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Sugita H, Amaya K, Kawata C, Nagaoka Y, Iwaki Y, Nishida Y, Hirose A, Tsukada T, Nakamura T, Hada M, Takeshita M, Yoshikawa A, Kaji M. Robotic Distal Pancreatectomy for Adult Pancreatoblastoma with Tumor Extension to the Main Pancreatic Duct: A Case Report. Surg Case Rep 2025; 11:25-0037. [PMID: 40292021 PMCID: PMC12022996 DOI: 10.70352/scrj.cr.25-0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2025] [Accepted: 03/27/2025] [Indexed: 04/30/2025] Open
Abstract
INTRODUCTION Adult pancreatoblastoma (PB) is an extremely rare malignant pancreatic epithelial tumor. Although no standard treatment strategy has been established, complete resection is recommended for long-term survival. Here, we presented a case of an adult patient with PB who successfully underwent complete resection via robotic surgery. Furthermore, this is the first report of robotic surgery for PB, highlighting its novelty and potential clinical relevance. CASE PRESENTATION A 40-year-old man presented with epigastric pain, and image examination revealed a well-defined tumor in the pancreatic tail extending into the main pancreatic duct (MPD) and reaching the pancreatic neck. With no evidence of distant metastases, surgery was planned following 2 courses of gemcitabine and S-1 chemotherapy for tumor shrinkage. There were no significant changes in the tumor's extension after chemotherapy, but no new lesions appeared, and robotic distal pancreatectomy was performed. Intraoperative findings confirmed the tumor extension into the MPD just above the superior mesenteric vein (SMV). The pancreas was sharply divided at the right edge of the SMV, and a negative transection margin was obtained. The pancreatic stump was closed by suture. The postoperative course was uneventful, and the pathological diagnosis confirmed PB with MPD and inferior mesenteric vein invasion. CONCLUSIONS We successfully resected an adult case of PB with tumor extension into the MPD via robotic surgery. Robotic surgery enabled precise pancreatic transection at the right edge of the SMV, ensuring a negative pancreatic transection margin in this case. In addition, robotic surgery contributed to the safe and secure suture closure of the pancreatic stump.
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Affiliation(s)
- Hiroaki Sugita
- Department of Surgery, Toyama Prefectural Central Hospital, Toyama, Toyama, Japan
| | - Koji Amaya
- Department of Surgery, Toyama Prefectural Central Hospital, Toyama, Toyama, Japan
| | - Chihiro Kawata
- Department of Surgery, Toyama Prefectural Central Hospital, Toyama, Toyama, Japan
| | - Yasuhiro Nagaoka
- Department of Surgery, Toyama Prefectural Central Hospital, Toyama, Toyama, Japan
| | - Yoshitaka Iwaki
- Department of Surgery, Toyama Prefectural Central Hospital, Toyama, Toyama, Japan
| | - Yoji Nishida
- Department of Surgery, Toyama Prefectural Central Hospital, Toyama, Toyama, Japan
| | - Atsushi Hirose
- Department of Surgery, Toyama Prefectural Central Hospital, Toyama, Toyama, Japan
| | - Tomoya Tsukada
- Department of Surgery, Toyama Prefectural Central Hospital, Toyama, Toyama, Japan
| | - Takashi Nakamura
- Department of Surgery, Toyama Prefectural Central Hospital, Toyama, Toyama, Japan
| | - Masahiro Hada
- Department of Surgery, Toyama Prefectural Central Hospital, Toyama, Toyama, Japan
| | - Masaki Takeshita
- Department of Surgery, Toyama Prefectural Central Hospital, Toyama, Toyama, Japan
| | - Akemi Yoshikawa
- Department of Surgery, Toyama Prefectural Central Hospital, Toyama, Toyama, Japan
| | - Masahide Kaji
- Department of Surgery, Toyama Prefectural Central Hospital, Toyama, Toyama, Japan
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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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Okamoto H, Yamamoto A, Kawashima K, Fukasawa T. Simpler and safer anastomosis by pancreaticogastrostomy using a linear stapler after pancreaticoduodenectomy. Medicine (Baltimore) 2024; 103:e40456. [PMID: 39533592 PMCID: PMC11557076 DOI: 10.1097/md.0000000000040456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2024] [Accepted: 10/22/2024] [Indexed: 11/16/2024] Open
Abstract
Postoperative pancreatic fistula (POPF) remains a major and serious problem after pancreaticoduodenectomy (PD). In its presence, pancreatic juice may leak from the main duct or branches of the pancreatic stump. To prevent this, we have applied a newly modified anastomosis of pancreaticogastrostomy (PG) using a linear stapler (stapled PG). Clinical records of 30 consecutive patients who underwent PD were reviewed between 2013 and 2023 at our community hospital. Regarding procedures, 12 stapled PGs and eighteen pancreaticojejunostomies (PJs) were performed after PD, from 2018 to 2023 and from 2013 to 2017, respectively. The pancreas was transected for long compression by a linear stapler, involving: pre-compression for 5 min, stapling for 5 min, and dissection for 5 min. After removal of the staples at the main duct opening of the pancreatic stump, PG anastomosis was performed. The outer layer was anastomosed by a straight single row pancreas-transfixing suture with the posterior gastric wall, and inner layer duct-to-mucosa anastomosis was also performed in a radial axis manner. Anastomosis of PJ was conducted without using a linear stapler. POPF was defined as a clinical manifestation of POPF (grade B/C) based on the ISGPF (International Study Group of Pancreatic Fistula) criteria. None of the 12 patients who had undergone stapled PG developed clinically relevant POPF, whereas 5 (27%) patients who had received PJ developed POPF. Three patients showed POPF grade B and 2 patients exhibited POPF grade C. Stapled PG after PD may reduce clinically relevant POPF. Because our sample size was small, the further accumulation of cases is required to validate this method.
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Affiliation(s)
- Hirotaka Okamoto
- Department of Surgery, Tsuru Municipal Hospital, Tsuru City, Yamanashi, Japan
| | - Atsushi Yamamoto
- Department of Surgery, Tsuru Municipal Hospital, Tsuru City, Yamanashi, Japan
| | - Kenji Kawashima
- Department of Surgery, Tsuru Municipal Hospital, Tsuru City, Yamanashi, Japan
| | - Toshio Fukasawa
- Department of Surgery, Tsuru Municipal Hospital, Tsuru City, Yamanashi, Japan
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Funakoshi S, Suzuki Y, Yoshida M, Momose H, Matsuki R, Kogure M, Abe N, Sunami E, Sakamoto Y. Advantage of Postoperative Inflammatory Status after Laparoscopic Distal Pancreatectomy. Dig Surg 2024; 41:213-223. [PMID: 39380462 DOI: 10.1159/000541449] [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: 11/18/2023] [Accepted: 09/07/2024] [Indexed: 10/10/2024]
Abstract
INTRODUCTION Laparoscopic distal pancreatectomy (LDP) is a safe and effective procedure; however, its impact on perioperative inflammatory reactions compared with open distal pancreatectomy (ODP) remains unclear. This study aimed to assess short-term outcomes following LDP and ODP regarding inflammatory reactions. METHODS This retrospective study of 77 consecutive patients who underwent distal pancreatectomy for low-grade malignancies between 2005 and 2022 compared white blood cell (WBC) count, C-reactive protein (CRP) level, serum albumin level, and CRP/albumin ratio (CAR) between LDP and ODP. Complications, especially postoperative pancreatic fistula (POPF), recovery program, and hospital stay period, were also compared. RESULTS POPF (17.1% vs. 38.7%, p = 0.039) and surgical morbidity (≥Clavien-Dindo grade III, 12.2% vs. 32.3%, p = 0.038) were significantly lower in LDP than in ODP, as for the difference in postoperative inflammatory response, including CRP and CAR, was just temporary. By multivariate analysis, CAR ≥6.94 on POD 3 was significant predictor of POPF (42.1% vs. 13.2%, odds ratio 4.828, p = 0.030). CONCLUSION LDP has lower POPF and earlier postoperative recovery. CAR could be a predictor of POPF.
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Affiliation(s)
- Saori Funakoshi
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Tokyo, Japan
- Department of General and Gastroenterological Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Yutaka Suzuki
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Tokyo, Japan
- Department of General and Gastroenterological Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Masao Yoshida
- Department of Public Health, Kyorin University School of Medicine, Tokyo, Japan
| | - Hirokazu Momose
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Tokyo, Japan
- Department of General and Gastroenterological Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Ryota Matsuki
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Tokyo, Japan
- Department of General and Gastroenterological Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Masaharu Kogure
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Tokyo, Japan
- Department of General and Gastroenterological Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Nobutsugu Abe
- Department of General and Gastroenterological Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Eiji Sunami
- Department of General and Gastroenterological Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | - Yoshihiro Sakamoto
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Tokyo, Japan
- Department of General and Gastroenterological Surgery, Kyorin University School of Medicine, Tokyo, 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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Quero G, Laterza V, Schena CA, Massimiani G, Lucinato C, Fiorillo C, Mezza T, Taglioni F, Menghi R, Di Cesare L, Biffoni B, De Sio D, Rosa F, Tondolo V, Alfieri S. Prolonged pre-firing pancreatic compression with linear staplers in distal pancreatectomy: a valuable technique for post-operative pancreatic fistula prevention. Langenbecks Arch Surg 2024; 409:184. [PMID: 38862717 PMCID: PMC11166744 DOI: 10.1007/s00423-024-03350-8] [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: 02/24/2024] [Accepted: 05/12/2024] [Indexed: 06/13/2024]
Abstract
PURPOSE Post-operative pancreatic fistula (POPF) remains the main complication after distal pancreatectomy (DP). The aim of this study is to evaluate the potential benefit of different durations of progressive stapler closure on POPF rate and severity after DP. METHODS Patients who underwent DP between 2016 and 2023 were retrospectively enrolled and divided into two groups according to the duration of the stapler closure: those who underwent a progressive compression for < 10 min and those for ≥ 10 min. RESULTS Among 155 DPs, 83 (53.5%) patients underwent pre-firing compression for < 10 min and 72 (46.5%) for ≥ 10 min. As a whole, 101 (65.1%) developed POPF. A lower incidence rate was found in case of ≥ 10 min compression (34-47.2%) compared to < 10 min compression (67- 80.7%) (p = 0.001). When only clinically relevant (CR) POPFs were considered, a prolonged pre-firing compression led to a lower rate (15-20.8%) than the < 10 min cohort (32-38.6%; p = 0.02). At the multivariate analysis, a compression time of at least 10 min was confirmed as a protective factor for both POPF (OR: 5.47, 95% CI: 2.16-13.87; p = 0.04) and CR-POPF (OR: 2.5, 95% CI: 1.19-5.45; p = 0.04) development. In case of a thick pancreatic gland, a prolonged pancreatic compression for at least 10 min was significantly associated to a lower rate of CR-POPF compared to < 10 min (p = 0.04). CONCLUSION A prolonged pre-firing pancreatic compression for at least 10 min seems to significantly reduce the risk of CR-POPF development. Moreover, significant advantages are documented in case of a thick pancreatic gland.
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Affiliation(s)
- Giuseppe Quero
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
- Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, Rome, 00168, Italy
| | - Vito Laterza
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Carlo Alberto Schena
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Giuseppe Massimiani
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Chiara Lucinato
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Claudio Fiorillo
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Teresa Mezza
- Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, Rome, 00168, Italy
- Pancreas Unit, Medicina Interna e Gastroenterologia, CEMAD Centro Malattie dell'Apparato Digerente, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Flavia Taglioni
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Roberta Menghi
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy.
- Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, Rome, 00168, Italy.
- Pancreatic Surgery Unit, Department of Surgery, Fondazione Policlinico Universitario "Agostino Gemelli", IRCCS, Largo Agostino Gemelli, 8, Rome, 00168, Italy.
| | - Ludovica Di Cesare
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Beatrice Biffoni
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Davide De Sio
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
| | - Fausto Rosa
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
- Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, Rome, 00168, Italy
| | - Vincenzo Tondolo
- General Surgery Unit, Fatebenefratelli Isola Tiberina - Gemelli Isola, Via di Ponte Quattro Capi, 39, Rome, 00186, Italy
| | - Sergio Alfieri
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center), Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli 8, Rome, 00168, Italy
- Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, Rome, 00168, Italy
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Kjeseth T, Yaqub S, Edwin B, Kleive D, Sahakyan MA. Peri-firing compression in prevention of pancreatic fistula after distal pancreatectomy: A systematic review and a cohort study. Scand J Surg 2024; 113:73-79. [PMID: 37982224 DOI: 10.1177/14574969231211084] [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] [Indexed: 11/21/2023]
Abstract
BACKGROUND/AIMS Clinically relevant postoperative pancreatic fistula (CR-POPF) after distal pancreatectomy (DP) occurs in 20%-40% of patients and remains a leading cause of morbidity and increased healthcare cost in this patient group. Recently, several studies suggested decreased risk of CR-POPF with the use of peri-firing compression (PFC) technique. The aim of this report was to conduct a systematic review to get an overview of the current knowledge on the use of PFC in DP. In addition, our experience with PFC was presented. METHODS The systematic literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Also, 19 patients undergoing DP with the use of PFC at Oslo University Hospital were studied. The primary endpoint was incidence of CR-POPF. RESULTS Seven articles reporting a total of 771 patients were ultimately included in the systematic review. Only two of these were case-control studies examining outcomes in patients with and without PFC, while the rest were case series. These were heterogeneous in terms of staplers used, cartridge selection policy, and PFC technique. Both case-control studies reported significantly reduced CR- POPF incidence with PFC. Eight (21%) of our patients developed CR-POPF after DP with PFC. Only one patient developed CR-POPF among those with pancreatic transection site thickness ⩽1.5 cm. CONCLUSION Evidence on potential benefits of PFC in DP is limited in quantity and quality. Our findings suggest that the use of PFC does not lead to reduction in the incidence of CR-POPF. Yet, there might be a benefit from PFC when dealing with a thin pancreas.
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Affiliation(s)
- Trond Kjeseth
- Department of Hepato-Pancreato-Biliary Surgery Oslo University Hospital Rikshospitalet Sognsvannsveien 20 0372 Oslo Norway
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Sheraz Yaqub
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Bjørn Edwin
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- The Intervention Centre, Oslo University Hospital-Rikshospitalet, Oslo, Norway
- Department of Research & Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Dyre Kleive
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Mushegh A Sahakyan
- The Intervention Centre, Oslo University Hospital-Rikshospitalet, Oslo, Norway
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
- Department of Surgery N1, Yerevan State Medical University after M. Heratsi, Yerevan, Armenia
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Hirashita T, Fujinaga A, Nagasawa Y, Orimoto H, Amano S, Kawamura M, Kawasaki T, Kawano Y, Masuda T, Endo Y, Inomata M. Efficacy of pancreaticojejunostomy of the pancreatic stump during distal or central pancreatectomy. Langenbecks Arch Surg 2024; 409:145. [PMID: 38687358 DOI: 10.1007/s00423-024-03335-7] [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: 02/29/2024] [Accepted: 04/23/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND A stapler is usually used for transection and closure of the pancreas in distal pancreatectomy (DP) or central pancreatectomy (CP). When the pancreas is transected to the right of the portal vein, it is difficult to use a stapler and clinically relevant postoperative pancreatic fistula (CR-POPF) frequently occurs. We report on the efficacy of pancreaticojejunostomy (PJ) of the pancreatic stump for patients in whom stapler use is difficult. METHODS Patients who underwent DP or CP were enrolled in this study. The pancreas was usually transected by a stapler, and ultrasonic coagulating shears (UCS) were used depending on the tumor situation. When using UCS, hand-sewn closure or PJ was performed for the pancreatic stump. The relationship between clinicopathological factors and the methods of pancreatic transection and closure were investigated. RESULTS In total, 164 patients underwent DP or CP, and the pancreas was transected with a stapler in 150 patients and UCS in 14 patients. The rate of CR-POPF was higher and the postoperative hospital stay was longer in the UCS group than in the stapler group. PJ of the pancreatic stump, which was performed for 7 patients, did not worsen intraoperative factors. CR-POPF was not seen in these 7 patients, which was significantly less than that with hand-sewn closure. CONCLUSIONS PJ of the pancreatic stump during DP or CP reduces CR-POPF compared with hand-sewn closure and may be useful especially when the pancreas is transected to the right of the portal vein.
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Affiliation(s)
- Teijiro Hirashita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan.
| | - Atsuro Fujinaga
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Yuiko Nagasawa
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Hiroki Orimoto
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Shota Amano
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Masahiro Kawamura
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Takahide Kawasaki
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Yoko Kawano
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Takashi Masuda
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Yuichi Endo
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Masafumi Inomata
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Oita, Japan
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Borys M, Wysocki M, Gałązka K, Stanek M, Budzyński A. Laparoscopic radical antegrade modular pancreatosplenectomy (RAMPS) for adenocarcinoma of the body and tail of the pancreas - technical considerations with analysis of surgical outcomes. Langenbecks Arch Surg 2024; 409:74. [PMID: 38400929 DOI: 10.1007/s00423-024-03265-4] [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: 07/03/2023] [Accepted: 02/17/2024] [Indexed: 02/26/2024]
Abstract
PURPOSE The aim of this study was to establish whether laparoscopic RAMPS (L-RAMPS) is a safe procedure with better oncological outcomes compared to laparoscopic distal pancreatectomy (LDP) with splenectomy among patients with distal pancreatic ductal adenocarcinoma (PDAC). METHODS This is a retrospective study performed on consecutive patients who underwent L-RAMPS and LDP with splenectomy for resectable or borderline resectable PDAC of the body and tail. In this paper, we presented our technique of laparoscopic RAMPS and analyzed intraoperative and perioperative complications, oncological efficacy, and long-term survival. RESULTS The study included 12 patients in the L-RAMPS group and 13 patients in the LDP with splenectomy. L-RAMPS was associated with significantly higher rates of R0 resection (91.7% vs. 69.2%, p = 0.027). There were no differences between the L-RAMPS and LDP with splenectomy groups in intraoperative blood loss (400 mL vs 400 mL, p = 0.783) and median operative time (250 min vs 220 min, p = 0.785). No differences were found in terms of perioperative complications, including the incidence of pancreatic fistula. CONCLUSION Laparoscopic RAMPS is a feasible and safe procedure. It provides higher radicality as compared with LDP with splenectomy, without increasing the risk of complications. Further studies are necessary to evaluate long-term outcomes.
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Affiliation(s)
- Maciej Borys
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital, Osiedle Zlotej Jesieni 1, 31-826, Cracow, Poland
| | - Michał Wysocki
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital, Osiedle Zlotej Jesieni 1, 31-826, Cracow, Poland.
| | - Krystyna Gałązka
- Department of Pathomorphology, Jagiellonian University Medical College, Cracow, Poland
| | - Maciej Stanek
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital, Osiedle Zlotej Jesieni 1, 31-826, Cracow, Poland
| | - Andrzej Budzyński
- Department of General Surgery and Surgical Oncology, Ludwik Rydygier Memorial Hospital, Osiedle Zlotej Jesieni 1, 31-826, Cracow, Poland
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10
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Sermet M. Compression pre-stapler firing and post-ignition wait during sleeve gastrectomy: a prospective randomized trial. SAO PAULO MED J 2023; 142:e2023163. [PMID: 38126605 PMCID: PMC10727512 DOI: 10.1590/1516-3180.2023.0163.140823] [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: 05/25/2023] [Revised: 06/17/2023] [Accepted: 08/14/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Insufficient research exists on the stapling technique in and duration of laparoscopic sleeve gastrectomy (LSG). OBJECTIVES This study aimed to assess the clinical outcomes using a 30-second precompression and post-firing waiting time without extra support for the stapling line. DESIGN AND SETTINGS Randomized controlled prospective study at a university hospital. METHODS This study included 120 patients treated between January 2022 and February 2023. The patients were divided into the non-waiting group (T0) and waiting group (T1), each with 60 patients. Perioperative complications were analyzed using statistical tests. RESULTS The waiting group (T1) showed a significant reduction in the number of intraoperative bleeding points requiring intervention compared with the non-waiting group (T0) (81 versus 134, P < 0.05). In T0, postoperative C-reactive protein (CRP) levels increased (P < 0.05) and hemoglobin levels decreased significantly (P <0.05). The study recorded 22 postoperative complications, accounting for 18.3% of all cases during the 30-day postoperative period. CONCLUSIONS The study concluded that the 30 sec + 30 sec stapling technique reduces perioperative bleeding, length of stay, and serious complication rates and is practical and effective for LSG. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov with registration code NCT05703035; link: https://clinicaltrials.gov/ct2/show/NCT05703035.
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Affiliation(s)
- Medeni Sermet
- MD, PhD. Department of General Surgery, Goztepe Prof. Dr.
Suleyman Yalcin City Hospital, Medeniyet University, Istanbul, Turkey
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11
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Nakata K, Abe T, Ideno N, Nakamura S, Ikenaga N, Nagayoshi K, Mizuuchi Y, Moriyama T, Ohuchida K, Nakamura M. Minimally invasive distal pancreatectomy for pancreatic cancer: cranial-to-caudal approach with identification of Gerota's fascia (with video). Surg Endosc 2023; 37:8901-8909. [PMID: 37845535 DOI: 10.1007/s00464-023-10438-7] [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: 05/09/2023] [Accepted: 08/31/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Although radical antegrade modular pancreatosplenectomy for pancreatic ductal adenocarcinoma (PDAC) has become the gold standard procedure in open distal pancreatectomy, there has been no gold standardized procedure for PDAC in minimally invasive distal pancreatectomy (MIDP). In this study, we analyzed our novel cranial-to-caudal approach (CC approach) for patients undergoing MIDP and provide a video clip illustrating the details of the CC approach. METHODS Ninety-four patients who underwent MIDP with splenectomy between 2016 and 2021 were included in this study. The CC approach was performed in 23 (24.5%) of the 94 patients. The concept of the CC approach is easy identification of Gerota's fascia from the cranial side of the pancreas and secure tumor removal (R0 resection) wrapped by Gerota's fascia. The short- and long-term outcomes were compared between the CC and non-CC approaches. RESULTS The median operation time and blood loss were similar between the two groups. The ratios of grade ≥ B postoperative pancreatic fistula and Clavien-Dindo grade ≥ III complications were also comparable. All patients in the CC approach group achieved R0 resection, and the R0 ratio was similar in the two groups (p = 0.345). The 2-year survival rate in CC and non-CC approach groups was 87.5% and 83.6%, respectively (p = 0.903). CONCLUSIONS The details of the CC approach for MIDP were demonstrated based on an anatomical point of view. This approach has the potential to become a standardized approach for left-sided PDAC.
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Affiliation(s)
- Kohei Nakata
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Toshiya Abe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Noboru Ideno
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - So Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Naoki Ikenaga
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kinuko Nagayoshi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yusuke Mizuuchi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Taiki Moriyama
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kenoki Ohuchida
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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12
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Yamasaki Y, Kurahara H, Oi H, Hozaka Y, Idichi T, Kawasaki Y, Mataki Y, Ohtsuka T. Metal-free laparoscopic distal pancreatectomy using transpancreatic mattress suture with polyglycolic acid sheet and fibrin glue: A case report. Asian J Endosc Surg 2023; 16:770-773. [PMID: 37483158 DOI: 10.1111/ases.13229] [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: 06/05/2023] [Accepted: 06/27/2023] [Indexed: 07/25/2023]
Abstract
Laparoscopic distal pancreatectomy (LDP) is the standard surgery for malignant and premalignant tumors of the pancreatic body and tail. A stapler is commonly used to close the pancreatic stump due to its simplicity; however, the use of a stapler is associated with the risk of metal allergy and postoperative pancreatic fistula, especially in thick pancreases. Here, we present a case of LDP without metal instruments, including staplers and clips, in a 54-year-old woman with a metal allergy and a thick pancreas. The pancreatic stump was closed using the transpancreatic mattress suture method with a polyglycolic acid sheet (PGA) and fibrin glue. The postoperative course was uneventful. Metal-free LDP is useful and can be adopted regardless of the patient's background, such as a metal allergy or pancreatic thickness.
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Affiliation(s)
- Yoichi Yamasaki
- Department of Digestive Surgery, and Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Hiroshi Kurahara
- Department of Digestive Surgery, and Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Hideyuki Oi
- Department of Digestive Surgery, and Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Yuto Hozaka
- Department of Digestive Surgery, and Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Tetsuya Idichi
- Department of Digestive Surgery, and Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Yota Kawasaki
- Department of Digestive Surgery, and Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Yuko Mataki
- Department of Digestive Surgery, and Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Takao Ohtsuka
- Department of Digestive Surgery, and Breast and Thyroid Surgery, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
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13
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Ishida J, Toyama H, Asari S, Goto T, Nanno Y, Mizumoto T, Tsugawa D, Komatsu S, Kuramitsu K, Yanagimoto H, Kido M, Fukumoto T. Use of a short cartridge stapler is beneficial in pancreatic transection at the neck during laparoscopic distal pancreatectomy. Surg Today 2023; 53:153-157. [PMID: 35879473 DOI: 10.1007/s00595-022-02540-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 06/01/2022] [Indexed: 01/11/2023]
Abstract
Stapling is the standard method for pancreatic transection during laparoscopic distal pancreatectomy. Although most surgeons use a 60 mm cartridge stapler, space limitations created by laparoscopic surgery make the instrument difficult to handle, especially during pancreatic transection at the neck. Therefore, we currently use a 45 mm cartridge stapler for laparoscopic pancreatic transection at the neck. Between October 2019 and December 2020, we performed pancreatic transection using a 45 mm cartridge stapler in 27 patients. Fifteen patients experienced biochemical leakage, but no patients developed clinically relevant pancreatic fistula. The compactness of the 45 mm cartridge has several benefits: (1) less space is required for flexing, opening, and closing the device; (2) it enables easy insertion of the lower jaw behind the pancreas, even if the dissected space behind the pancreas is narrow; (3) less obstruction of the surgeons' view prevents accidental injury to the surrounding tissues and vessels. These benefits may enable safe pancreatic transection.
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Affiliation(s)
- Jun Ishida
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Hirochika Toyama
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
| | - Sadaki Asari
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Tadahiro Goto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Yoshihide Nanno
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Takuya Mizumoto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Daisuke Tsugawa
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Shohei Komatsu
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Kaori Kuramitsu
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Hiroaki Yanagimoto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Masahiro Kido
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Takumi Fukumoto
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
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14
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Jia B, Chen Q, Jiang P, Liu Y. An analysis of the effectiveness of stapler closure combined with a titanium clip in distal pancreatectomy. Surg Today 2022; 52:1430-1437. [PMID: 35138460 DOI: 10.1007/s00595-022-02470-2] [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: 10/25/2021] [Accepted: 01/09/2022] [Indexed: 10/19/2022]
Abstract
PURPOSES Postoperative pancreatic fistula is the most common and severe postoperative complication of distal pancreatectomy. Treatment of pancreatic stump to reduce the incidence of postoperative pancreatic fistula is crucial. This study evaluated the effectiveness of stapler closure combined with a titanium clip in distal pancreatectomy. METHODS Prospectively collected data of consecutive patients who underwent distal pancreatectomy from April 2013 to May 2020 with pancreatic transection performed by the bare stapler method (131 patients), stapler + hand-sewn closure method (199 patients), and stapler + titanium clip method (209 patients) were reviewed retrospectively and compared between groups. RESULTS No statistically significant differences were observed in basic data among the three groups. There were also no significant differences among the three groups in terms of the intraoperative data or tumor pathological types, except for the number of laparoscopic treatment cases (23, 53, and 80 for bare stapler method, stapler + hand-sewn closure method, and stapler + titanium clip method, respectively; P < 0.05) and pancreatic neuroendocrine tumor cases (15, 29, and 12, respectively; P < 0.05). There were no significant differences in postoperative complications or parameters, except for the number of clinical pancreatic fistula cases (31, 27, and 13 for bare stapler method, stapler + hand-sewn closure method, and stapler + titanium clip method, respectively; P < 0.05) and postoperative length of hospital stay (11.6 ± 8.3, 10.6 ± 9.7, and 9.3 ± 6.9 days, respectively; P < 0.05). The stapler + titanium clip group had a significantly lower number of clinical pancreatic fistula cases and shorter postoperative length of hospital stay than the other groups. The univariate analysis showed that pancreatic resection line thickness was an independent risk factor for clinical pancreatic fistula after operation. CONCLUSION Stapler closure combined with titanium clips to reinforce the pancreatic stump is simple and easy to implement, effectively reduces the incidence of clinical pancreatic fistula, and shortens the postoperative length of hospital stay.
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Affiliation(s)
- Baoxing Jia
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Qingmin Chen
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Peiqiang Jiang
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Yahui Liu
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130021, Jilin, China.
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15
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Vissers FL, Balduzzi A, van Bodegraven EA, van Hilst J, Festen S, Hilal MA, Asbun HJ, Mieog JSD, Koerkamp BG, Busch OR, Daams F, Luyer M, De Pastena M, Malleo G, Marchegiani G, Klaase J, Molenaar IQ, Salvia R, van Santvoort HC, Stommel M, Lips D, Coolsen M, Bassi C, van Eijck C, Besselink MG. Prophylactic abdominal drainage or no drainage after distal pancreatectomy (PANDORINA): a binational multicenter randomized controlled trial. Trials 2022; 23:809. [PMID: 36153559 PMCID: PMC9509576 DOI: 10.1186/s13063-022-06736-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 09/13/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Prophylactic abdominal drainage is current standard practice after distal pancreatectomy (DP), with the aim to divert pancreatic fluid in case of a postoperative pancreatic fistula (POPF) aimed to prevent further complications as bleeding. Whereas POPF after pancreatoduodenectomy, by definition, involves infection due to anastomotic dehiscence, a POPF after DP is essentially sterile since the bowel is not opened and no anastomoses are created. Routine drainage after DP could potentially be omitted and this could even be beneficial because of the hypothetical prevention of drain-induced infections (Fisher, Surgery 52:205-22, 2018). Abdominal drainage, moreover, should only be performed if it provides additional safety or comfort to the patient. In clinical practice, drains cause clear discomfort. One multicenter randomized controlled trial confirmed the safety of omitting abdominal drainage but did not stratify patients according to their risk of POPF and did not describe a standardized strategy for pancreatic transection. Therefore, a large pragmatic multicenter randomized controlled trial is required, with prespecified POPF risk groups and a homogeneous method of stump closure. The objective of the PANDORINA trial is to evaluate the non-inferiority of omitting routine intra-abdominal drainage after DP on postoperative morbidity (Clavien-Dindo score ≥ 3), and, secondarily, POPF grade B/C. METHODS/DESIGN Binational multicenter randomized controlled non-inferiority trial, stratifying patients to high and low risk for POPF grade B/C and incorporating a standardized strategy for pancreatic transection. Two groups of 141 patients (282 in total) undergoing elective DP (either open or minimally invasive, with or without splenectomy). Primary outcome is postoperative rate of morbidity (Clavien-Dindo score ≥ 3), and the most relevant secondary outcome is grade B/C POPF. Other secondary outcomes include surgical reintervention, percutaneous catheter drainage, endoscopic catheter drainage, abdominal collections (not requiring drainage), wound infection, delayed gastric emptying, postpancreatectomy hemorrhage as defined by the international study group for pancreatic surgery (ISGPS) (Wente et al., Surgery 142:20-5, 2007), length of stay (LOS), readmission within 90 days, in-hospital mortality, and 90-day mortality. DISCUSSION PANDORINA is the first binational, multicenter, randomized controlled non-inferiority trial with the primary objective to evaluate the hypothesis that omitting prophylactic abdominal drainage after DP does not worsen the risk of postoperative severe complications (Wente etal., Surgery 142:20-5, 2007; Bassi et al., Surgery 161:584-91, 2017). Most of the published studies on drain placement after pancreatectomy focus on both pancreatoduodenectomy and DP, but these two entities present are associated with different complications and therefore deserve separate evaluation (McMillan et al., Surgery 159:1013-22, 2016; Pratt et al., J Gastrointest Surg 10:1264-78, 2006). The PANDORINA trial is innovative since it takes the preoperative risk on POPF into account based on the D-FRS and it warrants homogenous stump closing by using the same graded compression technique and same stapling device (de Pastena et al., Ann Surg 2022; Asbun and Stauffer, Surg Endosc 25:2643-9, 2011).
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Affiliation(s)
- F. L. Vissers
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - A. Balduzzi
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - E. A. van Bodegraven
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - J. van Hilst
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, OLVG, Amsterdam, the Netherlands
| | - S. Festen
- Department of Surgery, OLVG, Amsterdam, the Netherlands
| | - M. Abu Hilal
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Department of Surgery, Poliambulanza Hospital Brescia, Brescia, Italy
| | - H. J. Asbun
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, USA
| | | | | | - O. R. Busch
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - F. Daams
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - M. Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - M. De Pastena
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - G. Malleo
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - G. Marchegiani
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - J. Klaase
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - I. Q. Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht, the Netherlands
| | - R. Salvia
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - H. C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, Utrecht, the Netherlands
| | - M. Stommel
- Department of Surgery, Radboud UMC, Nijmegen, the Netherlands
| | - D. Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - M. Coolsen
- Department of Surgery, Maastricht Universitair Medisch Centrum, Maastricht, the Netherlands
| | - C. Bassi
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
| | - C. van Eijck
- Department of Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - M. G. Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - for the Dutch Pancreatic Cancer Group
- Department of Surgery, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Pancreas Institute, Verona University Hospital, Verona, Italy
- Department of Surgery, OLVG, Amsterdam, the Netherlands
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Department of Surgery, Poliambulanza Hospital Brescia, Brescia, Italy
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, USA
- Department of Surgery, LUMC, Leiden, the Netherlands
- Department of Surgery, Erasmus MC, Rotterdam, the Netherlands
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Surgery, Regional Academic Cancer Center Utrecht, St Antonius Hospital Nieuwegein, Utrecht, the Netherlands
- Department of Surgery, Radboud UMC, Nijmegen, the Netherlands
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
- Department of Surgery, Maastricht Universitair Medisch Centrum, Maastricht, the Netherlands
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16
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Ciprani D, Bannone E, Marchegiani G, Nessi C, Salvia R, Bassi C. Progression from biochemical leak to pancreatic fistula after distal pancreatectomy. Don't cry over spilt amylase. Pancreatology 2022; 22:817-822. [PMID: 35773177 DOI: 10.1016/j.pan.2022.06.257] [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: 03/22/2022] [Revised: 05/22/2022] [Accepted: 06/19/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is a frequent complication after distal pancreatectomy (DP), but its upgrading from biochemical leak (BL) still represents an unexplored phenomenon. This study aims at identifying risk factors of the clinical evolution from BL to grade-B POPF after DP. METHODS Patients who underwent DP between 2015 and 2019 and who developed either BL (n = 89,56%) or BL upgraded to late B fistula (LB) after postoperative day 5 (n = 71,44%) were included. Preoperative, surgical, postoperative predictors were compared between the two groups. RESULTS Patients with LB were significantly older (61 vs 56 years, P < 0.025) and received neoadjuvant chemotherapy more frequently (22.5% vs 8.5%,P = 0.017). Extended lymphadenectomy (52.8% vs 31.0%,P = 0.006), longer operative times (OT) (307 vs 250 min,P = 0.002), greater estimated blood loss (250 vs 150 ml, P = 0.021), and the appearance of purulent fluid in surgical drains (58.4% vs 21.1%; P < 0.001) were more frequently observed in LB group. Only purulent fluid in surgical drains and longer OT were confirmed as independent predictors of BL clinical progression. CONCLUSIONS Purulent fluid from surgical drains should be suspicious of BL upgrading. Frail patients undergoing longer interventions may represent key targets of mitigation strategies to minimize the magnitude of an incipient fistula and its increase in morbidity.
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Affiliation(s)
- D Ciprani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
| | - E Bannone
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - G Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - C Nessi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - R Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - C Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
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17
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Imamura H, Takahashi H, Akita H, Wada H, Mukai Y, Asukai K, Hasegawa S, Fujii Y, Sugase T, Yamamoto M, Takeoka T, Shinno N, Hara H, Kanemura T, Haraguchi N, Nishimura J, Matsuda C, Yasui M, Omori T, Miyata H, Ohue M, Sakon M. The clinical impact of modified transpancreatic mattress sutures with polyglactin 910 woven mesh on postoperative pancreatic fistula in distal pancreatectomy. Surgery 2022; 172:1220-1227. [PMID: 35773024 DOI: 10.1016/j.surg.2022.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 05/08/2022] [Accepted: 05/16/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND We previously reported the stump closure method for the remnant pancreas in distal pancreatectomy, in which soft coagulation and polyglycolic acid felt attached with fibrin glue were utilized. Transpancreatic mattress suture with polyglactin 910 woven mesh was recently reported as a novel stump closure technique. We developed the modified transpancreatic mattress suture with polyglactin 910 woven mesh method, which combined our polyglycolic acid felt method with the transpancreatic mattress suture with polyglactin 910 woven mesh method. METHODS The polyglycolic acid felt group included patients undergoing distal pancreatectomy in whom the pancreatic stump was closed with the polyglycolic acid felt method from 2017 to 2018 (n = 54); whereas the modified transpancreatic mattress suture with polyglactin 910 woven mesh group included those whose stump was closed with the modified transpancreatic mattress suture with polyglactin 910 woven mesh method from 2019 to 2020 (n = 51). Perioperative parameters, including grade B/C postoperative pancreatic fistula (clinically relevant postoperative pancreatic fistula), were assessed according to the stump closure method. RESULTS The incidence of clinically relevant postoperative pancreatic fistula was significantly lower in the modified transpancreatic mattress suture with polyglactin 910 woven mesh group than in the polyglycolic acid felt group (7.8% vs 22.2%, P = .036). In multivariate analysis, the use of neoadjuvant chemoradiotherapy and the transpancreatic mattress suture with polyglactin 910 woven mesh method were independent factors for preventing clinically relevant postoperative pancreatic fistula (P = .011 and 0.0038, respectively). Moreover, in the modified transpancreatic mattress suture with polyglactin 910 woven mesh group, the incidence of clinically relevant postoperative pancreatic fistula in patients with a thick pancreas (≥13 mm, 6.7%) was comparably as low as that in patients with a thin pancreas (<13 mm, 9.5%). CONCLUSION The modified transpancreatic mattress suture with polyglactin 910 woven mesh method is an effective stump closure technique to prevent clinically relevant postoperative pancreatic fistula after distal pancreatectomy. Our results warrant further prospective investigation to evaluate the efficacy of the modified transpancreatic mattress suture with polyglactin 910 woven mesh method compared with other standard closure methods (eg, stapler closure or hand-sewn closure).
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Affiliation(s)
- Hiroki Imamura
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Hidenori Takahashi
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan.
| | - Hirofumi Akita
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Hiroshi Wada
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Yosuke Mukai
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Kei Asukai
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Shinichiro Hasegawa
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Yoshiaki Fujii
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Takahito Sugase
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Masaaki Yamamoto
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Tomohira Takeoka
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Naoki Shinno
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Hisashi Hara
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Takashi Kanemura
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Naotsugu Haraguchi
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Junichi Nishimura
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Chu Matsuda
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Masayoshi Yasui
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Takeshi Omori
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Hiroshi Miyata
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Masayuki Ohue
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
| | - Masato Sakon
- Department of Surgery, Osaka International Cancer Institute, Chuo-ku, Osaka, Japan
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18
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Watanabe Y, Nakata K, Mori Y, Ideno N, Ikenaga N, Ohtsuka T, Nakamura M. Extensive (subtotal) distal pancreatectomy for pancreatic ductal adenocarcinoma: a propensity score matched cohort study of short- and long-term outcomes compared with those of conventional distal pancreatectomy. Langenbecks Arch Surg 2022; 407:1479-1488. [PMID: 35146547 DOI: 10.1007/s00423-022-02453-4] [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: 07/05/2021] [Accepted: 01/19/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE Extensive distal pancreatectomy (ExDP) can transect the pancreatic parenchyma more from the right side than conventional distal pancreatectomy (CDP) can. This study aimed to evaluate the short- and long-term outcomes of ExDP for pancreatic ductal adenocarcinoma (PDAC) of the pancreatic body, located adjacent to the portal vein (PV). METHODS Medical records of 98 patients who underwent ExDP (n = 15) or CDP (n = 83) for PDAC were retrospectively reviewed. Short- and long-term outcomes of the two groups were compared. Propensity score matched analysis was additionally performed to minimize the impact of treatment allocation bias. RESULTS In the total cohort, the CDP group had a significantly higher proportion of pancreatic tail lesions (P < 0.01), higher proportion of males, and larger tumor size. Of the 15 patients who underwent ExDP, 11 could be matched. These differences of patients' characteristics were not observed after matching. Before and after matching, the duration of surgery, blood loss, rate of morbidity including pancreatic fistula, and postoperative course were comparable between the groups. The rate of recurrence and recurrence pattern were also not significantly different between the groups. ExDP for PDAC of the pancreatic body near the PV did not increase local or lymph node recurrence. The disease-free and overall survival did not differ between the groups. CONCLUSIONS Surgical and oncological outcomes after ExDP for PDAC were acceptable and comparable to those after CDP. ExDP is a feasible procedure, and could be an option for the treatment of PDAC of the pancreatic body near PV.
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Affiliation(s)
- Yusuke Watanabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kohei Nakata
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yasuhisa Mori
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
- Department of Surgery 1, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan
| | - Noboru Ideno
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Naoki Ikenaga
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takao Ohtsuka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
- Department of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
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19
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Nishikimi K, Tate S, Matsuoka A, Otsuka S, Shozu M. Predictors of postoperative pancreatic fistula after splenectomy with or without distal pancreatectomy performed as a component of cytoreductive surgery for advanced ovarian cancer. J Gynecol Oncol 2022; 33:e30. [PMID: 35128860 PMCID: PMC9024180 DOI: 10.3802/jgo.2022.33.e30] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 10/12/2021] [Accepted: 01/02/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Kyoko Nishikimi
- Department of Gynecology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shinichi Tate
- Department of Gynecology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Ayumu Matsuoka
- Department of Gynecology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Satoyo Otsuka
- Department of Gynecology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Makio Shozu
- Department of Gynecology, Chiba University Graduate School of Medicine, Chiba, Japan
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20
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Cawich SO, Kluger MD, Francis W, Deshpande RR, Mohammed F, Bonadie KO, Thomas DA, Pearce NW, Schrope BA. Review of minimally invasive pancreas surgery and opinion on its incorporation into low volume and resource poor centres. World J Gastrointest Surg 2021; 13:1122-1135. [PMID: 34754382 PMCID: PMC8554718 DOI: 10.4240/wjgs.v13.i10.1122] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/19/2021] [Accepted: 09/23/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic surgery has been one of the last areas for the application of minimally invasive surgery (MIS) because there are many factors that make laparoscopic pancreas resections difficult. The concept of service centralization has also limited expertise to a small cadre of high-volume centres in resource rich countries. However, this is not the environment that many surgeons in developing countries work in. These patients often do not have the opportunity to travel to high volume centres for care. Therefore, we sought to review the existing data on MIS for the pancreas and to discuss. In this paper, we review the evolution of MIS on the pancreas and discuss the incorporation of this service into low-volume and resource-poor countries, such as those in the Caribbean. This paper has two parts. First, we performed a literature review evaluating all studies published on laparoscopic and robotic surgery of the pancreas. The data in the Caribbean is examined and we discuss tips for incorporating this operation into resource poor hospital practice. Low pancreatic case volume in the Caribbean, and financial barriers to MIS in general, laparoscopic distal pancreatectomy, enucleation and cystogastrostomy are feasible operations to integrate in to a resource-limited healthcare environment. This is because they can be performed with minimal to no consumables and require an intermediate MIS skillset to complement an open pancreatic surgeon’s peri-operative experience.
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Affiliation(s)
- Shamir O Cawich
- Clinical Surgical Sciences, University of the West Indies, Tunapuna 331333, Trinidad and Tobago
| | - Michael D Kluger
- Department of Surgery, New York Presbyterian Hospital/Columbia University Medical Center, New York, NY 10032, United States
| | - Wesley Francis
- Department of Surgery, University of the West Indies, Nassau N-1184, Bahamas
| | - Rahul R Deshpande
- Department of Surgery, Manchester Royal Infirmary, Manchester M13 9WL, United Kingdom
| | - Fawwaz Mohammed
- Department of Clinical Surgical Sciences, University of the West Indies, Tunapuna 331333, Trinidad and Tobago
| | - Kimon O Bonadie
- Department of Surgery, Health Service Authority, Georgetown 915 GT, Cayman Islands
| | - Dexter A Thomas
- Department of Clinical Surgical Sciences, University of the West Indies, Tunapuna 331333, Trinidad and Tobago
| | - Neil W Pearce
- Department of Surgery, Southampton General Hospital, Southampton SO16 6YD, United Kingdom
| | - Beth A Schrope
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY 10032, United States
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21
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Goh BKP, Lee CY, Koh YX, Teo JY, Kam JH, Cheow PC, Chung AYF, Chan CY, Lee SY. Use of Reinforced Staplers Decreases the Rate of Postoperative Pancreatic Fistula Compared to Bare Staplers After Minimally Invasive Distal Pancreatectomies. J Laparoendosc Adv Surg Tech A 2021; 31:1124-1129. [PMID: 33449857 DOI: 10.1089/lap.2020.0754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: Postoperative pancreatic fistula (POPF) is the most common and important cause of morbidity after distal pancreatectomy. Various transection and closure techniques of the pancreatic stump have been proposed with no robust evidence unanimously supporting one technique over the other. This study aims to compare the outcomes of minimally invasive distal pancreatectomy (MIDP) performed with reinforced stapler (RS) versus bare stapler (BS) with particular attention to the POPF. Methods: Retrospective review of 90 consecutive elective MIDP performed at a single institution between 2014 and 2019 was performed. The primary outcome was POPF as defined by the latest International Study Group of Pancreatic Fistula classification. MIDP with RS was adopted by two surgeons who subsequently performed all their consecutive surgeries with RS. Results: There were 25 and 65 patients who underwent MIDP with RS and BS, respectively. There were 8 (8.9%) open conversions and 17 (18.9%) patients experienced a POPF. Patients who underwent MIDP with RS had a significantly lower POPF rate (4% versus 24.6%, P = .025), lower major (>grade 2) morbidity rate (4% versus 21.5%, P = .046), and lower readmission rate (4% versus 27.7%, P = .014). On multivariate analysis, only the use of BS and obesity (body mass index ≥27.5) was independently associated with the development of a POPF. Conclusion: MIDP performed with RS was associated with a significantly lower rate of POPF, major morbidity, and readmissions compared to BS. The use of RS was protective against POPF.
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Affiliation(s)
- Brian K P Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Chuan-Yaw Lee
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Ye-Xin Koh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Jin-Yao Teo
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Juinn-Huar Kam
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Peng-Chung Cheow
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Alexander Y F Chung
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Chung-Yip Chan
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Ser-Yee Lee
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
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22
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Matsumoto I, Kamei K, Satoi S, Murase T, Matsumoto M, Kawaguchi K, Yoshida Y, Dongha L, Takebe A, Nakai T, Takeyama Y. Efficacy of the slow firing method using a reinforced triple-row stapler for preventing postoperative pancreatic fistula during laparoscopic distal pancreatectomy. Surg Today 2021; 52:260-267. [PMID: 34322726 DOI: 10.1007/s00595-021-02344-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/07/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Postoperative pancreatic fistula (POPF) remains the most clinically relevant complication of laparoscopic distal pancreatectomy (LDP). The present study evaluated the efficacy of the "slow firing method" using a reinforced triple-row stapler (Covidien, Tokyo, Japan) during LDP. METHODS This retrospective single-center study included 73 consecutive patients who underwent LDP using the slow firing method. A black cartridge was used in all patients. The primary endpoint was the rate of clinically relevant POPF (CR-POPF) after LDP. Secondary endpoints included perioperative outcomes and factors associated with CR-POPF as well as the correlation between the transection time and thickness of the pancreas. RESULTS Four patients (5.5%) developed CR-POPF (grade B). Overall morbidity rates, defined as grade ≥ II and ≥ III according to the Clavien-Dindo classification, were 21 and 11%, respectively. The median postoperative hospital stay was 10 days. Preoperative diabetes (13.6 vs. 0.2%, P = 0.044) and thickness of the pancreas ≥ 15 mm (13.8% vs. 0%, P = 0.006) were identified as independent risk factors for CR-POPF. The median transection time was 16 (8-29) min. CONCLUSION The slow firing method using a reinforced triple-row stapler for pancreatic transection is simple, safe, and effective for preventing CR-POPF after LDP.
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Affiliation(s)
- Ippei Matsumoto
- Department of Surgery, Kindai University Faculty of Medicine, 377-2 Ohno-higashi, Osakasayama, Osaka, 589-8511, Japan.
| | - Keiko Kamei
- Department of Surgery, Kindai University Faculty of Medicine, 377-2 Ohno-higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Shumpei Satoi
- Department of Surgery, Kindai University Faculty of Medicine, 377-2 Ohno-higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Takaaki Murase
- Department of Surgery, Kindai University Faculty of Medicine, 377-2 Ohno-higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Masataka Matsumoto
- Department of Surgery, Kindai University Faculty of Medicine, 377-2 Ohno-higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Kohei Kawaguchi
- Department of Surgery, Kindai University Faculty of Medicine, 377-2 Ohno-higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Yuta Yoshida
- Department of Surgery, Kindai University Faculty of Medicine, 377-2 Ohno-higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Lee Dongha
- Department of Surgery, Kindai University Faculty of Medicine, 377-2 Ohno-higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Atsushi Takebe
- Department of Surgery, Kindai University Faculty of Medicine, 377-2 Ohno-higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Takuya Nakai
- Department of Surgery, Kindai University Faculty of Medicine, 377-2 Ohno-higashi, Osakasayama, Osaka, 589-8511, Japan
| | - Yoshifumi Takeyama
- Department of Surgery, Kindai University Faculty of Medicine, 377-2 Ohno-higashi, Osakasayama, Osaka, 589-8511, Japan
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23
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Kang MK, Kim H, Byun Y, Han Y, Choi YJ, Kang JS, Kwon W, Han IW, Shin SH, Choi DW, You Y, Heo JS, Jang JY. Optimal stapler cartridge selection to reduce post-operative pancreatic fistula according to the pancreatic characteristics in stapler closure distal pancreatectomy. HPB (Oxford) 2021; 23:633-640. [PMID: 33012640 DOI: 10.1016/j.hpb.2020.09.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/05/2020] [Accepted: 09/07/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is associated with potentially fatal complications, but there is lack of data on relationship between pancreas thickness, and stapler size and the POPF rate. This study aimed to suggest optimal stapler that reduces POPF rate according to the pancreas thickness. METHODS This retrospective cohort study was conducted in two tertiary high-volume pancreas centers. 599 patients who underwent distal pancreatectomy were assessed for stump reinforcement methods, pathology findings, pancreas thickness, and cartridge used. The cartridges were grouped as I, II, III according to the closed height ≤1.5 mm, 1.8 mm, and ≥2.0 mm, respectively. RESULTS The POPF rate increased according to the thickness. The stapler Groups I, II, and III had an overall POPF rate of 66.4% vs. 61.7% vs. 57.8%, but Group II stapler cartridge showed a significant reduction in the POPF rate than other cartridges in pancreas with thickness <13 mm (53.5% vs. 21.7% vs. 36.0%, p = 0.031). There was no significant difference between the POPF rate according to stapler groups when the pancreas was thicker than 13 mm. CONCLUSION Thickness is the strongest risk factor in predicting POPF. Use of Group II stapler cartridge for pancreas with a thickness of <13 mm can help reduce POPF.
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Affiliation(s)
- Min Kyu Kang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hongbeom Kim
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yoonhyeong Byun
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Youngmin Han
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yoo Jin Choi
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jae Seung Kang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Wooil Kwon
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - In Woong Han
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sang Hyun Shin
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Wook Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yunghun You
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jin Seok Heo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Jin-Young Jang
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
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24
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Andrianello S, Bannone E, Marchegiani G, Malleo G, Paiella S, Esposito A, Salvia R, Bassi C. Characterization of postoperative acute pancreatitis (POAP) after distal pancreatectomy. Surgery 2021; 169:724-731. [PMID: 33268073 DOI: 10.1016/j.surg.2020.09.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/25/2020] [Accepted: 09/02/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Postoperative acute pancreatitis has recently been reported as a specific complication after pancreatoduodenectomy. The aim of this study was to characterize postoperative acute pancreatitis after distal pancreatectomy. METHODS We analyzed the outcomes retrospectively of 368 patients who underwent distal pancreatectomies during the period January 2016 to December 2019. Postoperative acute pancreatitis was defined as an increase of serum amylase activity greater than our laboratory normal upper limit on postoperative days 0 to 2. We assessed the incidence of postoperative acute pancreatitis after distal pancreatectomy and examined possible predictors of postoperative acute pancreatitis and relationships of postoperative acute pancreatitis with postoperative pancreatic fistula. RESULTS The rates of postoperative acute pancreatitis and postoperative pancreatic fistula after distal pancreatectomy were 67.9% and 28.8%, respectively. Patients who developed postoperative acute pancreatitis experienced an increased rate of severe morbidity (18.4 vs 9.3%; P = .030). Neoadjuvant therapy (odds ratio 0.28, 0.09-0.85; P = .025), age ≥ 65 y (odds ratio 0.34, 0.13-0.85; P = .020), duct size (odds ratio 0.02, 0.002-0.47; P = .013), pancreatic thickness (odds ratio 3.4, 1.29-8.9; P = .013), resection at the body-tail level (odds ratio 4.3, 1.15-23.19; P = .041), and neuroendocrine histology (odds ratio 1.14, 1.06-3.90; P = .013) were independent predictors of postoperative acute pancreatitis. Furthermore, postoperative acute pancreatitis was an independent predictor of postoperative pancreatic fistula (odds ratio 5.8, 2.27-15.20; P < .001). Postoperative pancreatic fistula occurred in 37% of patients who developed postoperative acute pancreatitis. Patients developing postoperative acute pancreatitis alone demonstrated a statistically significantly increased rate of biochemical leakage and bacterial contamination in the peripancreatic drainage fluid. CONCLUSION Postoperative acute pancreatitis is a frequent event after distal pancreatectomy and, despite its close association with postoperative pancreatic fistula, evidently represents a separate phenomenon. A universally accepted definition of postoperative acute pancreatitis that applies to all types of pancreatic resections is needed, because it may identify patients at greater risk for additional morbidity immediately after pancreatic resections.
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Affiliation(s)
- Stefano Andrianello
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Elisa Bannone
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alessandro Esposito
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
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25
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Updated outcomes using clockwise technique for laparoscopic distal pancreatectomy: Optimal treatment of benign and malignant disease of the left pancreas. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2021. [DOI: 10.1016/j.lers.2021.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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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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Zimmitti G, La Mendola R, Manzoni A, Sega V, Malerba V, Treppiedi E, Codignola C, Monfardini L, Garatti M, Rosso E. Investigation of intraoperative factors associated with postoperative pancreatic fistula following laparoscopic left pancreatectomy with stapled closure: a video review-based analysis : Video-review for predictors of pancreatic leak. Surg Endosc 2021; 35:941-954. [PMID: 32914358 DOI: 10.1007/s00464-020-07912-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/17/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Postoperative pancreatic fistula (POPF) following distal pancreatectomy (DP) remains the most frequent complication, potential precursor of more serious events, and mechanisms behind POPF development are not clear. Primary aim of the current study is to investigate correlations between patients' characteristics, including technical intraoperative data assessed by retrospective video review of laparoscopic DP (L-PD), and development of clinically relevant (CR-)POPF and major complication. METHODS Patients undergoing L-DP whose surgery video was available for review were included in this study. Retrospective video review, performed by two surgeons blinded for postoperative outcomes, was focused on pancreatic neck transection and identification of pancreatic capsule disruption (PCD)/staple line bleeding (SLB). Correlation between clinical, demographic, and intraoperative factors and CR-POPF/major complications and assessment of factors associated with PCD and SLB were investigated. RESULTS Of 41 L-DP performed at our institution (June 2015-June 2020) using a triple-row stapler (EndoGIA™ Reloads with Tri-Staple™), surgery video was available for 38 patients [men/women, 13/25; median age (range) 62 (25-84) years; median BMI (range) 24 (17-42)]. PCD and SLB occurred in 15(39%) and 19(50%) patients and were concomitant in 9(24%). CR-POPF and major complications occurred in 8(21%) and 12(31%) patients, respectively. PCD, SLB, and PCD + SLB rates were significantly higher among patients with CR-POPF, compared to patients without (all p < 0.05). Among patients with PCD, pancreatic thickness at pancreatic transection site was higher (19 mm), compared to non-PCD patients (13 mm, p < 0.001). A directly proportional relation between PCD, CR-POPF, and major complication rate and pancreatic thickness was confirmed by ROC analysis (AUC = 0.949, 0.798, and 0.740, respectively). CONCLUSION PCD and SLB close to the staple line detected by retrospective video-review are intraoperatively detectable indicators of severe pancreatic traumatism and a potential precursors of CR-POPF following L-PD. Given the strict correlation between PCD and pancreatic thickness, alternative techniques to stapled closure for pancreatic transection may be recommended for patients with a thick pancreas and modification in postoperative care may be considered in patients with PCD/SLB.
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Affiliation(s)
- Giuseppe Zimmitti
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Via L. Bissolati 57, 25124, Brescia, Italy.
| | - Roberta La Mendola
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Via L. Bissolati 57, 25124, Brescia, Italy
| | - Alberto Manzoni
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Via L. Bissolati 57, 25124, Brescia, Italy
| | - Valentina Sega
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Via L. Bissolati 57, 25124, Brescia, Italy
| | - Valentina Malerba
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Via L. Bissolati 57, 25124, Brescia, Italy
| | - Elio Treppiedi
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Via L. Bissolati 57, 25124, Brescia, Italy
| | - Claudio Codignola
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Via L. Bissolati 57, 25124, Brescia, Italy
| | - Lorenzo Monfardini
- Department of Radiology, Istituto Ospedaliero Fondazione Poliambulanza, Via L. Bissolati 57, 25124, Brescia, Italy
| | - Marco Garatti
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Via L. Bissolati 57, 25124, Brescia, Italy
| | - Edoardo Rosso
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Via L. Bissolati 57, 25124, Brescia, Italy
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Efficacy of Early Endoscopic Ultrasound-Guided Transluminal Drainage for Postoperative Pancreatic Fistula. Can J Gastroenterol Hepatol 2021; 2021:6691705. [PMID: 33564656 PMCID: PMC7850853 DOI: 10.1155/2021/6691705] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 01/09/2021] [Accepted: 01/16/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Endoscopic ultrasound-guided transluminal drainage (EUS-TD) is generally performed 4 weeks after disease onset for evacuating pancreatic fluid collections. However, the optimal timing for conducting the procedure in those diagnosed with postoperative pancreatic fistula (POPF) has not been established. We aimed to elucidate the efficacy and safety of early EUS-TD procedures for treating POPF. METHODS We retrospectively reviewed patients diagnosed with POPF who underwent EUS-TD in the Kyushu University Hospital between 2008 and 2019. Clinical features were comparatively analyzed between the two patient groups who underwent either early (≤15 days postoperatively) or late (>15 days postoperatively) EUS-TD. Factors prolonging hospital stay were also analyzed using Cox proportional hazard models. RESULTS Thirty patients (median age, 64.5 years) were enrolled. The most common initial operation was distal pancreatectomy with splenectomy (60.0%). Median size of POPF was 69.5 (range, 38-145) mm, and median time interval between surgery and EUS-TD was 17.5 (range, 3-232) days. Totally, 47% patients underwent early EUS-TD. Rates of technical success, clinical success, and complications were 100%, 97%, and 6.9%, respectively. No recurrence of POPF occurred during a median follow-up period of 14 months. Clinical characteristics and outcomes were comparable between the early and late drainage patient groups, except for the rates of infection and nonencapsulation of POPF, which were significantly higher in the early drainage group. Performing simultaneous internal and external drainage (hazard ratio (HR): 0.31; 95% confidence interval (CI): 0.11-0.93, p=0.04) and conducting ≥2 treatment sessions (HR: 0.26; 95% CI: 0.08-0.84, p=0.02) were significantly associated with prolonged hospitalization after EUS-TD. CONCLUSIONS EUS-TD is a safe and effective method for managing POPF, regardless of when it is performed in the postoperative period. Once infected POPF occurs, clinicians should not hesitate to perform EUS-TD even within 15 days of the initial operation.
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Goh BKP. A Multicenter, Randomized, Controlled Trial Comparing Reinforced Staplers with Bare Staplers During Distal Pancreatectomy (HiSCO-07 Trial). Ann Surg Oncol 2020; 27:948-949. [PMID: 32221735 DOI: 10.1245/s10434-020-08401-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Brian K P Goh
- Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital, Singapore, Singapore.
- Duke-National University of Singapore Medical School, Singapore, Singapore.
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30
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Kondo N, Murakami Y. Reply to the Letter to the Editor "Re: A Multicenter, Randomized, Controlled Trial Comparing Reinforced Staplers with Bare Staplers During Distal Pancreatectomy (HiSCO-07 Trial)". Ann Surg Oncol 2020; 27:950-951. [PMID: 32221739 DOI: 10.1245/s10434-020-08406-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Naru Kondo
- Department of Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Yoshiaki Murakami
- Department of Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan.
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31
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Kobayashi E, Tsuchiya S, Akagi Y, Tomii N, Nakagawa K, Inai K, Muragaki Y, Asano T, Kim D. A novel reaction force-fluorescence measurement system for evaluating pancreatic juice leakage from an excised swine pancreas during distal pancreatectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:877-886. [PMID: 32510850 DOI: 10.1002/jhbp.775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 05/19/2020] [Accepted: 05/26/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Resection using a stapler is a popular approach to distal pancreatectomy. However, the resulting leakage of pancreatic juice represents a serious problem. We have developed a force-fluorescence measurement as a first step towards the quantitative evaluation of pancreatic leakage due to tissue tearing under compression. METHODS The system comprises a testing machine with an indenter, similar in size to a stapler, which controls compression speed and measures reaction force, and a fluorescence measurement system to measure pancreatic juice leakage. Pancreatic juice leakage is measured as the maximum value of the increasing rate of fluorescence intensity (max value). Ten excised swine pancreases were compressed at a speed of 500, 100, and 10 mm/min until their thicknesses became 2 mm. RESULTS A strong positive correlation (0.804) was observed between the increase in max value before and after compression and the amount of reaction force drop due to tissue destruction. No pancreatic juice leakage was observed when compressed slowly (10 mm/min). CONCLUSIONS We have successfully developed a novel force-fluorescence measurement system that can detect and quantify pancreatic juice leakage caused by tissue tearing. This system can determine the optimal compression conditions for preventing pancreatic juice leakage.
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Affiliation(s)
- Etsuko Kobayashi
- Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, Shinjuku-ku, Japan
| | - Shuto Tsuchiya
- School of Engineering, the University of Tokyo, Bunkyo-ku, Japan
| | - Yuki Akagi
- School of Engineering, the University of Tokyo, Bunkyo-ku, Japan
| | - Naoki Tomii
- School of Medicine, the University of Tokyo, Bunkyo-ku, Japan
| | - Keiichi Nakagawa
- School of Engineering, the University of Tokyo, Bunkyo-ku, Japan
| | - Kunihiro Inai
- School of Medical Sciences, University of Fukui, Fukui, Japan
| | - Yoshihiro Muragaki
- Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University, Shinjuku-ku, Japan
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Aoki T, Mansour DA, Koizumi T, Matsuda K, Kusano T, Wada Y, Hakozaki T, Tomioka K, Hirai T, Yamazaki T, Watanabe M, Otsuka K, Gahin AEA, Murakami M. Preventing clinically relevant pancreatic fistula with combination of linear stapling plus continuous suture of the stump in laparoscopic distal pancreatectomy. BMC Surg 2020; 20:223. [PMID: 33023558 PMCID: PMC7541328 DOI: 10.1186/s12893-020-00876-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 09/22/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Pancreatic fistula is one of the serious complications for patients undergoing distal pancreatectomy, which leads to significant morbidity. The aim of our study is to compare linear stapling closure plus continuous suture with linear stapling closure alone during laparoscopic distal pancreatectomy (LDP) in terms of clinically relevant postoperative pancreatic fistula (POPF) rate. METHODS Twenty-two patients underwent LDP at our institution between 2011 and 2013. Twelve patients had linear stapling closure with peri-firing compression (LSC) alone compared with ten patients who had linear stapling closure, peri-firing compression plus continuous suture (LSC/CS) for stump closure of remnant pancreas in LDP. Biochemical leak and clinically relevant POPF were compared between both groups. RESULTS POPF occurred in 4 of 12 (33.3%) patients with linear stapling closure while no patient developed a clinically relevant POPF in the triple combination of linear stapling, peri-firing compression plus continuous suture group (p = 0.043).1 patient (8.3%) in the LSC group and 5 patients (50%) in the LSC/CS group had evidence of a biochemical leak. There were no significant differences in operative time (188.3 vs 187.0 min) and blood loss (135 vs. 240 g) between both groups but there was a significantly of shorter length of hospital stay (11.9 vs. 19.9 days) in LSC/CS group (p = 0.037). There was no mortality in either group. CONCLUSIONS The triple combination of linear stapling, peri-firing compression plus continuous suture in LDP has effectively prevented occurrence of clinically relevant ISGPF POPF. TRIAL REGISTRATION The study was retrospectively registered September 30, 2019 at Showa University Ethics Committee as IRB protocol numbers 2943.
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Affiliation(s)
- Takeshi Aoki
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan.
| | - Doaa A Mansour
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
- General Surgery Department, Cairo University Hospitals, Kasr Alainy, Al-Saray street, El-Manial, Cairo, 11956, Egypt
| | - Tomotake Koizumi
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
| | - Kazuhiro Matsuda
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
| | - Tomokazu Kusano
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
| | - Yusuke Wada
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
| | - Tomoki Hakozaki
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
| | - Kodai Tomioka
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
| | - Takahito Hirai
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
| | - Tatsuya Yamazaki
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
| | - Makoto Watanabe
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
| | - Koji Otsuka
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
| | - Ahmed Elewa Abbas Gahin
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
- General Surgery Department, National Hepatology and Tropical Medicine Research Institute, 10. Kasr Alainy street, Cairo, 11562, Egypt
| | - Masahiko Murakami
- Division of Gastroenterological and General Surgery, Department of Surgery, School of Medicine, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 1428666, Japan
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Utilization of the Falciform Ligament to Buttress the Pancreatic Transection Staple Line: A Novel Technique. Surg Laparosc Endosc Percutan Tech 2020; 30:e39-e42. [PMID: 32941356 DOI: 10.1097/sle.0000000000000839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) remains a common complication after distal pancreatectomy and is a major source of operative morbidity. Although various mechanical, biological, and synthetic aids have been used to reduce the risk of POPF, none have a proven benefit. MATERIALS AND METHODS The authors describe (and present a video, Supplemental Digital Content 1, http://links.lww.com/SLE/A256) a novel technique in which the autologous falciform ligament was harvested, wrapped around the pancreas at the site of proposed pancreatic transection, and secured with sutures to buttress the pancreatic transection staple line. The pancreas was then transected with a triple-row stapler. RESULTS Two male patients aged 40 and 57 years each with a 4.3 and 4.2 cm solid mass in the body of the pancreas respectively underwent laparoscopic anterior radical antegrade modular pancreaticosplenectomy, the former patient underwent an en block transverse colectomy for suspected malignancy. Both patients had soft pancreata. They experienced no POPF, made an uneventful recovery, and were discharged from the hospital on the second and fourth postoperative days, respectively. No pancreatic complications were encountered at 5 and 6 months follow-up, respectively. CONCLUSIONS The use of the falciform ligament to buttress the staple line at the time of pancreatic transection is a novel technique. Its potential benefit in reducing the risk of POPF warrants further assessment.
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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: 40] [Impact Index Per Article: 8.0] [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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The Miami International Evidence-based Guidelines on Minimally Invasive Pancreas Resection. Ann Surg 2020; 271:1-14. [PMID: 31567509 DOI: 10.1097/sla.0000000000003590] [Citation(s) in RCA: 310] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The aim of this study was to develop and externally validate the first evidence-based guidelines on minimally invasive pancreas resection (MIPR) before and during the International Evidence-based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR) meeting in Miami (March 2019). SUMMARY BACKGROUND DATA MIPR has seen rapid development in the past decade. Promising outcomes have been reported by early adopters from high-volume centers. Subsequently, multicenter series as well as randomized controlled trials were reported; however, guidelines for clinical practice were lacking. METHODS The Scottisch Intercollegiate Guidelines Network (SIGN) methodology was used, incorporating these 4 items: systematic reviews using PubMed, Embase, and Cochrane databases to answer clinical questions, whenever possible in PICO style, the GRADE approach for assessment of the quality of evidence, the Delphi method for establishing consensus on the developed recommendations, and the AGREE-II instrument for the assessment of guideline quality and external validation. The current guidelines are cosponsored by the International Hepato-Pancreato-Biliary Association, the Americas Hepato-Pancreato-Biliary Association, the Asian-Pacific Hepato-Pancreato-Biliary Association, the European-African Hepato-Pancreato-Biliary Association, the European Association for Endoscopic Surgery, Pancreas Club, the Society of American Gastrointestinal and Endoscopic Surgery, the Society for Surgery of the Alimentary Tract, and the Society of Surgical Oncology. RESULTS After screening 16,069 titles, 694 studies were reviewed, and 291 were included. The final 28 recommendations covered 6 topics; laparoscopic and robotic distal pancreatectomy, central pancreatectomy, pancreatoduodenectomy, as well as patient selection, training, learning curve, and minimal annual center volume required to obtain optimal outcomes and patient safety. CONCLUSION The IG-MIPR using SIGN methodology give guidance to surgeons, hospital administrators, patients, and medical societies on the use and outcome of MIPR as well as the approach to be taken regarding this challenging type of surgery.
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Usefulness of Drain Lipase to Predict Postoperative Pancreatic Fistula After Distal Pancreatectomy. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02128-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Yang SJ, Hwang HK, Kang CM, Lee WJ. Revisiting the potential advantage of robotic surgical system in spleen-preserving distal pancreatectomy over conventional laparoscopic approach. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:188. [PMID: 32309335 PMCID: PMC7154491 DOI: 10.21037/atm.2020.01.80] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 01/10/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND This study aimed to compare success rate of spleen preservation between robotic and laparoscopic distal pancreatectomy (DP). METHODS Between November 2007 and March 2018, forty-one patients underwent the conventional laparoscopic DP (Lap group) and the other 37 patients underwent robotic DP (Robot group). The perioperative clinicopathologic variables were compared. RESULTS The robotic procedure was chosen by younger patients compared to conventional laparoscopic surgery (42.9±14.0 vs. 51.3±14.6 years, P=0.016). The mean operation time was longer (313 vs. 246 min, P=0.000), but the mean tumor size was smaller in Robot group (2.7±1.2 vs. 4.2±3.3 cm, P=0.018). The overall spleen-preserving rate was higher in the Robot group (91.9% vs. 68.3%, P=0.012). However, with accumulating laparoscopic experiences (after 16th case), the statistical differences in spleen preservation rate between the Robot and Lap groups had diminished (P=0.428). CONCLUSIONS The present results suggest a robot can be helpful to save the spleen during DP for benign and borderline malignancy. However, a surgeon highly experienced in the laparoscopic approach can also produce a high success rate of spleen preservation, similar to that shown with the robotic approach.
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Affiliation(s)
- Seok Jeong Yang
- Department of Surgery, Yonsei University College of Medicine, Yongin Severance Hospital, Gyeonggi, Korea
| | - Ho Kyoung Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Chang Moo Kang
- Division of Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Woo Jung Lee
- Department of Surgery, Yonsei University College of Medicine, Yongin Severance Hospital, Gyeonggi, Korea
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Relationship between pancreatic thickness and staple height is relevant to the occurrence of pancreatic fistula after distal pancreatectomy. HPB (Oxford) 2020; 22:398-404. [PMID: 31416785 DOI: 10.1016/j.hpb.2019.07.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/11/2019] [Accepted: 07/19/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND A triple-row stapler is widely used to divide the pancreas in distal pancreatectomy (DP). However, the selection criteria of the stapler cartridge to prevent postoperative pancreatic fistula (POPF) remain unclear. The objective of this study was to determine if factors concerning pancreatic thickness or staple size affect POPF after DP. METHODS Datasets of patients from the Mayo Clinic and National Cancer Center Hospital East who underwent DP using a triple-row stapler were merged. Risk of POPF was analyzed using clinicopathological variables, including data for pancreatic thickness and staple height. A compression index was defined as the designated staple height (mm) after closure divided by the pancreatic thickness (mm). RESULTS Among the 277 patients, POPF occurred in 65 (23%) patients. The median pancreatic thickness was 13.7 mm and the median compression index was 0.137. Multivariable logistic models showed that a greater pancreatic thickness (odds ratio, 1.190, P < 0.001) and a compression index ≤0.160 (odds ratio, 4.754, P < 0.001) were independently related with POPF. CONCLUSION In patients undergoing DP using a triple-row stapler, the thickness of the pancreas was related with the occurrence of POPF. Selection of the stapler cartridge with a compression index of ≤0.160 may reduce the occurrence of POPF.
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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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Song KB, Kwon J, Lee YJ, Hwang DW, Lee JH, Shin SH, Kim MH, Lee SK, Seo DW, Lee SS, Park DH, Song TJ, Park G, Park Y, Lee SJ, Kim SC. The treatment indication and optimal management of fluid collection after laparoscopic distal pancreatectomy. Surg Endosc 2019; 33:3314-3324. [PMID: 30535935 DOI: 10.1007/s00464-018-06621-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 12/04/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Recently, laparoscopic distal pancreatectomy (LDP) has become the standard procedure for resection of left-sided pancreatic tumors. Fluid collection (FC) at the resection margin of the pancreatic stump after LDP is a frequent radiological finding. However, there have been few treatment guidelines and the optimal management for this clinical finding is unclear. The aim of present study is to define the incidence of FC and suggest the optimal management for FC after LDP. METHODS A total of 1227 patients who underwent LDP between March 2005 and December 2015 were collected. FC was considered present when the longest diameter of the lesion on CT scan was > 3 cm. RESULTS A follow-up with at least two CT image was available for 1102 patients. Of these, 689 (62.5%) patients showed initial fluid collection (IFC) at the pancreas resection site in immediate postoperative CT. IFC (+) group had higher proportion of men, BMI, and higher rate of concomitant splenectomy than IFC (-) group. Among patients with FC after LDP, the treatment group had more frequent leukocytosis and accompanying symptoms than the observation group. Seventy-seven patients underwent therapeutic interventions for FC after LDP. Among them, 55 (71.4%) patients underwent endoscopic ultrasonography-guided gastrocystostomy (EUS-GC). EUS-GC group had a higher success rate (85.6 vs. 63.6%, p < 0.033) and shorter hospital stay after the intervention (5.2 vs. 13.3 days, p < 0.001) than those who underwent other procedures. CONCLUSIONS High BMI, male, and concomitant splenectomy contribute to the occurrence of FC after LDP. In most cases, FC after LDP resolved spontaneously over time with observation. The patients with symptomatic FC ultimately required treatment. EUS-GC is the optimal intervention therapy for FC after LDP.
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Affiliation(s)
- Ki Byung Song
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jaewoo Kwon
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Young-Joo Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Dae Wook Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jae Hoon Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Sang Hyun Shin
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Myung-Hwan Kim
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Sung Koo Lee
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Dong-Wan Seo
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Sang Soo Lee
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Do Hyun Park
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Tae Jun Song
- Division of Gastroenterology, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Guisuk Park
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Yejong Park
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Seung Jae Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Song Cheol Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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Pulvirenti A, Landoni L, Borin A, De Pastena M, Fontana M, Pea A, Esposito A, Casetti L, Tuveri M, Paiella S, Marchegiani G, Malleo G, Salvia R, Bassi C. Reinforced stapler versus ultrasonic dissector for pancreatic transection and stump closure for distal pancreatectomy: A propensity matched analysis. Surgery 2019; 166:271-276. [PMID: 30975498 DOI: 10.1016/j.surg.2019.02.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula is the primary contributor to morbidity after distal pancreatectomy. To date, no techniques used for the transection and closure of the pancreatic stump have shown clear superiority over the others. This study aimed to compare the rate of postoperative pancreatic fistula after pancreatic transection conducted with a reinforced stapler versus an ultrasonic dissector after a distal pancreatectomy. METHOD Prospectively collected data of consecutive patients who underwent distal pancreatectomy from 2014 to 2017 were reviewed retrospectively. We included distal pancreatectomies in which pancreatic transection was performed by reinforced stapler or ultrasonic dissector; we excluded extended distal pancreatectomies. To overcome the absence of randomization, we conducted a propensity matching analysis according to risk factors for postoperative pancreatic fistula. RESULTS Overall, 200 patients met the inclusion criteria. The reinforced stapler was employed in 108 patients and the ultrasonic dissector in 92 cases. After one-to-one propensity matching, 92 patients were selected from each group. The matched reinforced stapler and ultrasonic dissector cohort had no differences in baselines characteristics except for the mini-invasive approach, which was more common in the ultrasonic dissector group (34% vs 51%, P = .025). Overall, 48 patients (26%) developed a postoperative pancreatic fistula, 46 (25%) a grade B postoperative pancreatic fistula, and 2 (1%) a grade C postoperative pancreatic fistula. In the reinforced stapler group, the rate of postoperative pancreatic fistula was 12% (n = 11) and in the ultrasonic dissector group 40% (n = 37) with a P < .001. CONCLUSION The results of this study suggest that the use of reinforced stapler for pancreatic transection decreases the risk of postoperative pancreatic fistula. A randomized trial is required to confirm these preliminary data.
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Affiliation(s)
| | - Luca Landoni
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy
| | - Alex Borin
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy
| | - Matteo De Pastena
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy
| | - Martina Fontana
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy
| | - Antonio Pea
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy
| | - Alessandro Esposito
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy
| | - Luca Casetti
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy
| | - Massimiliano Tuveri
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy
| | - Salvatore Paiella
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy
| | - Giovanni Marchegiani
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy
| | - Roberto Salvia
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy.
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, University of Verona Hospital Trust, Italy
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Morikawa T, Ishida M, Takadate T, Hata T, Iseki M, Kawaguchi K, Ohtsuka H, Mizuma M, Hayashi H, Nakagawa K, Motoi F, Kamei T, Naitoh T, Unno M. The superior approach with the stomach roll-up technique improves intraoperative outcomes and facilitates learning laparoscopic distal pancreatectomy: a comparative study between the superior and inferior approach. Surg Today 2019; 50:153-162. [DOI: 10.1007/s00595-019-01855-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/15/2019] [Indexed: 12/11/2022]
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Asbun HJ, Van Hilst J, Tsamalaidze L, Kawaguchi Y, Sanford D, Pereira L, Besselink MG, Stauffer JA. Technique and audited outcomes of laparoscopic distal pancreatectomy combining the clockwise approach, progressive stepwise compression technique, and staple line reinforcement. Surg Endosc 2019; 34:231-239. [DOI: 10.1007/s00464-019-06757-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 03/18/2019] [Indexed: 02/07/2023]
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Vass DG, Hodson J, Isaac J, Marudanayagam R, Mirza DF, Muiesan P, Roberts K, Sutcliffe RP. Utility of drain fluid amylase measurement on the first postoperative day after distal pancreatectomy. HPB (Oxford) 2018; 20:803-808. [PMID: 29802050 DOI: 10.1016/j.hpb.2017.08.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 06/29/2017] [Accepted: 08/02/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Early exclusion of a postoperative pancreatic fistula (POPF) may facilitate earlier drain removal in selected patients after distal pancreatectomy. The purpose of this study was to evaluate the role of first postoperative day drain fluid amylase (DFA1) measurement to predict POPF. METHODS Patients in whom DFA1 was measured after distal pancreatectomy were identified from a prospectively maintained database over a five-year period. A cut-off value of DFA1 was derived using ROC analysis, which yielded sensitivity and negative predictive value of 100% for excluding POPF. RESULTS DFA1 was available in 53 of 138 (38%) patients who underwent distal pancreatectomy. 19 of 53 patients (36%) developed a pancreatic fistula (Grade A - 15, Grade B - 3, Grade C - 1). Median DFA1 was significantly higher in those who developed a pancreatic fistula (5473; range 613-28,450) compared those without (802; range 57-2350). p < 0.0001. Using ROC analysis, a DFA1 less than 600 excluded pancreatic fistula with a sensitivity of 100% (AUROC of 0.91; SE = 0.04, p < 0.001). CONCLUSION First postoperative day drain fluid amylase measurement may have a role in excluding pancreatic fistula after distal pancreatectomy. Such patients may be suitable for earlier drain removal.
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Affiliation(s)
- David G Vass
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK.
| | - James Hodson
- Institute of Translational Medicine, University Hospitals Birmingham, Birmingham, UK
| | - John Isaac
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Ravi Marudanayagam
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Darius F Mirza
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Paolo Muiesan
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Keith Roberts
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Robert P Sutcliffe
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
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Hirashita T, Ohta M, Yada K, Tada K, Saga K, Takayama H, Endo Y, Uchida H, Iwashita Y, Inomata M. Effect of pre-firing compression on the prevention of pancreatic fistula in distal pancreatectomy. Am J Surg 2018; 216:506-510. [DOI: 10.1016/j.amjsurg.2018.03.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 02/12/2018] [Accepted: 03/23/2018] [Indexed: 01/08/2023]
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Splenic vein resection together with the pancreatic parenchyma versus separated resection after isolation of the parenchyma during distal pancreatectomy (COSMOS-DP trial): study protocol for a randomised controlled trial. Trials 2018; 19:369. [PMID: 29996884 PMCID: PMC6042420 DOI: 10.1186/s13063-018-2756-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 06/20/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In distal pancreatectomy (DP), it is customary to ligate and divide the splenic vein after isolating it from the pancreatic parenchyma. This is considered essential to prevent disruption of the stump of the splenic vein and consequent intra-abdominal haemorrhage in the event of pancreatic fistula (PF). However, this procedure can be technically demanding, especially when the vein is firmly embedded in the pancreatic parenchyma. The objective of the COSMOS-DP trial is to confirm the non-inferiority of resection of the splenic vein embedded in the pancreatic parenchyma compared with the conventional technique of isolating the splenic vein before resection during DP using a mechanical stapler. METHODS Patients with diseases of the pancreatic body and tail whose pancreatic parenchyma and splenic vein can be divided concurrently during open or laparoscopic DP are considered eligible for inclusion. This study is designed as a multicentre prospective randomised phase III trial. Eligible patients will be centrally randomised to either Arm A (resection of the splenic vein after isolation from the pancreatic parenchyma) or Arm B (co-resection of the vein together with the pancreas). This study aims to establish the non-inferiority of the safety of Arm B compared with that of Arm A; the primary endpoint is the incidence of PF (ISGPF grade B/C). DISCUSSION The COSMOS-DP trial will establish the safety of this procedure, such that it can be recommended with more confidence. The use of this procedure will likely result in significant reductions in operative time and blood loss during DP. TRIAL REGISTRATION ClinicalTrials.gov, NCT02871804 . Registered on 27 July 2016.
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[Closure of pancreas stump after distal and segmental resection : Suture, stapler, coverage or anastomosis?]. Chirurg 2018; 88:25-29. [PMID: 27778058 DOI: 10.1007/s00104-016-0301-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Postoperative pancreatic fistulas represent the most frequent complication after distal and segmental pancreatectomy and occur with a frequency of up to 50 %. There are many technical variations of pancreatic stump treatment for reduction of fistula rates after distal resection. Most of these techniques have only been analyzed in retrospective studies and the evidence for or against a specific technique is low. Several retrospective trials have been conducted with good results to compare suturing with stapled closure of the remnant and to assess the effect of a vascularized falciform ligament patch in reducing postoperative pancreatic fistula; however, in a recently published randomized trial, which analyzed closure of the remnant with a pancreaticojejunostomy compared to standard closure, these results could not be confirmed. Because stapler resection and closure is the most commonly used technique in laparoscopic distal pancreatectomy, there are a large number of studies which assessed various novel methods of improving stapling. Extended stapler compression time and mesh augmentation of the stapler line can be valid methods to reduce fistula rates. Central pancreatectomy is a relatively rarely used procedure where the right-sided pancreatic remnant is closed in the same fashion as during distal pancreatectomy and the left-sided remnant is connected to the intestines with a pancreaticojejunostomy or pancreaticogastrostomy. In conclusion, postoperative pancreatic fistula rates are still a relevant clinical problem after distal pancreatectomy and further studies on potentially improved novel techniques are required.
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Souther C, Murayama K. Fundamentals of Stapling Devices. FUNDAMENTALS OF GENERAL SURGERY 2018:137-142. [DOI: 10.1007/978-3-319-75656-1_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Date S, Noguchi H, Kaku K, Kurihara K, Miyasaka Y, Okabe Y, Nakamura U, Ohtsuka T, Nakamura M. Laparoscopy-Assisted Spleen-Preserving Distal Pancreatectomy for Living-Donor Pancreas Transplantation. Transplant Proc 2017; 49:1133-1137. [PMID: 28583543 DOI: 10.1016/j.transproceed.2017.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Living pancreas transplantation plays an important role in the treatment of patients with severe type 1 diabetes. However, pancreatectomy is very invasive for the donor, and less-invasive surgical procedures are needed. Although some reports have described hand-assisted laparoscopic surgery for distal pancreatectomy in living-donor operations, less-invasive laparoscopy-assisted (LA) procedures are expected to increase the donor pool. We herein report the outcomes of four cases of LA spleen-preserving distal pancreatectomy (Warshaw technique [WT]) in living pancreas donors. PATIENTS AND METHODS Four living pancreas donors underwent LA-WT at our institution from September 2010 to January 2013. All donors fulfilled the donor criteria established by the Japan Society for Pancreas and Islet Transplantation. RESULTS The median donor age was 54 years. Two donors underwent left nephrectomy in addition to LA-WT for simultaneous pancreas-kidney transplantation. The median donor operation time for pancreatectomy was 340.5 minutes. The median pancreas warm ischemic time was 3 minutes. The median donor blood loss was 246 g. All recipients immediately achieved insulin independence. One donor required reoperation because of obstructive ileus resulting from a port-site hernia. Another donor developed a pancreatic fistula (International Study Group of Pancreatic Fistula grade B), which was controlled with conservative management. After a maximum follow-up of 73 months, no clinically relevant adverse events had occurred. These results were comparable with those of previous studies concerning living-donor pancreas transplantation. CONCLUSION The LA-WT is a safe and acceptable operation for living-donor pancreas transplantation.
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Affiliation(s)
- S Date
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - H Noguchi
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - K Kaku
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - K Kurihara
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Y Miyasaka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Y Okabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - U Nakamura
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - T Ohtsuka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - M Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Zhang AB, Wang Y, Hu C, Shen Y, Zheng SS. Laparoscopic versus open distal pancreatectomy for pancreatic ductal adenocarcinoma: a single-center experience. J Zhejiang Univ Sci B 2017; 18:532-538. [PMID: 28585429 PMCID: PMC5482047 DOI: 10.1631/jzus.b1600541] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 03/04/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The aim of this study was to compare complications and oncologic outcomes of patients undergoing laparoscopic distal pancreatectomy (LDP) and open distal pancreatectomy (ODP) at a single center. METHODS Distal pancreatectomies performed for pancreatic ductal adenocarcinoma during a 4-year period were included in this study. A retrospective analysis of a database of this cohort was conducted. RESULTS Twenty-two patients underwent LDP for pancreatic ductal adenocarcinoma, in comparison to seventy-six patients with comparable tumor characteristics treated by ODP. No patients with locally advanced lesions were included in this study. Comparing LDP group to ODP group, there were no significant differences in operation time (P=0.06) or blood loss (P=0.24). Complications (pancreatic fistula, P=0.62; intra-abdominal abscess, P=0.44; postpancreatectomy hemorrhage, P=0.34) were similar. There were no significant differences in the number of lymph nodes harvested (11.2±4.6 in LDP group vs. 14.4±5.5 in ODP group, P=0.44) nor the rate of patients with positive lymph nodes (36% in LDP group vs. 41% in ODP group, P=0.71). Incidence of positive margins was similar (9% in LDP group vs. 13% in ODP group, P=0.61). The mean overall survival time was (29.6±3.7) months for the LDP group and (27.6±2.1) months for ODP group. There was no difference in overall survival between the two groups (P=0.34). CONCLUSIONS LDP is a safe and effective treatment for selected patients with pancreatic ductal adenocarcinoma. A slow-compression of pancreas tissue with the GIA stapler is effective in preventing postoperative pancreatic fistula. The oncologic outcome is comparable with the conventional open approach. Laparoscopic radical antegrade modular pancreatosplenectomy contributed to oncological clearance.
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