to compare complications associated with distal pancreatectomy, especially regarding the formation of pancreatic fistula, with particular attention to the stapler and hand-sewn closure technique. PATIENTS AND METHODS Between January 2004 and June 2012, 47 patients underwent laparoscopic distal pancreatectomy. These patient's pancreatic bodies were similar, and they were subjected to closure of the pancreatic stump either by stapler (Staple group, n=21) or by a modified hand-sewn technique (Sewn group, n=26), and were subsequently retrospectively reviewed. RESULTS The incidence of PF was significantly higher in the "Staple group" compared with the "Sewn group." Likewise, the amylase levels in the drainage fluid, were significantly higher in the "Staple group" compared with the "Sewn group." Patients in the Sewn group had shorter median hospital stay compared with those in the Sewn group (5 vs. 8 d, P<0.001). CONCLUSIONS The 2-layer hand-sewn technique is a simple method, and it significantly decreased the incidence of PF and hospital stay compared with the use of staples in laparoscopy.
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43
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Attempts to prevent postoperative pancreatic fistula after distal pancreatectomy. Surg Today 2016; 47:416-424. [DOI: 10.1007/s00595-016-1367-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 05/19/2016] [Indexed: 02/06/2023]
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Kollár D, Huszár T, Pohárnok Z, Cselovszky É, Oláh A. A Review of Techniques for Closure of the Pancreatic Remnant following Distal Pancreatectomy. Dig Surg 2016; 33:320-8. [PMID: 27215609 DOI: 10.1159/000445017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
The prevalence of pancreatic diseases needing surgical intervention is continuously rising. Distal pancreatectomy is performed in the case of pathologies affecting the left side of the pancreas. More and more sophisticated surgical techniques have appeared and an increasing number of published articles discuss the possibilities for closure of the pancreatic remnant. However, the optimum solution is still under debate, as none of the examined techniques have been proven superior in reducing the incidence of the most common surgical complication, the formation of a postoperative pancreatic fistula (PF). Fistula rates have been stationary at 20-30% in the past decades despite the apparent advancement of medicine. This review presents a survey of the relevant articles examining different closure strategies and risk factors to reduce fistula formation rate. International medical publication database search and assessment was carried out to include the findings of studies investigating the efficacy of pancreatic remnant closure techniques to gain a clearer view on the complexity of pancreas fistulas. Emphasis is on indications for surgery, risk factors for postoperative fistula formation and strategies to seal the pancreatic remnant to avoid leakage. Findings suggest that careful patient selection, meticulous surgical techniques are equally important to reduce fistula rates. Ideal closure of the pancreatic remnant is still to be developed, as none of the widespread techniques (hand-sewn suture or staple closure) proved to be statistically significantly superior. Additional closure and covering methods (seromuscular patch, falciform ligament patch, pancreatico-enteric anastomosis, reinforced staplers, fibrin glue etc.) can have profitable effect but strong evidences are yet to come due to small case numbers. The recent introduction of standardized classification of PFs and future prospective randomized trials are more likely to be susceptible to determine if any of the standard or experimental closure techniques is more beneficial than the others.
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Affiliation(s)
- Dániel Kollár
- Department of Surgery, Petz Aladx00E1;r Teaching Hospital, Gyx0151;r, Hungary
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Fujii T, Yamada S, Murotani K, Sugimoto H, Hattori M, Kanda M, Takami H, Nakayama G, Nomoto S, Fujiwara M, Nakao A, Kodera Y. Modified Blumgart Suturing Technique for Remnant Closure After Distal Pancreatectomy: a Propensity Score-Matched Analysis. J Gastrointest Surg 2016; 20:374-84. [PMID: 26497190 DOI: 10.1007/s11605-015-2980-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 10/07/2015] [Indexed: 01/31/2023]
Abstract
Despite recent advances in surgical techniques including staple closure and ultrasonic devices, the reported incidence of postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) remains high. Therefore, we devised a new strategy in which the pancreatic stump is enveloped with the elevated jejunum (EJ) by a modified Blumgart anastomotic technique. Eighty-one patients who underwent open DP with splenectomy from January 2008 to December 2014 were enrolled. Comparisons were made between 42 patients who underwent placement of an EJ patch using the modified Blumgart method after scalpel transection and 39 patients who underwent scalpel transection alone, using unmatched and propensity score-matched analysis. After 25 patients from each group were selected by propensity score matching, the EJ patch technique was significantly associated with a lower incidence of clinically relevant POPF (P = 0.036). Multivariate analysis showed that the EJ patch was an independent predictor of a lower incidence of POPF (odds ratio, 0.16; 95 % confidence interval, 0.01–0.48; P = 0.017) as was the estimated remnant pancreatic volume. Addition of the EJ patch improves postoperative outcomes in patients who undergo open DP with splenectomy by scalpel transection and hand-sewn closure of the pancreatic remnant.
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Park JS, Lee DH, Jang JY, Han Y, Yoon DS, Kim JK, Han HS, Yoon Y, Hwang D, Kang CM, Hwang HK, Lee WJ, Heo J, Chang YR, Kang MJ, Shin YC, Chang J, Kim H, Jung W, Kim SW. Use of TachoSil®patches to prevent pancreatic leaks after distal pancreatectomy: a prospective, multicenter, randomized controlled study. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:110-7. [DOI: 10.1002/jhbp.310] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 12/15/2015] [Indexed: 12/11/2022]
Affiliation(s)
- Joon Seong Park
- Department of Surgery, Gangnam Severance Hospital; Yonsei University College of Medicine; Seoul Korea
| | - Doo-ho Lee
- Department of Surgery; Seoul National University Hospital, Seoul National University College of Medicine; Seoul Korea
| | - Jin-Young Jang
- Department of Surgery; Seoul National University Hospital, Seoul National University College of Medicine; Seoul Korea
| | - Youngmin Han
- Department of Surgery; Seoul National University Hospital, Seoul National University College of Medicine; Seoul Korea
| | - Dong Sup Yoon
- Department of Surgery, Gangnam Severance Hospital; Yonsei University College of Medicine; Seoul Korea
| | - Jae Keun Kim
- Department of Surgery, Gangnam Severance Hospital; Yonsei University College of Medicine; Seoul Korea
| | - Ho-Seong Han
- Department of Surgery; Seoul National University Bundang Hospital, Seoul National University College of Medicine; Seongnam Korea
| | - YooSeok Yoon
- Department of Surgery; Seoul National University Bundang Hospital, Seoul National University College of Medicine; Seongnam Korea
| | - DaeWook Hwang
- Department of Surgery; Seoul National University Bundang Hospital, Seoul National University College of Medicine; Seongnam Korea
| | - Chang Moo Kang
- Department of Surgery, Severance Hospital; Yonsei University College of Medicine; Seoul Korea
| | - Ho Kyoung Hwang
- Department of Surgery, Severance Hospital; Yonsei University College of Medicine; Seoul Korea
| | - Woo Jung Lee
- Department of Surgery, Severance Hospital; Yonsei University College of Medicine; Seoul Korea
| | - JinSeok Heo
- Department of Surgery, Samsung Medical Center; Sungkyunkwan University College of Medicine; Seoul Korea
| | - Ye Rim Chang
- Department of Surgery; Seoul National University Hospital, Seoul National University College of Medicine; Seoul Korea
| | - Mee Joo Kang
- Department of Surgery; Seoul National University Hospital, Seoul National University College of Medicine; Seoul Korea
| | - Yong Chan Shin
- Department of Surgery; Seoul National University Hospital, Seoul National University College of Medicine; Seoul Korea
| | - Jihoon Chang
- Department of Surgery; Seoul National University Hospital, Seoul National University College of Medicine; Seoul Korea
| | - Hongbeom Kim
- Department of Surgery; Seoul National University Hospital, Seoul National University College of Medicine; Seoul Korea
| | - Woohyun Jung
- Department of Surgery; Seoul National University Hospital, Seoul National University College of Medicine; Seoul Korea
| | - Sun-Whe Kim
- Department of Surgery; Seoul National University Hospital, Seoul National University College of Medicine; Seoul Korea
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Fujii T, Yamada S, Murotani K, Okamura Y, Ishigure K, Kanda M, Takeda S, Morita S, Nakao A, Kodera Y. Oral Food Intake Versus Fasting on Postoperative Pancreatic Fistula After Distal Pancreatectomy: A Multi-Institutional Randomized Controlled Trial. Medicine (Baltimore) 2015; 94:e2398. [PMID: 26717392 PMCID: PMC5291633 DOI: 10.1097/md.0000000000002398] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The usefulness of enteral nutrition via a nasointestinal tube for patients who develop postoperative pancreatic fistula (POPF) after miscellaneous pancreatectomy procedures has been reported. However, no clear evidence regarding whether oral intake is beneficial or harmful during management of POPF after distal pancreatectomy (DP) is currently available.To investigate the effects of oral food intake on the healing process of POPF after DP.Multi-institutional randomized controlled trial in Nagoya University Hospital and 4 affiliated hospitals.Patients who developed POPF were randomly assigned to the dietary intake (DI) group (n = 15) or the fasted group (no dietary intake [NDI] group) (n = 15). The primary endpoint was the length of drain placement.No significant differences were found in the length of drain placement between the DI and NDI groups (12 [6-58] and 12 [7-112] days, respectively; P = 0.786). POPF progressed to a clinically relevant status (grade B/C) in 5 patients in the DI group and 4 patients in the NDI group (P = 0.690). POPF-related intra-abdominal hemorrhage was found in 1 patient in the NDI group but in no patients in the DI group (P = 0.309). There were no significant differences in POPF-related intra-abdominal hemorrhage, the incidence of other complications, or the length of the postoperative hospital stay between the 2 groups.Food intake did not aggravate POPF and did not prolong drain placement or hospital stay after DP. There may be no need to avoid oral DI in patients with POPF.
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Affiliation(s)
- Tsutomu Fujii
- From the Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Nagoya, Japan (TF, SY, YO, MK, AN, YK); Center for Clinical Research, Aichi Medical University, Nagakute, Japan (KM); Department of Surgery, Konan Kosei Hospital, Konan, Japan (KI); Department of Surgery, National Hospital Organization Nagoya Medical Center, Nagoya, Japan (ST); Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Kyoto, Japan (SM); and Department of Surgery, Nagoya Central Hospital, Nagoya, Japan (AN)
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Probst P, Hüttner FJ, Klaiber U, Knebel P, Ulrich A, Büchler MW, Diener MK, Cochrane Upper GI and Pancreatic Diseases Group. Stapler versus scalpel resection followed by hand-sewn closure of the pancreatic remnant for distal pancreatectomy. Cochrane Database Syst Rev 2015; 2015:CD008688. [PMID: 26544925 PMCID: PMC11131144 DOI: 10.1002/14651858.cd008688.pub2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Resections of the pancreatic body and tail reaching to the left of the superior mesenteric vein are defined as distal pancreatectomy. Most distal pancreatectomies are elective treatments for chronic pancreatitis, benign or malignant diseases, and they have high morbidity rates of up to 40%. Pancreatic fistula formation is the main source of postoperative morbidity, associated with numerous further complications. Researchers have proposed several surgical resection and closure techniques of the pancreatic remnant in an attempt to reduce these complications. The two most common techniques are scalpel resection followed by hand-sewn closure of the pancreatic remnant and stapler resection and closure. OBJECTIVES To compare the rates of pancreatic fistula in people undergoing distal pancreatectomy using scalpel resection followed by hand-sewn closure of the pancreatic remnant versus stapler resection and closure. SEARCH METHODS We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Biosis and Science Citation Index from database inception to October 2015. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing stapler versus scalpel resection followed by hand-sewn closure of the pancreatic remnant for distal pancreatectomy (irrespective of language or publication status). DATA COLLECTION AND ANALYSIS Two authors independently assessed trials for inclusion and extracted the data. Taking into consideration the clinical heterogeneity between the trials (e.g. different endpoint definitions), we analysed data using a random-effects model with Review Manager (RevMan), calculating risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI). MAIN RESULTS In two eligible trials, a total of 381 participants underwent distal pancreatic resection and were randomised to closure of the pancreatic remnant either with stapler (n = 191) or scalpel resection followed by hand-sewn closure (n = 190). One was a single centre pilot RCT and the other was a multicentre blinded RCT. The single centre pilot RCT evaluated 69 participants in five intervention arms (stapler, hand-sewn, fibrin glue, mesh and pancreaticojejunostomy), although we only assessed the stapler and hand-sewn closure groups (14 and 15 participants, respectively). The multicentre RCT had two interventional arms: stapler (n = 177) and hand-sewn closure (n = 175). The rate of postoperative pancreatic fistula was the main outcome, and it occurred in 79 of 190 participants in the hand-sewn group compared to 65 of 191 participants in the stapler group. Neither the individual trials nor the meta-analysis showed a significant difference between resection techniques (RR 0.90; 95% CI 0.55 to 1.45; P = 0.66). In the same way, postoperative mortality and operation time did not differ significantly. The single centre RCT had an unclear risk of bias in the randomisation, allocation and both blinding domains. However, the much larger multicentre RCT had a low risk of bias in all domains. Due to the small number of events and the wide confidence intervals that cannot exclude clinically important benefit or harm with stapler versus hand-sewn closure, there is a serious possibility of imprecision, making the overall quality of evidence moderate. AUTHORS' CONCLUSIONS The quality of evidence is moderate and mainly based on the high weight of the results of one multicentre RCT. Unfortunately, there are no other completed RCTs on this topic except for one relevant ongoing trial. Neither stapler nor scalpel resection followed by hand-sewn closure of the pancreatic remnant for distal pancreatectomy showed any benefit compared to the other method in terms of postoperative pancreatic fistula, overall postoperative mortality or operation time. Currently, the choice of closure is left up to the preference of the individual surgeon and the anatomical characteristics of the patient. Another (non-European) multicentre trial (e.g. with an equality or non-inferiority design) would help to corroborate the findings of this meta-analysis. Future trials assessing novel methods of stump closure should compare them either with stapler or hand-sewn closure as a control group to ensure comparability of results.
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Affiliation(s)
- Pascal Probst
- University of HeidelbergDepartment of General, Visceral and Transplant SurgeryIm Neuenheimer Feld 110HeidelbergGermanyD‐69120
| | - Felix J Hüttner
- University of HeidelbergDepartment of General, Visceral and Transplant SurgeryIm Neuenheimer Feld 110HeidelbergGermanyD‐69120
| | - Ulla Klaiber
- University of HeidelbergDepartment of General, Visceral and Transplant SurgeryIm Neuenheimer Feld 110HeidelbergGermanyD‐69120
| | - Phillip Knebel
- University of HeidelbergDepartment of General, Visceral and Transplant SurgeryIm Neuenheimer Feld 110HeidelbergGermanyD‐69120
| | - Alexis Ulrich
- University of HeidelbergDepartment of General, Visceral and Transplant SurgeryIm Neuenheimer Feld 110HeidelbergGermanyD‐69120
| | - Markus W Büchler
- University of HeidelbergDepartment of General, Visceral and Transplant SurgeryIm Neuenheimer Feld 110HeidelbergGermanyD‐69120
| | - Markus K Diener
- University of HeidelbergDepartment of General, Visceral and Transplant SurgeryIm Neuenheimer Feld 110HeidelbergGermanyD‐69120
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Laparoscopic Distal Pancreatectomy with or without Preservation of the Spleen for Solid Pseudopapillary Neoplasm. Case Rep Surg 2015; 2015:487639. [PMID: 26587305 PMCID: PMC4637475 DOI: 10.1155/2015/487639] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 09/30/2015] [Indexed: 02/06/2023] Open
Abstract
Solid pseudopapillary neoplasm (SPN) is a rare tumor of the pancreas. Laparoscopic distal pancreatectomy (DP) is a feasible and safe procedure, and successful spleen preservation rates are higher using a laparoscopic approach. We hypothesized that certain patients with SPN would be good candidates for laparoscopic surgery; however, few surgeons have reported laparoscopic DP for SPN. We discuss the preoperative assessment and surgical simulation for two SPN cases. A simulation was designed because we consider that a thorough preoperative understanding of the procedure based on three-dimensional image analysis is important for successful laparoscopic DP. We also discuss the details of the actual laparoscopic DP with or without splenic preservation that we performed for our two SPN cases. It is critical to use appropriate instruments at appropriate points in the procedure; surgical instruments are numerous and varied, and surgeons should maximize the use of each instrument. Finally, we discuss the key techniques and surgical pitfalls in laparoscopic DP with or without splenic preservation. We conclude that experience alone is inadequate for successful laparoscopic surgery.
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Pancreatic Fistula and Delayed Gastric Emptying After Pancreatectomy: Where do We Stand? Indian J Surg 2015; 77:409-25. [PMID: 26722205 DOI: 10.1007/s12262-015-1366-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 09/30/2015] [Indexed: 12/13/2022] Open
Abstract
Pancreatic resection has become a feasible treatment of pancreatic neoplasms, and with improvements in surgical techniques and perioperative management, mortality associated with pancreatic surgery has decreased considerably. Despite this improvement, a high rate of complications is still associated with these procedures. Among these complications, delayed gastric emptying (DGE) and postoperative pancreatic fistula (POPF) have a substantial impact on patient outcomes and burden our healthcare system. Technical modifications and postoperative approaches have been proposed to reduce rates of both POPF and DGE in patients undergoing pancreatectomy; however, to date, their rates have remained unchanged. In the present study, we summarize the findings of the most significant studies that have investigated these complications. In particular, several studies focused on technical modifications including extent of dissection, stent placement, nature of anastomosis, type of reconstruction, and application of biological or non-biological agents to site of anastomosis. Moreover, postoperatively, drain placement, duration of drain usage, postoperative feeding, and use of pharmacological agents were studied to reduce rates of POPF and DGE. In this review, we summarize the most relevant literature on this fundamental aspect of pancreatic surgery. Despite studies identifying the potential benefit of technical modifications and postoperative approaches, these findings remain controversial and suggest need for further extensive investigation. Most importantly, we recommend that all surgeons performing these procedures base their practice on the most updated and highest available level of evidence.
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