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Tang B, Wen Y, Li S, Ma J, Yang L, Duan N, Xiang C, Tian X, Dong J, Wang P, Wang X. Positive drain fluid culture on postoperative day one is associated with an increased risk of late postoperative pancreatic fistula after pancreaticoduodenectomy. Langenbecks Arch Surg 2025; 410:56. [PMID: 39875709 PMCID: PMC11775035 DOI: 10.1007/s00423-025-03621-y] [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: 10/25/2024] [Accepted: 01/16/2025] [Indexed: 01/30/2025]
Abstract
PURPOSE To investigate the risk factors for late postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy (PD), with a focus on positive drain fluid culture (DFC) results on postoperative day (POD) 1. METHODS Medical records of 198 patients who underwent PD with drain fluid amylase (DFA) on POD 5 < 3x upper limit of normal (ULN) were included. Late POPF was defined as POPF diagnosed post-POD 6, with DFA on POD 5 < 3xULN. Risk factors analyses were performed, with a focus on DFC on POD 1. RESULTS Nineteen patients (9.6%) were diagnosed with late POPF. Age > 65 years (OR: 4.019, P = 0.034) and positive DFC on POD 1 (OR: 10.151, P < 0.001) were identified as independent predictors of late POPF. Patients with positive DFC on POD 1 (n = 25) had higher rates of late POPF (44% vs. 4.6%, P < 0.001), postpancreatectomy hemorrhage (20% vs. 5.8%, P = 0.027) and Clavien-Dindo ≥ IIIa complications (44% vs. 6.4%, P < 0.001). The majority of patients (57.9%) with late POPF had positive DFC on POD 1 (11 of 19, 57.9%). The isolates from 11 patients with positive DFC on POD 1 yielded 12 microorganisms, the most prevalent of which were Enterobacter (n = 7), followed by Enterococcus (n = 3) and Staphylococcus (n = 2). Cefmetazole resistance was detected in 66.7% (8 of 12) of the microorganisms. CONCLUSION Age > 65 years and positive DFC on POD 1 were independent predictors of late POPF after PD. Positive DFC on POD 1 was associated with a higher rate of complications.
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Affiliation(s)
- Bingjun Tang
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yan Wen
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Sijia Li
- Department of Gastrointestinal Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Jiming Ma
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Liuqing Yang
- Department of Information administration, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Ning Duan
- Department of Clinical Laboratory, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Canhong Xiang
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Xiaodong Tian
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Jiahong Dong
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
- Key laboratory of Digital Intelligence Hepatology (Ministry of Education), School of Clinical Medicine, Tsinghua University, Beijing, China
- Research Unit of Precision Hepatobiliary Surgery Paradigm, Chinese Academy of Medical Sciences, Beijing, China
| | - Pengfei Wang
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China.
| | - Xuedong Wang
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China.
- Key laboratory of Digital Intelligence Hepatology (Ministry of Education), School of Clinical Medicine, Tsinghua University, Beijing, China.
- Research Unit of Precision Hepatobiliary Surgery Paradigm, Chinese Academy of Medical Sciences, Beijing, China.
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Watanabe A, Harimoto N, Araki K, Igarashi T, Tsukagoshi M, Ishii N, Hagiwara K, Tsunekawa K, Murakami M, Shirabe K. Perioperative pancreaticoduodenectomy management strategy focusing on postoperative early drain colonization. Surg Today 2024; 54:1067-1074. [PMID: 38502211 DOI: 10.1007/s00595-024-02810-4] [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: 11/25/2023] [Accepted: 01/21/2024] [Indexed: 03/21/2024]
Abstract
PURPOSE Pancreatoduodenectomy (PD) is a highly invasive procedure. Intra-abdominal infections and pancreatic fistulas are strongly correlated complications. In the present study, we identified the risk factors for postoperative early drain colonization (POEDC) and established a perioperative management strategy. METHODS A total of 205 patients who underwent pancreatoduodenectomy were included in the study. POEDC was defined as a positive drain fluid culture before postoperative day (POD) 4. We retrospectively investigated the correlation between POEDC, postoperative outcomes, and clinical factors. RESULTS POEDC was observed in 26 patients (12.6%) with poor postoperative outcomes, including pancreatic fistulas (P < 0.001). A multivariate analysis demonstrated a correlation between these postoperative outcomes and the age (P = 0.002), body mass index (BMI) (P = 0.002), procalcitonin (PCT) level (P < 0.001), and drain amylase level on POD 1 (P = 0.032). Enterococcus was detected most frequently, being found in 15 patients. CONCLUSION We observed a strong correlation between POEDC and poor postoperative outcomes. The BMI, age, and PCT and drain amylase level on POD 1 should be considered POEDC risk factors, with the need to propose an antibiotic perioperative strategy. POEDC control may represent the key to improving postoperative outcomes after PD.
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Affiliation(s)
- Akira Watanabe
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Norifumi Harimoto
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan.
| | - Kenichiro Araki
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Takamichi Igarashi
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Mariko Tsukagoshi
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Norihiro Ishii
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Kei Hagiwara
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Katsuhiko Tsunekawa
- Department of Clinical Laboratory Medicine, Gunma University, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Masami Murakami
- Department of Clinical Laboratory Medicine, Gunma University, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
| | - Ken Shirabe
- Department of Hepatobiliary and Pancreatic Surgery, Gunma University Graduate School of Medicine, 3-39-22 Showa-Machi, Maebashi, Gunma, 371-8511, Japan
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Kimura N, Ishido K, Wakiya T, Nagase H, Odagiri T, Wakasa Y, Hakamada K. Revealing the role of early peripancreatic bacterial contamination and Enterococcus faecalis in pancreatic fistula development after pancreaticoduodenectomy: Implications for useful antibiotic prophylaxis-An observational cohort study. Pancreatology 2024; 24:630-642. [PMID: 38508910 DOI: 10.1016/j.pan.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/26/2024] [Accepted: 03/13/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Peripancreatic bacterial contamination (PBC) is a critical factor contributing to the development of clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD). Controlling pathogenic bacteria is essential in preventing CR-POPF; however, the precise relationship between specific bacteria and CR-POPF remains unclear. This study aimed to investigate the relationship between PBC and CR-POPF after PD, with a focus on identifying potentially causative bacteria. METHODS This prospective observational study enrolled 370 patients who underwent PD. Microbial cultures were routinely collected from peripancreatic drain fluid on postoperative days (PODs) 1, 3, and 6. Predictive factors for CR-POPF and the bacteria involved in PBC were investigated. RESULTS CR-POPF occurred in 86 (23.2%) patients. In multivariate analysis, PBC on POD1 (Odds ratio [OR] = 3.59; P = 0.005) was one of the main independent predictive factors for CR-POPF, while prophylactic use of antibiotics other than piperacillin/tazobactam independently influenced PBC on POD1 (OR = 2.95; P = 0.010). Notably, Enterococcus spp., particularly Enterococcus faecalis, were significantly isolated from PBC in patients with CR-POPF compared to those without CR-POPF on PODs 1 and 3 (P < 0.001), and they displayed high resistance to all cephalosporins. CONCLUSIONS Early PBC plays a pivotal role in the development of CR-POPF following PD. Prophylactic antibiotic administration, specifically targeting Enterococcus faecalis, may effectively mitigate early PBC and subsequently reduce the risk of CR-POPF. This research sheds light on the importance of bacterial control strategies in preventing CR-POPF after PD.
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Affiliation(s)
- Norihisa Kimura
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan.
| | - Keinosuke Ishido
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan
| | - Taiichi Wakiya
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan
| | - Hayato Nagase
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan
| | - Tadashi Odagiri
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan
| | - Yusuke Wakasa
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan
| | - Kenichi Hakamada
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan
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Suto H, Matsukawa H, Ando Y, Oshima M, Fuke T, Norikane T, Sanomura T, Kamada H, Kobara H, Masaki T, Kumamoto K, Okano K. A combined score for predicting clinically relevant postoperative pancreatic fistula based on inflammatory parameters and drainage fluid culture results on postoperative day 3. World J Surg 2024; 48:1231-1241. [PMID: 38448035 DOI: 10.1002/wjs.12131] [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: 10/03/2023] [Accepted: 02/25/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatic resection can lead to severe postoperative complications. POPF is defined based on postoperative day (POD) 3 drainage fluid amylase level. POPF correlates with inflammatory parameters as well as drainage fluid bacterial infection. However, a standardized model based on these factors for predicting CR-POPF remains elusive. We aimed to identify inflammatory parameter- and drainage fluid culture-related risk factors for CR-POPF on POD 3 after pancreatoduodenectomy (PD) and distal pancreatectomy (DP). METHODS Data from 351 patients who underwent PD or DP between 2013 and 2022 at a single institution were retrospectively analyzed. Risk factors for CR-POPF were investigated using multivariate analyses, and a prediction model combining the risk factors for CR-POPF was developed. RESULTS Of the 351 patients, 254 and 97 underwent PD and DP, respectively. Multivariate analyses revealed that drainage fluid amylase level ≥722 IU/L, culture positivity, as well as neutrophil count ≥5473/mm3 on POD 3 were independent risk factors for CR-POPF in PD group. Similarly, drainage fluid, amylase level ≥500 IU/L, and culture positivity on POD 3 as well as pancreatic thickness ≥11.1 mm were independent risk factors in the DP group. The model for predicting CR-POPF achieved the maximum overall accuracy rate when the number of risk factors was ≥2 in both the PD and DP groups. CONCLUSIONS Inflammatory parameters on POD 3 significantly influence the risk of CR-POPF onset after pancreatectomy. The combined models based on these values can accurately predict the risk of CR-POPF after pancreatectomy.
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Affiliation(s)
- Hironobu Suto
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan
| | - Hiroyuki Matsukawa
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan
| | - Yasuhisa Ando
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan
| | - Minoru Oshima
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan
| | - Takuro Fuke
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan
| | - Takashi Norikane
- Department of Radiology, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan
| | - Takayuki Sanomura
- Department of Radiology, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan
| | - Hideki Kamada
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan
| | - Hideki Kobara
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan
| | - Tsutomu Masaki
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan
| | - Kensuke Kumamoto
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan
| | - Keiichi Okano
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kita-gun, Kagawa, Japan
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Mukai S, Itoi T. Preoperative endoscopic ultrasound-guided biliary drainage for primary drainage in obstructive jaundice. Expert Rev Gastroenterol Hepatol 2023; 17:1197-1204. [PMID: 38124621 DOI: 10.1080/17474124.2023.2293813] [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: 03/28/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION Endoscopic transpapillary approach by endoscopic retrograde cholangiopancreatography (ERCP) is the established technique for preoperative biliary drainage (PBD). Recently, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been reported to be a useful alternative technique after ERCP fail. However, the optimal strategy remain controversial. AREA COVERED This review summarizes the literature on EUS-BD techniques for PBD with a literature search using PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials database between 2000 and 2023 using keywords for 'preoperative biliary drainage' and all types of EUS-BD techniques. EXPERT OPINION As there is no consensus on the optimal EUS-BD technique for PBD, selection of the EUS-BD approach depends on the patient's condition, the biliary obstruction site, the anastomosis after surgical intervention, and the preference of the endoscopist. However, we consider that EUS-HGS using a dedicated plastic stent may have some advantages in the adverse impact of surgical procedure because the location where the fistula is created by EUS-HGS is away from the site of the surgical procedure. Although there remain many issues that require further investigation, EUS-BD can be a feasible and safe alternative method of PBD for malignant biliary obstruction after ERCP fail.
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Affiliation(s)
- Shuntaro Mukai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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Positive drain fluid culture on postoperative day 1 predicts clinically relevant pancreatic fistula in early drain removal with higher drain fluid amylase after pancreaticoduodenectomy. Surgery 2023; 173:511-520. [PMID: 36402610 DOI: 10.1016/j.surg.2022.10.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 09/07/2022] [Accepted: 10/05/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND This study aimed to clarify the risk factors of clinically relevant pancreatic fistula after early drain removal with higher drain fluid amylase after pancreaticoduodenectomy. Clinical evaluation of early drain removal with a higher drain fluid amylase after pancreaticoduodenectomy has been controversial. The safety and effectiveness have not been sufficiently examined. METHODS Between 2015 and 2020, prophylactic surgical drains were prospectively removed on postoperative day 4 regardless of drain fluid amylase level in 364 study-eligible patients who underwent pancreaticoduodenectomy. Patients were classified according to drain fluid amylase on postoperative day 1: 281 patients with drain fluid amylase <4,000 U/L, and 83 patients with drain fluid amylase ≥4,000 U/L. RESULTS Clinically relevant pancreatic fistula occurred in 40 of 364 enrolled patients (11.0%). In the entire cohort, male, positive postoperative day 1 drain fluid culture, and postoperative day 1 drain fluid amylase ≥4,000 U/L were independent risk factors for clinically relevant pancreatic fistula after early drain removal. When stratifying by 4,000 U/L of postoperative day 1 drain fluid amylase, the rate of clinically relevant pancreatic fistula in postoperative day 1 drain fluid amylase <4,000 U/L was significantly lower than that in postoperative day 1 drain fluid amylase ≥4,000 U/L (4% vs 35%, P < .001) after early drain removal. Moreover, in postoperative day 1 drain fluid amylase <4,000 U/L, positive postoperative day 1 drain fluid culture did not develop clinically relevant pancreatic fistula after early drain removal. However, in postoperative day 1 drain fluid amylase ≥4,000 U/L, multivariate analysis clarified that positive postoperative day 1 drain fluid culture was the only independent risk factor of clinically relevant pancreatic fistula after early drain removal (odds ratio 26.27, 95% confidence interval 5.59-123.56, P = .001). CONCLUSION Positive drain fluid culture on postoperative day 1 might predict clinically relevant pancreatic fistula in early drain removal with a higher drain fluid amylase.
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Okui J, Obara H, Uno S, Sato Y, Shimane G, Takeuchi M, Kawakubo H, Kitago M, Okabayashi K, Kitagawa Y. Adverse effects of long-term drain placement and the importance of direct aspiration: a retrospective cohort study. J Hosp Infect 2023; 131:156-163. [PMID: 36370963 DOI: 10.1016/j.jhin.2022.10.010] [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: 07/07/2022] [Revised: 09/20/2022] [Accepted: 10/31/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Long-term placement of prophylactic drains may result in retrograde infections. AIM To investigate the association between the timing of drain removal and clinical outcomes. METHODS This retrospective, single-centre cohort study evaluated 110 patients who underwent elective gastrointestinal or hepatopancreatobiliary surgery and developed subsequent organ/space surgical site infection (SSI) between 2016 and 2020. The difference between the culture-positive species of prophylactic drains and direct aspiration was evaluated; whether the prophylactic drains functioned effectively at the time of SSI diagnosis; and whether the empirical antibiotics administered before drainage were effective against all the detected bacteria. Finally, clinical outcomes were compared between early (i.e. cases wherein the prophylactic drain had already been removed or replaced at the time of SSI diagnosis) and late (removal after diagnosis) drain removal. FINDINGS The prophylactic drains functioned effectively in only 27 (25%) patients at the time of SSI diagnosis. Due to the results of direct aspiration cultures, 43% of patients required antibiotic escalation. The median time to drain removal or first replacement was seven postoperative days. The early removal group included 43 patients (39%). Compared with early removal, late removal resulted in a higher frequency of vancomycin use (7.0% vs 22.4%; P = 0.037). CONCLUSION Prolonged prophylactic drain placement is associated with complicated infections requiring vancomycin; therefore, the drains should be removed as soon as possible. Additionally, obtaining the cultures of direct aspiration should be actively considered, as escalation of antimicrobial therapy is often performed based on culture results.
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Affiliation(s)
- J Okui
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan; Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - H Obara
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan.
| | - S Uno
- Department of Infectious Diseases, Keio University School of Medicine, Tokyo, Japan
| | - Y Sato
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - G Shimane
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - M Takeuchi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - H Kawakubo
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - M Kitago
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - K Okabayashi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Y Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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Rykina-Tameeva N, Samra JS, Sahni S, Mittal A. Drain fluid biomarkers for prediction and diagnosis of clinically relevant postoperative pancreatic fistula: A narrative review. World J Gastrointest Surg 2022; 14:1089-1106. [PMID: 36386401 PMCID: PMC9640330 DOI: 10.4240/wjgs.v14.i10.1089] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 09/16/2022] [Accepted: 10/14/2022] [Indexed: 02/07/2023] Open
Abstract
Clinically relevant postoperative pancreatic fistula (CR-POPF) has continued to compromise patient recovery post-pancreatectomy despite decades of research seeking to improve risk prediction and diagnosis. The current diagnostic criteria for CR-POPF requires elevated drain fluid amylase to present alongside POPF-related complications including infection, haemorrhage and organ failure. These worrying sequelae necessitate earlier and easily obtainable biomarkers capable of reflecting evolving CR-POPF. Drain fluid has recently emerged as a promising source of biomarkers as it is derived from the pancreas and hence, capable of reflecting its postoperative condition. The present review aims to summarise the current knowledge of CR-POPF drain fluid biomarkers and identify gaps in the field to invigorate future research in this critical area of clinical need. These findings may provide robust diagnostic alternatives for CR-POPF and hence, to clarify their clinical utility require further reports detailing their diagnostic and/or predictive accuracy.
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Affiliation(s)
| | - Jaswinder S Samra
- Northern Clinical School, University of Sydney, St Leonards 2065, Australia
| | - Sumit Sahni
- Northern Clinical School, University of Sydney, St Leonards 2065, Australia
| | - Anubhav Mittal
- Northern Clinical School, University of Sydney, St Leonards 2065, Australia
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Li Y, Sun Y, Liu Z, Li Y, Gou S. Active drain system with reticulated open-pore foam-surface dressing for postoperative pancreatic fistula in a rat model. Ann Med Surg (Lond) 2021; 68:102559. [PMID: 34386219 PMCID: PMC8346361 DOI: 10.1016/j.amsu.2021.102559] [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: 05/31/2021] [Accepted: 07/10/2021] [Indexed: 02/07/2023] Open
Abstract
Background Postoperative pancreatic fistula (POPF) is one of the most harmful complications after pancreatic resection. Efficient drainage affects the clinical outcome of POPF. Inefficient drain of the fluid collection should contribute greatly to the need of additional interventional drainage, secondary morbid complications, and death. Methods A rat model of POPF was established by distal pancreatosplenectomy. A novel active drain system (ADS) for POPF was developed by wrapping polyvinyl alcohol sponges (PVA) to an end of the drainage tube. Passive drain system (PDS), ADS and ADS with PVA were used for POPF in rat models. The volume and amylase of ascites were measured. CT scan was applied to assess abdominal fluid collection. Rats pancreatic transection stumps were stained by hematoxylin and eosin (H&E). Results The volume of drainage of ADS with PVA group was less than that of PDS group and ADS group at late stage. CT scan showed obvious abdominal fluid collections in 2/8, 2/8 and 0/8 rats in PDS, ADS and ADS with PVA group separately. Macrofindings showed significant intra-abdominal adhesions and inflammation in PDS and ADS group but not in ADS with PVA group. H&E staining showed less inflammatory cells and destroyed pancreatic glands in ADS with PVA group. Conclusion ADS with PVA drained ascites effectively in the rat model of POPF. The effective drainage of pancreatic juice reduced the inflammation of abdominal organs and pancreatic resection stumps, and might promote the healing of POPF.
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Affiliation(s)
- Yang Li
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ying Sun
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Zhiqiang Liu
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yongfeng Li
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Shanmiao Gou
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
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Ju JW, Park SJ, Yoon S, Lee HJ, Kim H, Lee HC, Kim WH, Jang JY. Detrimental effect of intraoperative hypothermia on pancreatic fistula after pancreaticoduodenectomy: A single-centre retrospective study. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 28:983-992. [PMID: 34174019 DOI: 10.1002/jhbp.1017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 06/01/2021] [Accepted: 06/15/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Although perioperative hypothermia was found to be associated with gastrointestinal anastomotic leakage in preclinical studies, its association with postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy was never evaluated. We investigated the association between intraoperative hypothermia and clinically relevant (CR)-POPF following pancreaticoduodenectomy. METHODS We retrospectively reviewed 2163 consecutive patients who underwent pancreaticoduodenectomy during 2007-2019. Based on intraoperative time-weighted average core temperature, patients were grouped into normothermia (36.0-37.5°C), mild hypothermia (35.0-<36.0°C), and severe hypothermia (<35°C). We conducted multivariable logistic regression analysis for CR-POPF, a propensity score analysis using inverse probability of treatment weighting (IPTW) to adjust the baseline differences between the three groups, followed by multivariable logistic regression with IPTW for CR-POPF. RESULTS Among the 2008 patients analysed, 1118 (55.7%) and 120 (6.0%) had mild and severe hypothermia, respectively, and 14.2% overall incidence of CR-POPF. Severe intraoperative hypothermia was significantly associated with CR-POPF before and after IPTW (before: odds ratio [OR] 1.79, 95% confidence interval [CI]: 1.03-3.09, P = .038; after: OR 2.48, 95% CI: 1.28-4.81, P = .007); however, mild hypothermia had no significant associations. CONCLUSION Severe intraoperative hypothermia is significantly associated with the occurrence of CR-POPF following pancreaticoduodenectomy, suggesting that hypothermia is deleterious on pancreaticojejunal anastomotic healing.
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Affiliation(s)
- Jae-Woo Ju
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - So Jung Park
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Susie Yoon
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea.,Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Ho-Jin Lee
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea.,Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Hongbeom Kim
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
| | - Hyung-Chul Lee
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea.,Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Won Ho Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea.,Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Jin-Young Jang
- Department of Surgery, Seoul National University Hospital, Seoul, South Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, South Korea
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11
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Gupta N, Yelamanchi R. Pancreatic adenocarcinoma: A review of recent paradigms and advances in epidemiology, clinical diagnosis and management. World J Gastroenterol 2021; 27:3158-3181. [PMID: 34163104 PMCID: PMC8218366 DOI: 10.3748/wjg.v27.i23.3158] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/03/2021] [Accepted: 05/21/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is one of the dreaded malignancies for both the patient and the clinician. The five-year survival rate of pancreatic adenocarcinoma (PDA) is as low as 2% despite multimodality treatment even in the best hands. As per the Global Cancer Observatory of the International Agency for Research in Cancer estimates of pancreatic cancer, by 2040, a 61.7% increase is expected in the total number of cases globally. With the widespread availability of next-generation sequencing, the entire genome of the tumors is being sequenced regularly, providing insight into their pathogenesis. As invasive PDA arises from pancreatic intraepithelial neoplasia and mucinous neoplasm and intraductal papillary neoplasm, screening for them can be beneficial as the disease is curable with resection at an early stage. Routine preoperative biliary drainage has no role in patients suffering from PDA with obstructive jaundice. If performed, metallic stents are preferred over plastic ones. Minimally invasive procedures are preferred to open procedures as they have less morbidity. The duct-to-mucosa technique for pancreaticojejunostomy is presently widely practiced. The role of intraperitoneal drains after surgery for PDA is controversial. Neoadjuvant chemoradiotherapy has been proven to have a significant role both in locally advanced as well as in resectable PDA. Many new regimens and drugs have been added in the arsenal of chemoradiotherapy for metastatic disease. The roles of immunotherapy and gene therapy in PDA are being investigated. This review article is intended to improve the understanding of the readers with respect to the latest updates of PDA, which may help to trigger new research ideas and make better management decisions.
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Affiliation(s)
- Nikhil Gupta
- Department of Surgery, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, Delhi 110001, India
| | - Raghav Yelamanchi
- Department of Surgery, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, Delhi 110001, India
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12
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Fukui T, Noda H, Watanabe F, Kato T, Endo Y, Aizawa H, Kakizawa N, Iseki M, Rikiyama T. Drain output volume after pancreaticoduodenectomy is a useful warning sign for postoperative complications. BMC Surg 2021; 21:279. [PMID: 34082725 PMCID: PMC8176603 DOI: 10.1186/s12893-021-01285-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 06/01/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION The drain output volume (DOV) after pancreaticoduodenectomy (PD) is an easily assessable indicator in clinical settings. We explored the utility of the DOV as a possible warning sign of complications after PD. METHODS A total of 404 patients undergoing PD were considered for inclusion. The predictability of the DOV for overall morbidity, major complications, intraabdominal infection (IAI), clinically relevant (CR) postoperative pancreatic fistula (POPF), CR delayed gastric emptying (DGE), CR chyle leak (CL), and CR post-pancreatectomy hemorrhaging (PPH) was evaluated. RESULTS One hundred (24.8%) patients developed major complications, and 131 (32.4%) developed IAI. Regarding CR post-pancreatectomy complications, 75 (18.6%) patients developed CR-POPF, 23 (5.7%) developed CR-DGE, 20 (5.0%) developed CR-CL, and 28 (6.9%) developed CR-PPH. The median DOV on postoperative day (POD) 1 and POD 3 was 266 and 234.5 ml, respectively. A low DOV on POD 1 was an independent predictor of CR-POPF, and a high DOV on POD 3 was an independent predictor of CR-CL. A receiver operating characteristics (ROC) analysis revealed that the DOV on POD 1 had a negative predictive value (area under the curve [AUC] 0.655, sensitivity 65.0%, specificity 65.3%, 95% confidence interval [CI]: 0.587-0.724), with a calculated optimal cut-off value of 227 ml. An ROC analysis also revealed that the DOV on POD 3 had a positive predictive value (AUC 0.753, sensitivity 70.1%, specificity 75.0%, 95% CI: 0.651-0.856), with a calculated optimal cut-off value of 332 ml. CONCLUSION A low DOV on POD 1 might be a postoperative warning sign for CR-POPF, similar to high drain amylase (DA) on POD 1, high DA on POD 3, and high CRP on POD 3. When the DOV on POD 1 after PD was low, surgeons should evaluate the reasons of a low DOV. A high DOV on POD 3 was a postoperative warning sign CR-CL, and might require an appropriate management of protein loss.
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Affiliation(s)
- Taro Fukui
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Hiroshi Noda
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan.
| | - Fumiaki Watanabe
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Takaharu Kato
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Yuhei Endo
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Hidetoshi Aizawa
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Nao Kakizawa
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Masahiro Iseki
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
| | - Toshiki Rikiyama
- Department of Surgery, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama, 330-8503, Japan
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13
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Osakabe H, Nagakawa Y, Kozono S, Takishita C, Nakagawa N, Nishino H, Suzuki K, Shirota T, Hosokawa Y, Akashi M, Ishizaki T, Katsumata K, Tsuchida A. Causative bacteria associated with a clinically relevant postoperative pancreatic fistula infection after distal pancreatectomy. Surg Today 2021; 51:1813-1818. [PMID: 33907898 DOI: 10.1007/s00595-021-02287-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 02/22/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE Clinically relevant postoperative pancreatic fistulas (CR-POPF) occurring after distal pancreatectomy often cause intra-abdominal infections. We monitored the presence of bacterial contamination in the ascitic fluid after distal pancreatectomy to clarify the bacterial origin of intra-abdominal infections associated with CR-POPF. METHODS In 176 patients who underwent distal pancreatectomy, ascitic fluid bacterial cultures were performed on postoperative days (POD) 1-4 and when the drainage fluid became turbid. The association between postoperative ascitic bacterial contamination and CR-POPF incidence was investigated. RESULTS CR-POPF occurred in 18 cases (10.2%). Among the patients with CR-POPF, bacterial contamination was detected in 0% on POD 1, in 38.9% on POD 4, and in 72.2% on the day (median, day 9.5) when the drainage fluid became turbid. A univariate analysis revealed a significant difference in ascitic bacterial contamination on POD 4 (p < 0.001) and amylase level on POD 3-4 (p < 0.001). A multivariate analysis revealed the amylase level and ascitic bacterial contamination on POD 4 to be independent risk factors. CONCLUSIONS In the CR-POPF group, ascitic bacterial contamination was not observed in the early postoperative stage, but the bacterial contamination rate increased after pancreatic juice leakage occurred. Therefore, CR-POPF-related infections in distal pancreatectomy may be caused by a retrograde infection of pancreatic juice.
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Affiliation(s)
- Hiroaki Osakabe
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
| | - Shingo Kozono
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Chie Takishita
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Naoya Nakagawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Hitoe Nishino
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Kenta Suzuki
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Tomoki Shirota
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Yuichi Hosokawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Masanori Akashi
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Tetsuo Ishizaki
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Kenji Katsumata
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
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14
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Casciani F, Bassi C, Vollmer CM. Decision points in pancreatoduodenectomy: Insights from the contemporary experts on prevention, mitigation, and management of postoperative pancreatic fistula. Surgery 2021; 170:889-909. [PMID: 33892952 DOI: 10.1016/j.surg.2021.02.064] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 01/25/2021] [Accepted: 02/26/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite abundant, high-level scientific evidence, there is no consensus regarding the prevention, mitigation, and management of clinically relevant pancreatic fistula after pancreatoduodenectomy. The aim of the present investigation is three-fold: (1) to analyze the multiple decision-making points for pancreatico-enteric anastomotic creation and fistula mitigation and management after pancreatoduodenectomy, (2) to reveal the practice of contemporary experts, and (3) to indicate avenues for future research to reduce the burden of clinically relevant pancreatic fistula. METHODS A 109-item questionnaire was sent to a panel of international pancreatic surgery experts, recognized for their clinical and scientific authority. Their practice habits and thought processes regarding clinically relevant pancreatic fistula risk assessment, anastomotic construction, application of technical adjuncts, and mitigation strategies, as well as postoperative management, was explored. Sixteen clinical vignettes were presented to reveal their certain approaches to unique situations-both common and uncommon. RESULTS Sixty experts, with a cumulative 48,860 pancreatoduodenectomies, completed the questionnaire. Their median pancreatectomy/pancreatoduodenectomy case volume was 1,200 and 705 procedures, respectively, with a median career duration of 22 years and 200 indexed publications. Although pancreatico-jejunostomy reconstruction with transperitoneal drainage is the standard operative approach for most authorities, uncertainty emerges regarding the employment of objective risk stratification and adaptation of practice to risk. Concrete suggestions are offered to inform decision-making in intimidating circumstances. Early drain removal is frequently embraced, while a step-up approach is unanimously invoked to treat severe clinically relevant pancreatic fistula. CONCLUSION A comprehensive conceptual framework of 4 sequential phases of decision-making is proposed-risk assessment, anastomotic technique, mitigation strategy employment, and postoperative management. Basic science studies and outcome analyses are proposed for improvement.
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Affiliation(s)
- Fabio Casciani
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Surgery, University of Verona, Italy. https://twitter.com/F_Casciani
| | - Claudio Bassi
- Department of Surgery, University of Verona, Italy. https://twitter.com/pennsurgery
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
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15
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Matsuki R, Sugiyama M, Momose H, Kogure M, Suzuki Y, Mori T, Sakamoto Y. Double-Volume Intraoperative Lavage Reduce Bacterial Contamination After Pancreaticoduodenectomy. Am Surg 2020; 87:1025-1031. [PMID: 33295783 DOI: 10.1177/0003134820956344] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND To clarify whether double-volume peritoneal lavage can decrease the risk of clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy. MATERIALS AND METHODS Forty-nine patients who underwent pancreaticoduodenectomy and intraoperative peritoneal lavage using 6000 mL of saline before abdominal closure were studied retrospectively. Bacterial cultures of the lavage fluid were taken twice, after irrigation using 3000 mL of saline and then after an additional 3000 mL of saline. Bacterial culture of the drainage fluid was taken on day 1, and the relationship between the results of bacterial cultures and clinically relevant postoperative pancreatic fistula was examined. RESULTS Double amount of peritoneal lavage significantly decreased the incidence of positive bacterial cultures than single amount of peritoneal lavage (45% vs. 29%, P < .05). Multivariate analysis showed that positive bacterial culture of drainage fluid on day 1 and main pancreatic duct size (<3 mm) were independent risk factors for clinically relevant postoperative pancreatic fistula. A positive bacterial culture of the final lavage fluid and preoperative biliary drainage were independent factors related to a positive bacterial culture on day 1. DISCUSSION A positive bacterial culture on day 1 is an independent risk factor for clinically relevant postoperative pancreatic fistula during pancreaticoduodenectomy. Double-volume intraperitoneal lavage may be effective for reducing the incidence of clinically relevant postoperative pancreatic fistula.
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Affiliation(s)
- Ryota Matsuki
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Japan
| | - Masanori Sugiyama
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Japan
| | - Hirokazu Momose
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Japan
| | - Masaharu Kogure
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Japan
| | - Yutaka Suzuki
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Japan
| | - Toshiyuki Mori
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Japan
| | - Yoshihiro Sakamoto
- Department of Hepato-Biliary-Pancreatic Surgery, Kyorin University Hospital, Japan
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16
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Kawaida H, Kono H, Amemiya H, Hosomura N, Watanabe M, Saito R, Nakata Y, Shoda K, Shimizu H, Furuya S, Akaike H, Kawaguchi Y, Sudo M, Matusda M, Itakura J, Fujii H, Ichikawa D. Anastomosis technique for pancreatojejunostomy and early removal of drainage tubes may reduce postoperative pancreatic fistula. World J Surg Oncol 2020; 18:295. [PMID: 33183313 PMCID: PMC7661166 DOI: 10.1186/s12957-020-02067-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/26/2020] [Indexed: 12/11/2022] Open
Abstract
Background Postoperative pancreatic fistula (POPF) is one of the most serious complications after pancreaticoduodenectomy (PD). Various factors have been reported as POPF risks, but the most serious of these is soft pancreas. To reduce POPF occurrences, many changes to the PD process have been proposed. This study evaluates short-term results of anastomosis technique for PD. Methods In total, 123 patients with soft pancreases who had undergone PD at Yamanashi University between January 2012 and August 2020 were retrospectively analyzed. We divided these patients into two groups depending on the time PD was performed: a conventional group (n = 67) and a modified group (n = 56). Results The rate of clinically relevant POPF was significantly lower in the modified group than that in the conventional group (5.4% vs 22.4%, p value < 0.001), with there being only one case of POPF in the modified group. There were no cases of POPF-related hemorrhaging in the modified group. On the third day after the operation, the amylase levels in the drainage fluid for the modified group became less than half (1696 vs 650 U/L). Multivariate analysis showed that the modified method was the independent predictors to prevent clinical POPF (p value = 0.002). Conclusions Our novel anastomosis technique for pancreatojejunostomy reduced POPF in PD, especially in cases where the patient had a soft pancreas.
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Affiliation(s)
- Hiromichi Kawaida
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan.
| | - Hiroshi Kono
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Hidetake Amemiya
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Naohiro Hosomura
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Mitsuaki Watanabe
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Ryo Saito
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Yuuki Nakata
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Katsutoshi Shoda
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Hiroki Shimizu
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Shinji Furuya
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Hidenori Akaike
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Yoshihiko Kawaguchi
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Makoto Sudo
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Masanori Matusda
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Jun Itakura
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Hideki Fujii
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
| | - Daisuke Ichikawa
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Chuo-shi, Yamanashi, 409-3898, Japan
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17
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Ohgi K, Yamamoto Y, Sugiura T, Okamura Y, Ito T, Ashida R, Uesaka K. The clinical impact and risk factors of latent pancreatic fistula after pancreatoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:1002-1010. [DOI: 10.1002/jhbp.820] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/29/2020] [Accepted: 08/07/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Katsuhisa Ohgi
- Division of Hepato‐Biliary‐Pancreatic Surgery Shizuoka Cancer Center Shizuoka Japan
| | - Yusuke Yamamoto
- Division of Hepato‐Biliary‐Pancreatic Surgery Shizuoka Cancer Center Shizuoka Japan
| | - Teiichi Sugiura
- Division of Hepato‐Biliary‐Pancreatic Surgery Shizuoka Cancer Center Shizuoka Japan
| | - Yukiyasu Okamura
- Division of Hepato‐Biliary‐Pancreatic Surgery Shizuoka Cancer Center Shizuoka Japan
| | - Takaaki Ito
- Division of Hepato‐Biliary‐Pancreatic Surgery Shizuoka Cancer Center Shizuoka Japan
| | - Ryo Ashida
- Division of Hepato‐Biliary‐Pancreatic Surgery Shizuoka Cancer Center Shizuoka Japan
| | - Katsuhiko Uesaka
- Division of Hepato‐Biliary‐Pancreatic Surgery Shizuoka Cancer Center Shizuoka Japan
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18
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Hiraki M, Miyoshi A, Sadashima E, Shinkai Y, Yasunami M, Manabe T, Kitahara K, Noshiro H. The novel early predictive marker presepsin for postoperative pancreatic fistula: A pilot study. Exp Ther Med 2020; 20:2298-2304. [PMID: 32765708 DOI: 10.3892/etm.2020.8919] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 03/26/2020] [Indexed: 12/13/2022] Open
Abstract
Postoperative pancreatic fistula (PF) is a major and serious complication that occurs after pancreaticoduodenectomy (PD). The aim of the current study was to evaluate the use of a novel biomarker, presepsin, for predicting clinically relevant postoperative pancreatic fistula (CR-POPF) after PD. A prospective pilot study was conducted using 30 consecutive patients who underwent PD. Risk factors and candidates for predictive biomarkers for CR-POPF were statistically analyzed. CR-POPF (grade B and C; determined according to the guidelines of the International Study Group of Pancreatic Fistula) occurred in 15 patients (50%). Univariate analysis revealed that certain underlying conditions, including non-pancreatic cancer, smaller pancreatic ducts and soft pancreas texture were significantly associated with CR-POPF (P=0.005, P=0.004 and P=0.014, respectively). Furthermore, on day 1 post surgery (POD1), white blood cell count (P=0.040), levels of serum amylase (P=0.002) and serum presepsin (P=0.012), and the concentration of presepsin in drainage fluid (P<0.001) were significantly increased in CR-POPF compared with non-CR-POPF cases. Receiver operating characteristic curve analyses revealed that, on POD1, serum amylase and the concentration of presepsin in drainage fluid had an area under the curve value exceeding 0.8. A multivariate logistic regression analysis revealed that a higher concentration of presepsin in the drainage fluid was an independent predictive marker for CR-POPF (odds ratio, 14.503; 95% confidence interval, 1.750-120.229; P=0.013). To the best of our knowledge, the present study demonstrated for the first time that presepsin concentration in drainage fluid is a useful marker of CR-POPF after PD.
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Affiliation(s)
- Masatsugu Hiraki
- Department of Surgery, Saga Medical Center Koseikan, Saga 840-8571, Japan
| | - Atsushi Miyoshi
- Department of Surgery, Saga Medical Center Koseikan, Saga 840-8571, Japan
| | - Eiji Sadashima
- Life Science Research Institution, Saga Medical Center Koseikan, Saga 840-8571, Japan
| | - Yukio Shinkai
- Clinical Laboratory, Saga Medical Center Koseikan, Saga 840-8571, Japan
| | - Michio Yasunami
- Clinical Laboratory, Saga Medical Center Koseikan, Saga 840-8571, Japan
| | - Tatsuya Manabe
- Department of Surgery, Saga University Faculty of Medicine, Saga 849-8501, Japan
| | - Kenji Kitahara
- Department of Surgery, Saga Medical Center Koseikan, Saga 840-8571, Japan
| | - Hirokazu Noshiro
- Department of Surgery, Saga University Faculty of Medicine, Saga 849-8501, Japan
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19
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Akashi M, Nagakawa Y, Hosokawa Y, Takishita C, Osakabe H, Nishino H, Katsumata K, Akagi Y, Itoi T, Tsuchida A. Preoperative cholangitis is associated with increased surgical site infection following pancreaticoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:640-647. [DOI: 10.1002/jhbp.783] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/21/2020] [Accepted: 05/03/2020] [Indexed: 01/08/2023]
Affiliation(s)
- Masanori Akashi
- Department of Gastrointestinal and Pediatric Surgery Tokyo Medical University Tokyo Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery Tokyo Medical University Tokyo Japan
| | - Yuichi Hosokawa
- Department of Gastrointestinal and Pediatric Surgery Tokyo Medical University Tokyo Japan
| | - Chie Takishita
- Department of Gastrointestinal and Pediatric Surgery Tokyo Medical University Tokyo Japan
| | - Hiroaki Osakabe
- Department of Gastrointestinal and Pediatric Surgery Tokyo Medical University Tokyo Japan
| | - Hitoe Nishino
- Department of Gastrointestinal and Pediatric Surgery Tokyo Medical University Tokyo Japan
| | - Kenji Katsumata
- Department of Gastrointestinal and Pediatric Surgery Tokyo Medical University Tokyo Japan
| | - Yoshito Akagi
- Department of Surgery Kurume University School of Medicine Fukuoka Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology Tokyo Medical University Tokyo Japan
| | - Akihiko Tsuchida
- Department of Gastrointestinal and Pediatric Surgery Tokyo Medical University Tokyo Japan
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20
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Nakamura K, Sho M, Kinoshita S, Akahori T, Nagai M, Nakagawa K, Takagi T, Ikeda N. New insight into the association between bile infection and clinically relevant pancreatic fistula in patients undergoing pancreatoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:992-1001. [PMID: 32506812 DOI: 10.1002/jhbp.781] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/30/2020] [Accepted: 05/21/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND The association between bacterial infection and clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD) has not been fully elucidated. METHODS Microbiological data for intraoperative bile culture (BC) and drain culture on postoperative day 4 (DC) were collected. The study population was classified into the following three groups: P1 (positive BC and DC), P2 (positive BC and negative DC), and N (negative BC). A total of 209 patients (P1: 38, P2: 72, and N: 99) who underwent PD between May 2013 and May 2018 met the inclusion criteria of the study. RESULTS The rate of CR-POPF was significantly higher in the P1 group (34.2%) than in the P2 (12.5%; P = .007) and N groups (14.1%; P = .008). Between P1 and P2 groups, a significant difference was observed in the proportion of Enterococcus faecalis grown in BC (42.1% vs 4.2%; P < .001). Multivariable logistic regression analysis showed that the presence of E faecalis in bile was independently associated with CR-POPF. CONCLUSIONS The detection of both bile and postoperative abdominal fluid infections can be more accurate in predicting CR-POPF. Furthermore, the presence of E faecalis in bile may serve as a novel surrogate marker for CR-POPF.
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Affiliation(s)
- Kota Nakamura
- Department of Surgery, Nara Medical University, Kashihara, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Kashihara, Japan
| | | | - Takahiro Akahori
- Department of Surgery, Nara Medical University, Kashihara, Japan
| | - Minako Nagai
- Department of Surgery, Nara Medical University, Kashihara, Japan
| | - Kenji Nakagawa
- Department of Surgery, Nara Medical University, Kashihara, Japan
| | - Tadataka Takagi
- Department of Surgery, Nara Medical University, Kashihara, Japan
| | - Naoya Ikeda
- Department of Surgery, Nara Medical University, Kashihara, Japan
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21
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Smits FJ, Molenaar IQ, Besselink MG, Borel Rinkes IHM, van Eijck CHJ, Busch OR, van Santvoort HC. Early recognition of clinically relevant postoperative pancreatic fistula: a systematic review. HPB (Oxford) 2020; 22:1-11. [PMID: 31445782 DOI: 10.1016/j.hpb.2019.07.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 06/14/2019] [Accepted: 07/13/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Early recognition of postoperative pancreatic fistula might decrease the risk of subsequent life threatening complications. The aim of this review was to systematically evaluate the accuracy of postoperative clinical, biochemical and radiologic variables for early recognition of clinically relevant postoperative pancreatic fistula. METHODS A systematic literature search was performed up to August 2018. Clinical studies reporting on the association between postoperative variables and clinically relevant postoperative pancreatic fistula were included. Variables were stratified: early prediction (postoperative day 1-2) versus early diagnosis (day 3) and had to be reported in 2 cohorts. RESULTS Overall, 37 included studies reported on 17 different diagnostic variables after 8701 pancreatic resections. Clinically relevant postoperative pancreatic fistula occurred in 1532/8701 patients (18%). Early prediction variables included elevated serum and drain amylase (day 1). Identified variables for early diagnosis were: non-serous drain efflux (day 3); positive drain culture (day 3); elevated temperature (any day); elevated C-Reactive Protein (CRP; day 4); elevated white blood cell count (day 4) and peripancreatic collections on computed tomography (CT; day 5-10). CONCLUSION This review provides a comprehensive overview of postoperative variables associated with clinically relevant pancreatic fistula. Incorporation of variables in future algorithms could potentially mitigate the clinical impact of postoperative pancreatic fistula.
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Affiliation(s)
- F Jasmijn Smits
- Dept. of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584CX, Utrecht, the Netherlands
| | - I Quintus Molenaar
- Dept. of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584CX, Utrecht, the Netherlands; Dept. of Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, the Netherlands
| | - Marc G Besselink
- Dept. of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Inne H M Borel Rinkes
- Dept. of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584CX, Utrecht, the Netherlands
| | - Casper H J van Eijck
- Dept. of Surgery, Erasmus Medical Center, 's-Gravendijkwal 230, 3015 CE, Rotterdam, the Netherlands
| | - Olivier R Busch
- Dept. of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Hjalmar C van Santvoort
- Dept. of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584CX, Utrecht, the Netherlands; Dept. of Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, the Netherlands.
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22
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Yang F, Jin C, Hao S, Fu D. Drain Contamination after Distal Pancreatectomy: Incidence, Risk Factors, and Association with Postoperative Pancreatic Fistula. J Gastrointest Surg 2019; 23:2449-2458. [PMID: 30815778 DOI: 10.1007/s11605-019-04155-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 02/05/2019] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Distal pancreatectomy (DP) remains associated with significant morbidity, but little data is available about the clinical significance of drain contamination. We explored the incidence, risk factors, and association with surgical outcomes of positive drainage culture (PDC) after DP. In addition, the predictive capacity of early PDC for postoperative pancreatic fistula (POPF) was evaluated. METHODS We retrospectively analyzed our prospectively collected database of patients who underwent DP between January 2005 and December 2015. Surveillance drainage cultures for microorganisms were conducted until drain removal or positive culture. The relationships between clinical variables and PDC were examined. RESULTS Of 480 consecutive cases who underwent DP, 176 (36.7%) had PDC. One hundred twelve patients (23.3%) developed POPF according to the 2016 ISGPS definition, with the 90-day mortality rate of 0.2%. Staphylococcus spp. was the most frequent isolate. Thirty-eight (21.6%) patients had PDC within 3 days after surgery, and 129 (73.3%) within the first 7 days of operation. Body mass index (BMI) ≥ 25 kg/m2 and massive intraoperative blood loss were independent predictors for PDC. PDC had a negative impact on surgical outcomes, including POPF. Early PDC was identified as a newly independent risk factor for POPF. Compared with other microorganisms, those contaminated with Staphylococcus and Klebsiella had higher incidences of POPF. CONCLUSIONS PDC occurs commonly after DP and plays a critical role in the development of surgical morbidities including POPF. Extreme caution is warranted in patients involving contamination with specific types of microorganisms.
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Affiliation(s)
- Feng Yang
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China.
| | - Chen Jin
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China
| | - Sijie Hao
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China
| | - Deliang Fu
- Department of Pancreatic Surgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, 200040, China.
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Søreide K, Healey AJ, Mole DJ, Parks RW. Pre-, peri- and post-operative factors for the development of pancreatic fistula after pancreatic surgery. HPB (Oxford) 2019; 21:1621-1631. [PMID: 31362857 DOI: 10.1016/j.hpb.2019.06.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/03/2019] [Accepted: 06/09/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND The most hazardous complication to pancreatic surgery is the development of a post-operative pancreatic fistula (POPF). Appropriate understanding of the underlying pathophysiology, risk factors and perioperative mechanisms may allow for better management and use of preventive measures. METHODS Systematic literature search using the English PubMed literature up to April 2019, with emphasis on the past 5 years. RESULTS Several risk scores have been developed but none are perfect in predicting POPF risk. A conceptual framework of factors that contribute to the pathophysiology of pancreatic fistulae is still developing but incomplete. Recognized factors include those related to the patient, the pathology and the perioperative care. Interventions such as use of drains, stents and various drugs to mediate risk is still debated. Emerging data suggest that both the microbiome and the inflammation in the post-operative phase may play important roles in risk for POPF. Available risk scores allow for stratification of risk and mitigation strategies tailored to reduce this. However, accurate estimation of risk remains a challenge and mechanisms are only partially understood. CONCLUSIONS The pathophysiology of POPF remains poorly understood. Current models only partially explain risks or associated mechanisms. Novel areas of investigation need to be explored for better prediction.
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Affiliation(s)
- Kjetil Søreide
- Clinical Surgery, University of Edinburgh, UK; Hepatobiliary and Pancreatic Surgery, Royal Infirmary of Edinburgh, UK; Department of Gastrointestinal Surgery, HPB Unit, Stavanger University Hospital, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway; Gastrointestinal Translational Research Unit, Laboratory for Molecular Biology, Stavanger University Hospital, Stavanger, Norway.
| | - Andrew J Healey
- Hepatobiliary and Pancreatic Surgery, Royal Infirmary of Edinburgh, UK
| | - Damian J Mole
- Clinical Surgery, University of Edinburgh, UK; Hepatobiliary and Pancreatic Surgery, Royal Infirmary of Edinburgh, UK
| | - Rowan W Parks
- Clinical Surgery, University of Edinburgh, UK; Hepatobiliary and Pancreatic Surgery, Royal Infirmary of Edinburgh, UK
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24
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Early postoperative drainage fluid culture positivity from contaminated bile juice is predictive of pancreatic fistula after pancreaticoduodenectomy. Surg Today 2019; 50:248-257. [DOI: 10.1007/s00595-019-01885-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 08/10/2019] [Indexed: 12/12/2022]
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Kawaida H, Kono H, Hosomura N, Amemiya H, Itakura J, Fujii H, Ichikawa D. Surgical techniques and postoperative management to prevent postoperative pancreatic fistula after pancreatic surgery. World J Gastroenterol 2019; 25:3722-3737. [PMID: 31391768 PMCID: PMC6676555 DOI: 10.3748/wjg.v25.i28.3722] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/20/2019] [Accepted: 06/26/2019] [Indexed: 02/06/2023] Open
Abstract
Postoperative pancreatic fistula (POPF) is one of the most severe complications after pancreatic surgeries. POPF develops as a consequence of pancreatic juice leakage from a surgically exfoliated surface and/or anastomotic stump, which sometimes cause intraperitoneal abscesses and subsequent lethal hemorrhage. In recent years, various surgical and perioperative attempts have been examined to reduce the incidence of POPF. We reviewed several well-designed studies addressing POPF-related factors, such as reconstruction methods, anastomotic techniques, stent usage, prophylactic intra-abdominal drainage, and somatostatin analogs, after pancreaticoduodenectomy and distal pancreatectomy, and we assessed the current status of POPF. In addition, we also discussed the current status of POPF in minimally invasive surgeries, laparoscopic surgeries, and robotic surgeries.
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Affiliation(s)
- Hiromichi Kawaida
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, Yamanashi 409-3898, Japan
| | - Hiroshi Kono
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, Yamanashi 409-3898, Japan
| | - Naohiro Hosomura
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, Yamanashi 409-3898, Japan
| | - Hidetake Amemiya
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, Yamanashi 409-3898, Japan
| | - Jun Itakura
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, Yamanashi 409-3898, Japan
| | - Hideki Fujii
- Department of Surgery, Kofu Manicipal Hospital, Yamanashi 400-0832, Japan
| | - Daisuke Ichikawa
- First Department of Surgery, Faculty of Medicine, University of Yamanashi, Yamanashi 409-3898, Japan
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26
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Bacterial smear test of drainage fluid after pancreaticoduodenectomy can predict postoperative pancreatic fistula. Pancreatology 2019; 19:274-279. [PMID: 30718188 DOI: 10.1016/j.pan.2019.01.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 01/21/2019] [Accepted: 01/23/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES It is widely accepted that postoperative pancreatic fistula (POPF) accompanied by bacterial infection results in a worse outcome than POPF alone. However, few studies evaluating predictive indicators of POPF have focused on bacterial infection. METHODS A consecutive 100 patients who underwent pancreaticoduodenectomy at our institute for periampullary disease were enrolled. POPF was assessed according to the International Study Group of Pancreatic Fistula consensus guidelines; grades B and C were defined as clinically relevant POPF (CR-POPF). The patients' characteristics, perioperative surgical factors, and laboratory data including the results of culture and smear testing performed using drainage fluid on postoperative days (PODs) 1 and 3 were analyzed. RESULTS The overall incidence of CR-POPF was 25%. Univariate analyses revealed that the factors associated with CR-POPF were male sex, soft pancreas, MPD diameter, higher serum C-reactive protein concentration and white blood cell count on POD 3, higher amylase concentration in drainage fluid, and culture and/or smear positivity of drainage fluid. Multivariate analysis newly revealed that the smear positivity of drainage fluid on POD 3 was the independent risk factors for CR-POPF (p = 0.027). CONCLUSIONS Smear positivity of drainage fluid on POD 3 after pancreaticoduodenectomy may be a new predictor of CR-POPF.
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27
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Plat VD, van Gaal N, Covington JA, Neal M, de Meij TG, van der Peet DL, Zonderhuis B, Kazemier G, de Boer NK, Daams F. Non-Invasive Detection of Anastomotic Leakage Following Esophageal and Pancreatic Surgery by Urinary Analysis. Dig Surg 2019; 36:173-180. [PMID: 29909416 PMCID: PMC6482982 DOI: 10.1159/000488007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 02/22/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Esophagectomy or pancreaticoduodenectomy is the standard surgical approach for patients with tumors of the esophagus or pancreatic head. Postoperative mortality is strongly correlated with the occurrence of anastomotic leakage (AL). Delay in diagnosis leads to delay in treatment, which ratifies the need for development of novel and accurate non-invasive diagnostic tests for detection of AL. Urinary volatile organic compounds (VOCs) reflect the metabolic status of an individual, which is associated with a systemic immunological response. The aim of this study was to determine the diagnostic accuracy of urinary VOCs to detect AL after esophagectomy or pancreaticoduodenectomy. METHODS In the present study, urinary VOCs of 63 patients after esophagectomy (n = 31) or pancreaticoduodenectomy (n = 32) were analyzed by means of field asymmetric ion mobility spectrometry. AL was defined according to international study groups. RESULTS AL was observed in 15 patients (24%). Urinary VOCs of patients with AL after pancreaticoduodenectomy could be distinguished from uncomplicated controls, area under the curve 0.85 (95% CI 0.76-0.93), sensitivity 76%, and specificity 77%. However, this was not observed following esophagectomy, area under the curve 0.51 (95% CI 0.37-0.65). CONCLUSION In our study population AL following pancreaticoduodenectomy could be discriminated from uncomplicated controls by means of urinary VOC analysis, NTC03203434.
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Affiliation(s)
- Victor D. Plat
- Department of Gastrointestinal surgery, VU University Medical Center, Amsterdam, The Netherlands,*Victor D. Plat, BSc, Department of Gastrointestinal Surgery, VU University Medical Center, De Boelelaan 1117, ZH 7F020, NL–1081 HV Amsterdam (The Netherlands), E-Mail
| | - Nora van Gaal
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Matthew Neal
- Department of Statistics, University of Warwick, Coventry, United Kingdom
| | - Tim G.J. de Meij
- Department of Pediatric Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands
| | - Donald L. van der Peet
- Department of Gastrointestinal surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Babs Zonderhuis
- Department of Gastrointestinal surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Geert Kazemier
- Department of Gastrointestinal surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Nanne K.H. de Boer
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, The Netherlands
| | - Freek Daams
- Department of Gastrointestinal surgery, VU University Medical Center, Amsterdam, The Netherlands
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28
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Loos M, Strobel O, Legominski M, Dietrich M, Hinz U, Brenner T, Heininger A, Weigand MA, Büchler MW, Hackert T. Postoperative pancreatic fistula: Microbial growth determines outcome. Surgery 2018; 164:1185-1190. [PMID: 30217397 DOI: 10.1016/j.surg.2018.07.024] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/07/2018] [Accepted: 07/11/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula is a dangerous complication in pancreatic surgery. This study assessed the impact of microbiologic pathogens detected in postoperative pancreatic fistula on clinical outcomes after partial pancreatoduodenectomy and distal pancreatectomy. METHODS Microorganisms in postoperative pancreatic fistula were identified by microbiologic analyses from abdominal drains or intraoperative swabs during relaparotomy. Demographic, operative, and microbiologic data, as well as postoperative outcomes were examined. RESULTS Of 2,752 patients undergoing partial pancreatoduodenectomy and distal pancreatectomy, 256 patients with clinically relevant postoperative pancreatic fistula (International Study Group of Pancreatic Surgery [ISGPS] grades B and C) were identified (9.3%) and microbiologic cultures were positive in 210 patients (82.0%), with a higher rate after partial pancreatoduodenectomy (95.8%) than after distal pancreatectomy (64.3%; P < .001). Microbiologic spectra differed distinctively between partial pancreatoduodenectomy and distal pancreatectomy. Detection of microorganisms in postoperative pancreatic fistula resulted in a higher morbidity and mortality, including postpancreatectomy hemorrhage (42.4% vs 21.7%; P = .009), sepsis (38.1% vs 6.5%; P < .001), wound infection (30.0% vs 6.5%; P = .001), reoperation (48.1% vs 10.9%; P < .001), hospital stay (median 42 vs 26 days; P < .001), and overall 90-day mortality (19.5% vs 4.3%; P = .013) and was identified as an independent risk factor for sepsis, wound infection, and reoperation in the multivariate analysis. CONCLUSION Detection of microorganisms in postoperative pancreatic fistula is frequent after pancreatic resection and indicates a turning point in the development of postoperative pancreatic fistula into a life-threatening condition. Whether early anti-infective therapy in combination with interventional measures or a surgical reintervention are warranted, has yet to be elucidated.
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Affiliation(s)
- Martin Loos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - Matthias Legominski
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - Maximilian Dietrich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - Ulf Hinz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - Thorsten Brenner
- Department of Anesthesiology, Heidelberg University Hospital, Germany
| | - Alexandra Heininger
- Department of Infectious Diseases, Institute of Medical Microbiology and Hygiene, University of Heidelberg, Germany
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany.
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
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Yang F, Jin C, Li J, Di Y, Zhang J, Fu D. Clinical significance of drain fluid culture after pancreaticoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2018; 25:508-517. [PMID: 30328297 DOI: 10.1002/jhbp.589] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The mechanism of infected postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy (PD) is undefined. Drain amylase has been used to predict POPF, whereas little data are available about the value of drain fluid culture. The aim was to investigate the incidence, risk factors and association with surgical outcomes of positive drainage culture (PDC) after PD. METHODS A single-center retrospective analysis was conducted of prospectively collected data from patients who underwent PD between January 2005 and December 2015. Drain fluid samples were obtained for microbiological analysis after surgery. Risk factors for PDC were evaluated, and its influence on surgical outcomes was explored. RESULTS Of 768 patients, 261 (34%) had PDC during the postoperative period. Among them, a total of 434 isolates were yielded. One hundred and seven (24.7%) were Gram-positive, 283 (65.2%) Gram-negative, and 44 (10.1%) fungi. Multivariate analysis revealed that body mass index (BMI) ≥25 kg/m2 , preoperative chemoradiation and intra-operative red blood cell transfusion were independent risk factors for PDC. PDC was associated with higher incidences of complications including POPF, major complications and reoperation, but with no correlation between the day of PDC and complications. BMI ≥25 kg/m2 , early PDC (≤3 days), main pancreatic duct <3 mm, and soft pancreas were revealed as independent predictors for POPF. There was a correlation between type of microorganisms and complications. CONCLUSION Considering the correlation between PDC and postoperative complications, preventive measures are crucial to improve outcomes after PD. Whether antibiotic treatment for early PDC will alter the clinical course of POPF needs further evaluation.
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Affiliation(s)
- Feng Yang
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
| | - Chen Jin
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
| | - Ji Li
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
| | - Yang Di
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
| | - Jing Zhang
- Department of Nursing, Huashan Hospital affiliated to Fudan University, Shanghai, China
| | - Deliang Fu
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
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30
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Yamamoto T, Satoi S, Fujii T, Yamada S, Yanagimoto H, Yamaki S, Takami H, Hirooka S, Kosaka H, Kotsuka M, Miyara T, Kodera Y. Dual-center randomized clinical trial exploring the optimal duration of antimicrobial prophylaxis in patients undergoing pancreaticoduodenectomy following biliary drainage. Ann Gastroenterol Surg 2018; 2:442-450. [PMID: 30460348 PMCID: PMC6236101 DOI: 10.1002/ags3.12209] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/25/2018] [Accepted: 08/09/2018] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES The aim of this dual-center randomized controlled trial was to determine the optimal duration of antimicrobial prophylaxis in patients treated with pancreaticoduodenectomy (PD) who underwent preoperative biliary drainage (PBD) but were without cholangitis. BACKGROUND Some reports showed that PBD in patients undergoing pancreatectomy increased the rate of perioperative complications. However, no clinical trial has evaluated the optimal duration of antimicrobial prophylaxis with a focus on patients who underwent PD following PBD. METHODS A total of 82 patients who underwent PD between March 2012 and December 2016 were randomly assigned to either a 1-day group (n = 40), in which cefozopran (CZOP) as antimicrobial prophylaxis was given only on the day of surgery, or a 5-day group (n = 42), in which CZOP was given for 5 consecutive days beginning on the day of surgery. We evaluated the incidence of infectious and other complications after PD. RESULTS Outcomes were significantly better in the 1-day group compared with the 5-day group (P < 0.05) in terms of the incidence of overall infectious complications (15% vs 36%, respectively), intra-abdominal abscess (3% vs 21%, respectively), clinically relevant postoperative pancreatic fistula (8% vs 24%, respectively), and Clavien-Dindo grade III-V complications (10% vs 31%, respectively). Duration of postoperative hospital stay was significantly shorter in the 1-day group (10 days vs 15 days, P = 0.018). Anaerobic bacteria and methicillin-resistant cocci were isolated from the drainage fluid only among patients in the 5-day group. CONCLUSION Single-day prophylactic use of CZOP is appropriate for patients who undergo PD following PBD without preoperative cholangitis.
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Affiliation(s)
| | - Sohei Satoi
- Department of SurgeryKansai Medical UniversityHirakataJapan
| | - Tsutomu Fujii
- Department of Surgery and ScienceGraduate School of Medicine and Pharmaceutical Sciences for ResearchUniversity of ToyamaToyamaJapan
| | - Suguru Yamada
- Department of Gastroenterological Surgery (Surgery II)Nagoya University Graduate School of MedicineNagoyaJapan
| | | | - So Yamaki
- Department of SurgeryKansai Medical UniversityHirakataJapan
| | - Hideki Takami
- Department of Gastroenterological Surgery (Surgery II)Nagoya University Graduate School of MedicineNagoyaJapan
| | | | - Hisashi Kosaka
- Department of SurgeryKansai Medical UniversityHirakataJapan
| | - Masaya Kotsuka
- Department of SurgeryKansai Medical UniversityHirakataJapan
| | - Takayuki Miyara
- First Department of Internal MedicineKansai Medical UniversityHirakataJapan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery (Surgery II)Nagoya University Graduate School of MedicineNagoyaJapan
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31
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Adachi T, Ono S, Matsushima H, Soyama A, Hidaka M, Takatsuki M, Eguchi S. Efficacy of Triple-Drug Therapy to Prevent Pancreatic Fistulas in Patients With High Drain Amylase Levels After Pancreaticoduodenectomy. J Surg Res 2018; 234:77-83. [PMID: 30527504 DOI: 10.1016/j.jss.2018.08.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 07/21/2018] [Accepted: 08/03/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUNDS Prior studies have suggested that drain amylase level is a predictive marker for developing pancreatic fistulas (PFs) after pancreaticoduodenectomy (PD). However, means of preventing PF after discovering high drain amylase levels have not been previously established. The purpose of this study was to evaluate the efficacy of a combination drug therapy (using three drugs; gabexate mesilate, octreotide, and carbapenem antibiotics, named as triple-drug therapy [TDT]) regimen in preventing PF for patients with high drain amylase levels on postoperative day (POD) 1 after PD. MATERIALS AND METHODS We divided the 183 patients who underwent PD into two groups in accordance with their enrollment in the study: for those enrolled early in the study (early period), TDT was not administered to patients with high drain amylase level; however, for those enrolled later in the study (late period), TDT was administered if drain amylase levels were over 10,000 IU/L on POD 1. We retrospectively compared the incidence of PF between the two groups. RESULTS Incidences of PFs were statistically, significantly prevented in the late group (early 17% versus late 6%; P = 0.01). For patients with low levels of drain amylase (<10,000 IU/L), the PF ratio was equivalent between two groups (early 8% versus late 5%; P = 0.56); however, PFs in patients with high drain amylase levels in the late period group were dramatically prevented by TDT administration (early 89% versus late 11%; P < 0.001). CONCLUSIONS TDT may be a promising therapy to prevent PFs in patients with high drain amylase levels after PD.
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Affiliation(s)
- Tomohiko Adachi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Shinichiro Ono
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hajime Matsushima
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Akihiko Soyama
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masaaki Hidaka
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Mitsuhisa Takatsuki
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.
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Affiliation(s)
- William E Fisher
- Division of General Surgery, Michael E. DeBakey Department of Surgery, Elkins Pancreas Center, Baylor College of Medicine, 6620 Main Street, Suite 1425, Houston, TX 77030, USA.
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Contaminated drainage fluid and pancreatic fistula after pancreatoduodenectomy: A retrospective study. Int J Surg 2018. [DOI: 10.1016/j.ijsu.2018.02.057] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Computer tomographic assessment of postoperative peripancreatic collections after distal pancreatectomy. Langenbecks Arch Surg 2018; 403:349-357. [DOI: 10.1007/s00423-018-1668-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 03/19/2018] [Indexed: 01/04/2023]
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Kaneko T, Imaizumi H, Kida M, Miyata E, Yamauchi H, Okuwaki K, Iwai T, Koizumi W. Influence of cholangitis after preoperative endoscopic biliary drainage on postoperative pancreatic fistula in patients with middle and lower malignant biliary strictures. Dig Endosc 2018; 30:90-97. [PMID: 28475221 DOI: 10.1111/den.12894] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 05/01/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Preoperative cholangitis after preoperative drainage has been reported to increase postoperative complications, particularly pancreatic fistula. We therefore examined the effects of cholangitis after preoperative endoscopic biliary drainage (EBD) on postoperative pancreatic fistula in patients with middle and lower malignant biliary strictures. METHODS The study group comprised 102 patients who underwent EBD among patients who underwent surgery. RESULTS Of the 102 patients, 33 (32%) had postoperative pancreatic fistulas, and 56 (55%) had preoperative cholangitis after preoperative drainage. Analysis of risk factors for preoperative cholangitis showed that a total bilirubin level of 2.9 mg/dL or higher (hazard ratio [HR], 2.95; 95% confidence interval [CI], 1.223-7.130; P = 0.016) and a surgical waiting time of 29 days or longer (HR, 4.23; 95% CI, 1.681-10.637; P = 0.02) were independent risk factors for cholangitis. Patients with preoperative cholangitis had a significantly higher incidence of pancreatic fistula than did patients without preoperative cholangitis (78.8 vs 21.2%; P = 0.001). Patients with biliary cancer had a significantly higher incidence of pancreatic fistula than did those with pancreatic cancer (72.7 vs 27.2%; P = 0.005). Multivariate analysis showed that preoperative cholangitis (HR, 4.8; 95% CI, 1.785-12.992; P = 0.001) and biliary cancer (HR, 3.5; 95% CI, 1.335-8.942; P = 0.006) were significant independent risk factors for postoperative pancreatic fistula. CONCLUSION Prevention of preoperative cholangitis, a risk factor for postoperative pancreatic fistula, is likely to decrease the incidence of postoperative pancreatic fistula.
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Affiliation(s)
- Toru Kaneko
- Department of Gastroenterology, Kitasato University Hospital, Sagamihara, Japan
| | - Hiroshi Imaizumi
- Department of Gastroenterology, Kitasato University Hospital, Sagamihara, Japan
| | - Mitsuhiro Kida
- Department of Gastroenterology, Kitasato University Hospital, Sagamihara, Japan
| | - Eiji Miyata
- Department of Gastroenterology, Kitasato University Hospital, Sagamihara, Japan
| | - Hiroshi Yamauchi
- Department of Gastroenterology, Kitasato University Hospital, Sagamihara, Japan
| | - Kosuke Okuwaki
- Department of Gastroenterology, Kitasato University Hospital, Sagamihara, Japan
| | - Tomohisa Iwai
- Department of Gastroenterology, Kitasato University Hospital, Sagamihara, Japan
| | - Wasaburo Koizumi
- Department of Gastroenterology, Kitasato University Hospital, Sagamihara, Japan
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Sato A, Masui T, Nakano K, Sankoda N, Anazawa T, Takaori K, Kawaguchi Y, Uemoto S. Abdominal contamination with Candida albicans after pancreaticoduodenectomy is related to hemorrhage associated with pancreatic fistulas. Pancreatology 2017; 17:484-489. [PMID: 28336225 DOI: 10.1016/j.pan.2017.03.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 03/06/2017] [Accepted: 03/17/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Pancreatic fistulas are one of the most frequent morbidities after pancreaticoduodenectomy. Several reports have suggested a relationship between bacterial infections and postoperative pancreatic fistulas, although details of the mechanisms involved in hemorrhage in association with the fistulas have not been elucidated. This study retrospectively examined the relationship between positive drainage culture and hemorrhage associated with pancreatic fistulas after pancreaticoduodenectomy. METHODS From January 2012 to December 2015, 142 consecutive patients underwent pancreaticoduodenectomy at our institution. We retrospectively reviewed the patients' demographic data, perioperative laboratory data, and drainage culture results. RESULTS Twenty-four (17%) patients had clinically relevant postoperative pancreatic fistulas, whereas thirty-four (24%) patients experienced positive drainage culture. Multivariable analysis revealed that positive drainage culture was independently associated with clinically relevant postoperative pancreatic fistulas (odds ratio, 18.1; 95% confidence interval, 5.5-72.2; P < 0.001). Additionally, the prevalence of Candida albicans in the lavage of eight patients significantly correlated with hemorrhage associated with pancreatic fistulas (odds ratio, 43.5; 95% confidence interval, 6.2-513.3; P < 0.001). Seventy-five percent (6/8) of these patients suffered potentially lethal hemorrhagic complications and needed intervention. CONCLUSIONS A positive abdominal drainage culture is associated with the development of pancreatic fistulas. Moreover, the presence of Candida albicans in drainage fluid may be a risk factor for hemorrhagic complications.
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Affiliation(s)
- Asahi Sato
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
| | - Toshihiko Masui
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Japan.
| | - Kenzo Nakano
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
| | - Nao Sankoda
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
| | - Takayuki Anazawa
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
| | - Kyoichi Takaori
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
| | - Yoshiya Kawaguchi
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
| | - Shinji Uemoto
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
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Rogers MB, Aveson V, Firek B, Yeh A, Brooks B, Brower-Sinning R, Steve J, Banfield JF, Zureikat A, Hogg M, Boone BA, Zeh HJ, Morowitz MJ. Disturbances of the Perioperative Microbiome Across Multiple Body Sites in Patients Undergoing Pancreaticoduodenectomy. Pancreas 2017; 46:260-267. [PMID: 27846140 PMCID: PMC5235958 DOI: 10.1097/mpa.0000000000000726] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The goals of this study were to characterize bacterial communities within fecal samples, pancreatic fluid, bile, and jejunal contents from patients undergoing pancreaticoduodenectomy (PD) and to identify associations between microbiome profiles and clinical variables. METHODS Fluid was collected from the pancreas, common bile duct, and proximal jejunum from 50 PD patients. Postoperative fecal samples were also collected. The microbial burden within samples was quantified with droplet digital polymerase chain reaction. Bacterial 16S ribosomal RNA gene sequences were amplified, sequenced, and analyzed. Data from fecal samples were compared with publicly available data obtained from volunteers. RESULTS Droplet digital polymerase chain reaction confirmed the presence of bacteria in all sample types, including pancreatic fluid. Relative to samples from the American Gut Project, fecal samples from PD patients were enriched with Klebsiella and Bacteroides and were depleted of anaerobic taxa (eg, Roseburia and Faecalibacterium). Similar patterns were observed within PD pancreas, bile, and jejunal samples. Postoperative fecal samples from patients with a pancreatic fistula contained increased abundance of Klebsiella and decreased abundance of commensal anaerobes, for example, Ruminococcus. CONCLUSIONS This study confirms the presence of altered bacterial populations within samples from PD patients. Future research must validate these findings and may evaluate targeted microbiome modifications to improve outcomes in PD patients.
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Affiliation(s)
| | - Victoria Aveson
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Brian Firek
- Division of Pediatric General and Thoracic Surgery, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Andrew Yeh
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Brandon Brooks
- Department of Earth and Planetary Sciences, University of California Berkeley, Berkeley, CA
| | | | - Jennifer Steve
- Division of GI Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jillian F. Banfield
- Department of Earth and Planetary Sciences, University of California Berkeley, Berkeley, CA
| | - Amer Zureikat
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA,Division of GI Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Melissa Hogg
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA,Division of GI Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Brian A. Boone
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA,Division of GI Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Herbert J. Zeh
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA,Division of GI Surgical Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Michael J. Morowitz
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA,Division of Pediatric General and Thoracic Surgery, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA,Address Correspondence to: Michael J. Morowitz, MD, Division of Pediatric Surgery, Children’s Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, 7th Floor Faculty Pavilion, Pittsburgh, PA 15244, , phone 412-692-7282, fax 412-692-8299
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Kiyochi H. Pathologic Assessment of Pancreatic Fibrosis for Objective Prediction of Pancreatic Fistula and Management of Prophylactic Drain Removal After Pancreaticoduodenectomy: Reply. World J Surg 2017; 39:2967-74. [PMID: 26732669 DOI: 10.1007/s00268-015-3211-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Uemura K, Satoi S, Motoi F, Kwon M, Unno M, Murakami Y. Randomized clinical trial of duct-to-mucosa pancreaticogastrostomy versus handsewn closure after distal pancreatectomy. Br J Surg 2017; 104:536-543. [PMID: 28112814 DOI: 10.1002/bjs.10458] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 10/08/2016] [Accepted: 11/14/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) remains a major cause of morbidity after distal pancreatectomy. The aim of this study was to investigate whether duct-to-mucosa pancreaticogastrostomy of the pancreatic stump decreased clinical POPF formation compared with handsewn closure after distal pancreatectomy. METHODS This multicentre RCT was performed between April 2012 and June 2014. Patients undergoing distal pancreatectomy were assigned randomly to either duct-to-mucosa pancreaticogastrostomy or handsewn closure. The primary endpoint was the incidence of clinical POPF. Secondary endpoints were rates of other complications and length of hospital stay. RESULTS Some 80 patients were randomized, and 73 patients were evaluated in an intention-to-treat analysis: 36 in the pancreaticogastrostomy group and 37 in the handsewn closure group. The duration of operation was significantly longer in the pancreaticogastrostomy group than in the handsewn closure group (mean 268 versus 197 min respectively; P < 0·001). The incidence of clinical POPF did not differ between groups (7 of 36 versus 7 of 37; odds ratio (OR) 1·03, 95 per cent c.i. 0·32 to 3·10; P = 1·000). The rate of intra-abdominal fluid collection was significantly lower in the pancreaticogastrostomy group (6 of 36 versus 21 of 37; OR 0·15, 0·05 to 0·45; P < 0·001). There were no statistically significant differences in the rates of other complications or length of hospital stay. CONCLUSION Duct-to-mucosa pancreaticogastrostomy did not reduce the incidence of clinical POPF compared with handsewn closure of the pancreatic stump after distal pancreatectomy. Registration number UMIN000007426 (http://www.umin.ac.jp).
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Affiliation(s)
- K Uemura
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - S Satoi
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - F Motoi
- Division of Gastroenterological Surgery, Department of Surgery, Tohoku University, Sendai, Japan
| | - M Kwon
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - M Unno
- Division of Gastroenterological Surgery, Department of Surgery, Tohoku University, Sendai, Japan
| | - Y Murakami
- Department of Surgery, Institute of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Ohgi K, Sugiura T, Yamamoto Y, Okamura Y, Ito T, Uesaka K. Bacterobilia may trigger the development and severity of pancreatic fistula after pancreatoduodenectomy. Surgery 2016; 160:725-30. [DOI: 10.1016/j.surg.2016.03.032] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Revised: 03/06/2016] [Accepted: 03/31/2016] [Indexed: 01/04/2023]
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Jiang H, Liu N, Zhang M, Lu L, Dou R, Qu L. A Randomized Trial on the Efficacy of Prophylactic Active Drainage in Prevention of Complications after Pancreaticoduodenectomy. Scand J Surg 2016; 105:215-222. [PMID: 27528694 DOI: 10.1177/1457496916665543] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIMS This randomized controlled trial was conducted to examine whether prophylactic active drainage decreases morbidity associated with pancreati-coduodenectomy. MATERIAL AND METHODS A prospective, randomized controlled trial was conducted between April 2010 and May 2015 when 160 consecutive patients following elective pancreaticoduodenectomy were randomized intraoperatively to either prophylactic active drainage group or conventional passive drainage group. The main objectives were the incidence of postoperative pancreatic fistula and the associated clinical outcomes. RESULTS There were 82 patients in the active drain group and 78 patients in the passive drain group. The overall pancreatic fistula rate occurred similarly in the two groups (11.0% (9/82) vs 14.1% (11/78), p = 0.360). Grade C pancreatic fistula in active drain group was significantly less than that in passive drain group (0% (0/82) vs 6.4% (5/78), p = 0.026). The mean postoperative hospital stay and parenteral nutrition support time in active drainage group were shorter than those in passive drainage group (12.6 days vs 14.5 days, p = 0.037; 6.9 days vs 8.6 days, p = 0.047, respectively). CONCLUSION Prophylactic active drainage reveals significant reduction in severity of complications associated with pancreatic fistula and might be recommended as an alternative for patients with high risk of developing serious pancreatic fistula after pancreaticoduodenectomy.
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Affiliation(s)
- H Jiang
- 1 Department of General Surgery, The Affiliated Hospital of Qingdao University Medical College, Qingdao, China
| | - N Liu
- 2 Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Clinical Nutrition Department, Peking University Cancer Hospital and Institute, Beijing, China
| | - M Zhang
- 3 Department of General Surgery, The People' Hospital of Jimo City, Qingdao, China
| | - L Lu
- 1 Department of General Surgery, The Affiliated Hospital of Qingdao University Medical College, Qingdao, China
| | - R Dou
- 1 Department of General Surgery, The Affiliated Hospital of Qingdao University Medical College, Qingdao, China
| | - L Qu
- 1 Department of General Surgery, The Affiliated Hospital of Qingdao University Medical College, Qingdao, China
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Giglio MC, Spalding DRC, Giakoustidis A, Zarzavadjian Le Bian A, Jiao LR, Habib NA, Pai M. Meta-analysis of drain amylase content on postoperative day 1 as a predictor of pancreatic fistula following pancreatic resection. Br J Surg 2016; 103:328-36. [DOI: 10.1002/bjs.10090] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 10/14/2015] [Accepted: 11/23/2015] [Indexed: 01/06/2023]
Abstract
Abstract
Background
Drain amylase content in the days immediately after major pancreatic resection has been investigated previously as a predictor of postoperative pancreatic fistula (POPF). Its accuracy, however, has not been determined conclusively. The purpose of this study was to evaluate the accuracy of drain amylase content on the first day after major pancreatic resection in predicting the occurrence of POPF.
Methods
A literature search of the MEDLINE, Embase and Scopus® databases to 13 May 2015 was performed to identify studies evaluating the accuracy of drain amylase values on day 1 after surgery in predicting the occurrence of POPF. The area under the hierarchical summary receiver operating characteristic (ROC) curve (AUChSROC) was calculated as an index of accuracy, and pooled estimates of accuracy indices (sensitivity and specificity) were calculated at different cut-off levels. Subgroup and meta-regression analyses were performed to test the robustness of the results.
Results
Thirteen studies involving 4416 patients were included. The AUChSROC was 0·89 (95 per cent c.i. 0·86 to 0·92) for clinically significant POPF and 0·88 (0·85 to 0·90) for POPF of any grade. Pooled estimates of sensitivity and specificity were calculated for the different cut-offs: 90–100 units/l (0·96 and 0·54 respectively), 350 units/l (0·91 and 0·84) and 5000 units/l (0·59 and 0·91). Accuracy was independent of the type of operation, type of anastomosis performed and octreotide administration.
Conclusion
Evaluation of drain amylase content on the first day after surgery is highly accurate in predicting POPF following major pancreatic resection. It may allow early drain removal and institution of an enhanced recovery pathway.
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Affiliation(s)
- M C Giglio
- Hepatopancreaticobiliary Surgical Unit, Department of Surgery and Cancer, Imperial College, Hammersmith Hospital Campus, Du Cane Road, London W12 0HS, UK
| | - D R C Spalding
- Hepatopancreaticobiliary Surgical Unit, Department of Surgery and Cancer, Imperial College, Hammersmith Hospital Campus, Du Cane Road, London W12 0HS, UK
| | - A Giakoustidis
- Hepatopancreaticobiliary Surgical Unit, Department of Surgery and Cancer, Imperial College, Hammersmith Hospital Campus, Du Cane Road, London W12 0HS, UK
| | - A Zarzavadjian Le Bian
- Hepatopancreaticobiliary Surgical Unit, Department of Surgery and Cancer, Imperial College, Hammersmith Hospital Campus, Du Cane Road, London W12 0HS, UK
| | - L R Jiao
- Hepatopancreaticobiliary Surgical Unit, Department of Surgery and Cancer, Imperial College, Hammersmith Hospital Campus, Du Cane Road, London W12 0HS, UK
| | - N A Habib
- Hepatopancreaticobiliary Surgical Unit, Department of Surgery and Cancer, Imperial College, Hammersmith Hospital Campus, Du Cane Road, London W12 0HS, UK
| | - M Pai
- Hepatopancreaticobiliary Surgical Unit, Department of Surgery and Cancer, Imperial College, Hammersmith Hospital Campus, Du Cane Road, London W12 0HS, UK
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Early Drain Removal--The Middle Ground Between the Drain Versus No Drain Debate in Patients Undergoing Pancreaticoduodenectomy: A Prospective Validation Study. Ann Surg 2015; 262:378-83. [PMID: 25563864 DOI: 10.1097/sla.0000000000001038] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To perform an unbiased assessment of first postoperative day (POD 1) drain amylase level and pancreatic fistula (PF) after pancreaticoduodenectomy (PD). BACKGROUND Recent evidence demonstrated that drain abandonment in PD is unsafe. Early drain amylase levels have been proposed as predictors of PF after PD, allowing for selection of patients for early drain removal. METHODS Daily drain amylase levels were correlated with the development of PF in 2 independent cohorts of patients undergoing PD: training cohort (n = 126; year 2008) and validation cohort (n = 369; years 2009-2012). RESULTS POD 1 drain amylase level had the highest predictive ability (concordance index: 0.911) for PF in the training cohort. An amylase level of 612 U/L or higher showed the best accuracy (86%), sensitivity (93%), and specificity (79%). Thus, a cutoff value of 600 U/L was utilized. In the validation cohort, 229 (62.1%) patients had a POD 1 drain amylase level of lower than 600 U/L, and PF developed in only 2 (0.9%) cases; whereas in patients with POD 1 drain amylase level of 600 U/L or higher (n = 140) the PF rate was 31.4% (odds ratio [OR] = 52, P < 0.0001). On multivariate analysis, POD 1 drain amylase level of lower than 600 U/L (OR = 0.0192, P < 0.0001) was a stronger predictor of the absence of PF than pancreatic gland texture (OR = 0.193, P = 0.002) and duct diameter (OR = 0.861, P = 0.835). CONCLUSIONS After PD, the risk of PF is less than 1% if POD 1 drain amylase level is lower than 600 U/L. We propose that in this group, which comprise more than 60% of patients, drains should be removed on POD 1.
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Adachi T, Kuroki T, Kitasato A, Hirabaru M, Matsushima H, Soyama A, Hidaka M, Takatsuki M, Eguchi S. Safety and efficacy of early drain removal and triple-drug therapy to prevent pancreatic fistula after distal pancreatectomy. Pancreatology 2015; 15:411-6. [PMID: 26073457 DOI: 10.1016/j.pan.2015.05.468] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 04/15/2015] [Accepted: 05/12/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Prior studies suggested that early drain removal prevented the development of pancreatic fistula (PF) after pancreaticoduodenectomy (PD), but there has been no corresponding prospective trial for distal pancreatectomy (DP). The purpose of this study was to determine the safety and efficacy of early drain removal and triple-drug therapy (TDT) with gabexate mesilate, octreotide and carbapenem antibiotics to prevent PF after DP in patients at high-risk of developing PF. METHODS A total 71 patients who underwent a DP were enrolled. We prospectively divided them into two groups: the late-removal group, in which the drain remained in place for at least for 5 days postoperatively (n = 30) and the early-removal group in which the drain was removed on postoperative day 1 (POD1) (n = 41). For the patients with a high drain amylase level (≥10,000 IU/L) and patients with symptomatic intraperitoneal fluid collection, our original TDT was introduced. The primary endpoint was the safety and efficacy of this management, and the secondary endpoint was the incidence of PF. RESULTS The incidence of clinical PF was significantly lower in the early-removal group (0% vs. the late removal 16%; p < 0.001). In the early-removal group, TDT was administered to 12 patients (29%) and none of the patients needed additional treatment after TDT. CONCLUSIONS Postoperative management after DP with early drain removal and TDT was safe and effective for preventing PF.
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Affiliation(s)
- Tomohiko Adachi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.
| | - Tamotsu Kuroki
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Amane Kitasato
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masataka Hirabaru
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hajime Matsushima
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Akihiko Soyama
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masaaki Hidaka
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Mitsuhisa Takatsuki
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Yamashita K, Sasaki T, Itoh R, Kato D, Hatano N, Soejima T, Ishii K, Takenawa T, Hiromatsu K, Yamashita Y. Pancreatic fistulae secondary to trypsinogen activation by Pseudomonas aeruginosa infection after pancreatoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:454-62. [PMID: 25678202 DOI: 10.1002/jhbp.223] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 01/13/2015] [Indexed: 01/27/2023]
Abstract
BACKGROUND Pancreatic fistula after pancreatoduodenectomy (PD) is associated with high mortality and morbidity. Trypsinogen activation and bacteria, although hypothesized to be interrelated etiopathogenetically, have not had their relationship and pathogenic mechanisms elucidated. This study investigated bacterial involvement in pancreatic juice activation perioperatively after PD at sites of pancreatic fistula formation. METHODS Fifty patients underwent PD; postoperative pancreatic fistulae were graded based on the International Study Group for Pancreatic Fistula grading criteria. Bacteria were isolated from cultures of drainage fluid. Digested peptides from trypsinogen and bacterial culture supernatants underwent sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) separation and mass spectrometric analysis. Zymography was used to detect the trypsinogen activator. RESULTS Pseudomonas aeruginosa and Enterobacter cloacae isolated from drainage fluid in patients with grades B and C pancreatic fistulae could cause trypsinogen activation. Trypsinogen activation by P. aeruginosa and E. cloacae were preventable by the use of a serine protease inhibitor in vitro. A protease in the supernatant from P. aeruginosa-positive cultures acted as the trypsinogen activator. CONCLUSIONS Infection with P. aeruginosa perioperatively to PD entails secretion of a protease activator of trypsinogen to trypsin. Bacterial infection control in the perioperative PD period could be crucial to prevent development of pancreatic fistula.
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Affiliation(s)
- Kanefumi Yamashita
- Department of Gastroenterological Surgery, Fukuoka University School of Medicine, Nanakuma 7-45-1, Jonan-ku, Fukuoka 814-0180, Japan
| | - Takamitsu Sasaki
- Department of Gastroenterological Surgery, Fukuoka University School of Medicine, Nanakuma 7-45-1, Jonan-ku, Fukuoka 814-0180, Japan.
| | - Ryota Itoh
- Department of Microbiology and Immunology, Fukuoka University School of Medicine, Jonan-ku, Fukuoka, Japan
| | - Daisuke Kato
- Department of Gastroenterological Surgery, Fukuoka University School of Medicine, Nanakuma 7-45-1, Jonan-ku, Fukuoka 814-0180, Japan
| | - Naoya Hatano
- Integrated Center for Mass Spectrometry, Kobe University, Kobe, Hyogo, Japan
| | - Toshinori Soejima
- Department of Microbiology and Immunology, Fukuoka University School of Medicine, Jonan-ku, Fukuoka, Japan
| | - Kazunari Ishii
- Department of Microbiology and Immunology, Fukuoka University School of Medicine, Jonan-ku, Fukuoka, Japan
| | - Tadaomi Takenawa
- Integrated Center for Mass Spectrometry, Kobe University, Kobe, Hyogo, Japan
| | - Kenji Hiromatsu
- Department of Microbiology and Immunology, Fukuoka University School of Medicine, Jonan-ku, Fukuoka, Japan
| | - Yuichi Yamashita
- Department of Gastroenterological Surgery, Fukuoka University School of Medicine, Nanakuma 7-45-1, Jonan-ku, Fukuoka 814-0180, Japan
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The value of drains as a fistula mitigation strategy for pancreatoduodenectomy: something for everyone? Results of a randomized prospective multi-institutional study. J Gastrointest Surg 2015; 19:21-30; discussion 30-1. [PMID: 25183409 DOI: 10.1007/s11605-014-2640-z] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 08/21/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND A recent randomized, controlled trial investigating intraperitoneal drain use during pancreatoduodenectomy (PD) had a primary goal of assessing overall morbidity. It was terminated early with findings that routine elimination of drains in PD increases mortality and the severity and frequency of overall complications. Here, we provide a follow-up analysis of drain value in reference to clinically relevant postoperative pancreatic fistula (CR-POPF). METHODS Nine institutions performed 137 PDs, with patients randomized to intraperitoneal drainage (N = 68) or no drainage (N = 69). The Fistula Risk Score (FRS), a 10-point scale derived from four validated risk factors for CR-POPF, facilitated risk adjustment between treatment groups. RESULTS There was no difference in fistula risk between the two cohorts. Overall, CR-POPF rates were higher in the no drain group compared to the drain group (20.3 vs. 13.2%; p = 0.269). Patients with negligible/low FRS risk had higher rates of CR-POPF when drains were used (14.8 vs. 4.0%; p = 0.352). Conversely, there were significantly fewer CR-POPFs (12.2 vs. 29.5%; p = 0.050) when drains were used with moderate/high risk patients. Lastly, moderate/high risk patients who suffered a CR-POPF had reduced 90-day mortality (22.2 vs. 42.9%) when a drain was used. CONCLUSION The results of this analysis suggest that drains diminish the rate and severity of CR-POPF in patients with moderate/high risk, but they could possibly be avoided in the roughly one third of patients with negligible/low risk.
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Sato N, Mori Y, Minagawa N, Tamura T, Shibao K, Higure A, Yamaguchi K. Rapid postoperative reduction in prognostic nutrition index is associated with the development of pancreatic fistula following distal pancreatectomy. Pancreatology 2014; 14:216-20. [PMID: 24854618 DOI: 10.1016/j.pan.2014.02.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 02/17/2014] [Accepted: 02/19/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUNDS Despite recent advances in surgical techniques and devices for pancreatic remnant closure, postoperative pancreatic fistula (POPF) still remains one of the common complications after distal pancreatectomy (DP). Identification of risk factors for POPF may lead to the development of new strategies to prevent this ominous complication. METHODS We retrospectively reviewed data on 44 patients undergoing DP with the use of a stapler to identify risk factors for POPF. Study variables included preoperative prognostic nutritional index (PNI) and reduction rate of PNI on postoperative day (POD) 7. RESULTS POPF occurred in 23 patients (52%), of which 13 (56%) were grade B or C. Univariate analyses comparing patients with POPF and those without POPF showed significant differences in body mass index (P = 0.0102), pancreatic thickness (P = 0.0134), white blood cell count on POD7 (P = 0.0432), C-reactive protein level on POD7 (P = 0.0123), and PNI reduction rate (P = 0.0471). A multivariate analysis revealed pancreatic thickness (P = 0.0121) and PNI reduction rate (P = 0.0165) to be significant factors for POPF. Furthermore, the PNI reduction rate was significantly higher in patients with clinically relevant (grade B/C) POPF than in those with no or grade A POPF (P = 0.0257). In most patients, the massive postoperative PNI reduction preceded the diagnosis of clinically relevant POPF. CONCLUSIONS These findings suggest that rapid postoperative reduction in PNI is associated with the development of POPF.
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Affiliation(s)
- Norihiro Sato
- Department of Surgery 1, University of Occupational and Environmental Health, Kitakyushu, Japan.
| | - Yasuhisa Mori
- Department of Surgery 1, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Noritaka Minagawa
- Department of Surgery 1, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Toshihisa Tamura
- Department of Surgery 1, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kazunori Shibao
- Department of Surgery 1, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Aiichiro Higure
- Department of Surgery 1, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Koji Yamaguchi
- Department of Surgery 1, University of Occupational and Environmental Health, Kitakyushu, Japan
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