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Jiménez-Romero C, de Juan Lerma A, Marcacuzco Quinto A, Caso Maestro O, Alonso Murillo L, Rioja Conde P, Justo Alonso I. Risk factors for delayed gastric emptying after pancreatoduodenectomy: a 10-year retrospective study. Ann Med 2025; 57:2453076. [PMID: 39817563 PMCID: PMC11740295 DOI: 10.1080/07853890.2025.2453076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2024] [Revised: 12/06/2024] [Accepted: 12/20/2024] [Indexed: 01/18/2025] Open
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a frequent complication of pancreatoduodenectomy (PD) and is associated with prolonged hospital stay, readmission, increased hospital costs and decreased quality of life. However, the pathophysiology of DGE remains unclear. METHODS This is a retrospective study of patients who underwent PD for pancreatic or periampullary tumours. All these patients were operated between January 2012 and February 2023. The patients were divided into four groups according to the development of DGE after PD: No DGE, DGE grade A, DGE grade B and DGE grade C. The groups were compared in terms of outcomes and complications. We also analysed the preoperative and perioperative risk factors for DGE development. RESULTS Between January 2012 and February 2023, a total of 250 patients underwent PD. These patients were divided into four groups: No DGE (n = 152); DGE grade A (n = 42); DGE grade B (n = 45); and DGE grade C (n = 11). The incidence of the postoperative pancreatic fistulas (POPFs) grade B/C was significantly higher in the DGE grade C group (p < .001), and the rates of post-pancreatectomy haemorrhage (p = .004) and reoperation (p < .001) were significantly higher in the DGE grade B/C groups. A significantly higher rate of grade III-IV Clavien-Dindo complications (p < .001), longer intensive care unit (p < .001) and longer hospital stays (p < .001) were observed in the DGE grade C group; and 90-day mortality (p < .001) and morbidity (p < .001) were significantly higher in the DGE grade B/C groups. Multivariate analysis demonstrated that the POPF grade B/C was a risk factor of DGE grade B/C (OR: 9.147; 95%CI: 4.125-20.281; p < .001). CONCLUSIONS POPF B/C is a risk factor for grade B/C DGE. Prevention of surgical complications and early treatment could contribute to the decreased incidence of DGE.
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Affiliation(s)
- Carlos Jiménez-Romero
- Department of Surgery, Faculty of Medicine, Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, Doce de Octubre University Hospital, Instituto de Investigación (imas12), Complutense University, Madrid, Spain
| | - Agustín de Juan Lerma
- Department of Surgery, Faculty of Medicine, Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, Doce de Octubre University Hospital, Instituto de Investigación (imas12), Complutense University, Madrid, Spain
| | - Alberto Marcacuzco Quinto
- Department of Surgery, Faculty of Medicine, Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, Doce de Octubre University Hospital, Instituto de Investigación (imas12), Complutense University, Madrid, Spain
| | - Oscar Caso Maestro
- Department of Surgery, Faculty of Medicine, Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, Doce de Octubre University Hospital, Instituto de Investigación (imas12), Complutense University, Madrid, Spain
| | - Laura Alonso Murillo
- Department of Surgery, Faculty of Medicine, Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, Doce de Octubre University Hospital, Instituto de Investigación (imas12), Complutense University, Madrid, Spain
| | - Paula Rioja Conde
- Department of Surgery, Faculty of Medicine, Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, Doce de Octubre University Hospital, Instituto de Investigación (imas12), Complutense University, Madrid, Spain
| | - Iago Justo Alonso
- Department of Surgery, Faculty of Medicine, Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, Doce de Octubre University Hospital, Instituto de Investigación (imas12), Complutense University, Madrid, Spain
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Czarnecka Z, Verhoeff K, Bigam D, Dajani K, Shapiro J, Anderson B. Impact of soft pancreas on pancreaticoduodenectomy outcomes and the development of the preoperative soft pancreas risk score. Ann Hepatobiliary Pancreat Surg 2025; 29:62-71. [PMID: 39617392 PMCID: PMC11830892 DOI: 10.14701/ahbps.24-172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2024] [Revised: 10/28/2024] [Accepted: 11/04/2024] [Indexed: 02/14/2025] Open
Abstract
Backgrounds/Aims Pancreatic texture is difficult to predict without palpation. Soft pancreatic texture is associated with increased post-operative complications, including postoperative pancreatic fistula (POPF), cardiac, and respiratory complications. We aimed to develop a calculator predicting pancreatic texture using patient factors and to illustrate complications from soft pancreatic texture following pancreaticoduodenectomy. Methods Data was collected from the 2016 to 2021 American College of Surgeons National Surgical Quality Improvement database including 17,706 pancreaticoduodenectomy cases. Patients were categorized into two cohorts based on pancreatic texture (9,686 hard, 8,020 soft). Multivariable modeling assessed the impact of patient factors on complications, mortality, and pancreatic texture. These preoperative factors were integrated into a risk calculator (preoperative soft pancreas risk score [PSPRS]) that predicts pancreatic texture. Results Patients with a soft pancreas had higher rates of postoperative complications compared to those with a hard pancreas (56.5% vs 42.2%; p < 0.001), particularly a threefold increase in POPF rate, and at least a twofold increase in rates of acute kidney injury, deep organ space infection, septic shock, and prolonged length of stay. Female sex (odds ratio [OR]: 1.14, confidence interval [CI]: 1.06-1.22, p < 0.001) and higher body mass index (OR: 1.12, CI: 1.09-1.16, p < 0.001) were independently associated with a soft pancreas. PSPRS ≥6 correctly identified >40% of patients preoperatively as having a hard pancreas (68.9% specificity). Conclusions A soft pancreas was independently associated with serious postoperative complications. Our results were integrated into a risk calculator predicting pancreatic texture from preoperative patient factors, potentially enhancing preoperative counseling and surgical decision-making.
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Affiliation(s)
- Zofia Czarnecka
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Kevin Verhoeff
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - David Bigam
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Khaled Dajani
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - James Shapiro
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Blaire Anderson
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
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Dai Y, Lu X, Jiang L, Lu Z, Jiang K, Miao Y, Wei J. The impact of pancreatic duct stent placement on the clinically relevant postoperative pancreatic fistula rate for high-risk anastomoses: a systematic review and meta-analysis. BMC Gastroenterol 2025; 25:116. [PMID: 40000944 PMCID: PMC11852884 DOI: 10.1186/s12876-025-03700-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Accepted: 02/14/2025] [Indexed: 02/27/2025] Open
Abstract
BACKGROUND To evaluate the impact of pancreatic duct stent outcomes on the prognosis of postoperative pancreatic fistula in patients with high-risk anastomoses. METHODS Randomized controlled trials were identified through comprehensive searches in Cochrane Library, Web of Science, Embase, and PubMed databases. Cochrane Collaboration's tool RoB2 was used to evaluate study quality. The presence of non-dilated main pancreatic duct and soft gland texture were used to identify high risk anastomoses. The primary outcome measured was clinically relevant postoperative pancreatic fistula rate. The heterogeneity and sensitivity analyses were performed. RESULTS Six studies (n = 476) were included. The pooled data showed no significant difference in the clinically relevant postoperative pancreatic fistula rate between stented and nonstented groups for at least one high-risk factor out of two factors selected (p = 0.234). Patients with non-dilated main pancreatic duct who received stent placement had a lower clinically relevant postoperative pancreatic fistula rate (RR = 0.582, 95%CI = 0.383-0.883, p = 0.011). In contrast, patients with soft pancreatic texture showed no significant difference between two groups (p = 0.879). After removing the study identified by sensitivity analysis as the origin of heterogeneity from general cohorts, the stented group had a lower clinically relevant postoperative pancreatic fistula rate (RR = 0.608, 95%CI = 0.413-0.895, p = 0.012). CONCLUSIONS There is a lack of robust evidence to support pancreatic duct stent placement for high-risk anastomoses. Nevertheless, stent implantation may be beneficial for patients with non-dilated pancreatic duct or external stent drainage. TRIAL REGISTRATION The protocol was registered in advance with PROSPERO (CRD42023471943).
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Affiliation(s)
- Yuran Dai
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaozhi Lu
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lei Jiang
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zipeng Lu
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Pancreas Institute, Nanjing Medical University, Nanjing, China
| | - Kuirong Jiang
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Pancreas Institute, Nanjing Medical University, Nanjing, China
| | - Yi Miao
- Pancreas Institute, Nanjing Medical University, Nanjing, China
- Pancreas Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, China
| | - Jishu Wei
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
- Pancreas Institute, Nanjing Medical University, Nanjing, China.
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Kato T, Watanabe Y, Baba Y, Oshima Y, Takase K, Watanabe Y, Okada K, Aikawa M, Okamoto K, Koyama I. Preoperative risk-stratified analysis: External versus internal pancreatic stents in pancreatoduodenectomy. Surgery 2025; 178:108845. [PMID: 39384476 DOI: 10.1016/j.surg.2024.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 07/08/2024] [Accepted: 09/09/2024] [Indexed: 10/11/2024]
Abstract
BACKGROUND Several risk-stratified studies have compared the outcomes of external and internal pancreatic stents in pancreatoduodenectomy (PD), but no resolute standard for a fistula-mitigation strategy exists. The study investigated the efficacy of these stents in a preoperative risk-stratified setting. METHODS Data from 285 patients who underwent PD with pancreaticojejunostomy using an external or internal stent from 2015 to 2023 were analyzed. The preoperative pancreatic fistula score (preFRS) was used to classify patients into low-risk (preFRS: 0-5) and high-risk (preFRS: 6-8) groups. RESULTS PreFRS accurately predicted the risk of clinically relevant postoperative pancreatic fistula (CR-POPF) as 0% and >40% in patients with preFRS ≤1 and ≥7, respectively. Although no significant difference was observed in postoperative outcomes in low-risk patients, the external stent significantly reduced CR-POPF (21% vs 44%, P = .024) and postpancreatectomy hemorrhage (PPH, 0% vs 19%, P = .02) in high-risk patients, leading to the superiority of the external stent in the entire cohort in terms of CR-POPF (12% vs 24%, P = .033) and PPH (1% vs 11%, P = .013). There were no significant differences in stent-related complications or pancreatic dysfunction. External stent malfunction occurred in 14% and significantly affected CR-POPF development in both low- (20% vs 0%, P < .01) and high-risk groups (60% vs 14%, P = .021). CONCLUSION The external pancreatic stent showed a more beneficial effect on CR-POPF and PPH, especially in high-risk patients, without increasing other complications. Risk-stratified strategy and improving stent management might enhance postoperative outcomes.
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Affiliation(s)
- Tomotaka Kato
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Yuichiro Watanabe
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan.
| | - Yasutaka Baba
- Department of Diagnostic Radiology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Yuhei Oshima
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Kenichiro Takase
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Yukihiro Watanabe
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Katsuya Okada
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Masayasu Aikawa
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Kojun Okamoto
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Isamu Koyama
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
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Wang X, Teng X, Liu Y, Cheng W. Indocyanine green fluorescence-guided laparoscopic central pancreatectomy for complete pancreatic transection trauma: a rare case and literature review. Front Surg 2025; 11:1448064. [PMID: 39872405 PMCID: PMC11770029 DOI: 10.3389/fsurg.2024.1448064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 12/18/2024] [Indexed: 01/30/2025] Open
Abstract
Background Pancreatic trauma is a rare solid organ injury. Conservative treatment is often indicated in patients with no pancreatic duct injury, while patients with high-grade pancreatic damage most often require surgical intervention. Laparoscopic central pancreatectomy (LCP) is a parenchyma-sparing approach and can prevent endocrine and exocrine insufficiency after pancreatic resection. Indocyanine green (ICG) fluoroscopy can help the surgeon assess the blood supply of the target organ. Case presentation The case we describe here is a 33-year-old male patient who was transferred to our hospital due to blunt abdominal trauma caused by a car accident. The patient was hemodynamically stable on admission and was diagnosed with isolated pancreatic trauma by a multidisciplinary team that included radiologists, emergency physicians, and pancreatic surgeons. The patient then underwent emergency laparoscopic central pancreatectomy, during which we used ICG fluoroscopy to assess the blood perfusion of the damaged pancreas to determine the extent of resection. The patient developed a biochemical fistula (grade A pancreatic fistula) after surgery, and no other intervention was performed except for continuous drainage. The patient was discharged on postoperative day 13. At the 3-month follow-up, the patient did not present any clinical manifestations of pancreatic endocrine and exocrine insufficiency. Conclusion To the best of our knowledge, there have been no reports of ICG-guided emergency LCP for blunt abdominal trauma. In selected patients, emergency LCP is feasible and should be supported by a multidisciplinary team and performed by an experienced pancreatic surgeon with advanced laparoscopic skills.
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Affiliation(s)
| | | | | | - Wei Cheng
- Department of Hepato-Pancreato-Biliary Surgery, Hunan Provincial People's Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, Hunan, China
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Abdelwahab M, El Nakeeb A, Shehta A, Hamed H, Elsabbagh AM, Attia M, El-Wahab RA, Allah TA, Ali MA. Pancreaticoduodenectomy with pancreaticogastrostomy and an external pancreatic stent in risky patients: a propensity score-matched analysis. Langenbecks Arch Surg 2024; 410:1. [PMID: 39652097 DOI: 10.1007/s00423-024-03519-1] [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: 03/23/2024] [Accepted: 10/16/2024] [Indexed: 02/11/2025]
Abstract
BACKGROUND There is an ongoing debate about the most appropriate method for reconstructing the pancreas after a pancreaticoduodenectomy (PD). This study assessed the impact of pancreaticogastrostomy (PG) with an external pancreatic stent on postoperative outcomes following PD in high-risk patients. PATIENTS AND METHODS This study involves a propensity score-matched analysis of high-risk patients who underwent PD with PG reconstruction. The primary outcome measure was the occurrence of Postoperative Pancreatic Fistula (POPF). Secondary outcomes included operative time, intraoperative blood loss, length of hospital stay, re-exploration rate, as well as postoperative morbidity and mortality rates. RESULTS The study included 78 patients; 26 patients underwent PD with Pancreatogastrostomy (PG) and an external pancreatic stent, while 52 underwent PG without a pancreatic stent. Blood loss and operative time did not significantly differ between the two groups. The overall postoperative morbidity was higher in the group without a stent than in the stented group (34.6% vs. 15.4%, P = 0.06). No patient in the pancreatic stent group developed a clinically relevant POPF; however, in the non-stented group of PG, 17.3% developed POPF. There were no cases of hospital mortality in the stented group. However, in the non-stented group, two hospital mortality happened (one case was due to the systemic inflammatory response syndrome (SIRS) secondary to POPF grade C, and the other was due to pulmonary embolism. CONCLUSION PG with an external pancreatic stent results in fewer clinically relevant pancreatic fistulas, a decrease in postoperative morbidities, and a non-existent mortality rate in high-risk patients.
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Affiliation(s)
- Mohamed Abdelwahab
- Gastroenterology Surgical Center, Mansoura University, Mansoura, 35516, Egypt
| | - Ayman El Nakeeb
- Gastroenterology Surgical Center, Mansoura University, Mansoura, 35516, Egypt.
| | - Ahmed Shehta
- Gastroenterology Surgical Center, Mansoura University, Mansoura, 35516, Egypt
| | - Hosam Hamed
- Gastroenterology Surgical Center, Mansoura University, Mansoura, 35516, Egypt
| | - Ahmed M Elsabbagh
- Gastroenterology Surgical Center, Mansoura University, Mansoura, 35516, Egypt
| | - Mohamed Attia
- Gastroenterology Surgical Center, Mansoura University, Mansoura, 35516, Egypt
| | | | - Talaat Abd Allah
- Gastroenterology Surgical Center, Mansoura University, Mansoura, 35516, Egypt
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Symeonidis D, Zacharoulis D, Tzovaras G, Kissa L, Samara AA, Petsa E, Tepetes K. Stent A pancreaticojejunostomy after pancreatoduodenectomy: Is it always necessary? World J Methodol 2024; 14:90164. [PMID: 39310242 PMCID: PMC11230077 DOI: 10.5662/wjm.v14.i3.90164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 02/19/2024] [Accepted: 04/07/2024] [Indexed: 06/25/2024] Open
Abstract
The establishment of a postoperative pancreatic fistula (POPF) is considered the most common and, concomitantly, the most serious complication associated with pancreaticoduodenectomy (PD). The search for either technical modifications of the operative technique or pharmaceutical interventions that could possibly aid in decreasing the incidence of this often-devastating complication appears justified. The stenting of the pancreatic duct, with the use of either internal or external stents, has been evaluated in this direction. In theory, it is an approach that could eliminate many pathophysiological factors responsible for the occurrence of a POPF. The purpose of the present study was to review the current data regarding the role of pancreatic duct stenting on the incidence of POPF, after PD, by using PubMed and Reference Citation Analysis. In general, previous studies seem to highlight the superiority of external stents over their internal counterparts in regard to the incidence of POPF; this is at the cost, however, of increased morbidity associated mainly with the stent removal. Certainly, the use of an internal stent is a less invasive approach with acceptable results and is definitely deprived of the drawbacks arising through the complete diversion of pancreatic juice from the gastrointestinal tract. Bearing in mind the scarcity of high-quality data on the subject, an approach of reserving stent placement for the high-risk for POPF patients and individualizing the selection between the use of an internal or an external stent according to the distinct characteristics of each individual case scenario appears appropriate.
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Affiliation(s)
| | | | - Georgios Tzovaras
- Department of Surgery, University Hospital of Larissa, Larissa 41110, Greece
| | - Labrini Kissa
- Department of Surgery, University Hospital of Larissa, Larissa 41110, Greece
| | - Athina A Samara
- Department of Surgery, University Hospital of Larissa, Larissa 41110, Greece
| | - Eleana Petsa
- Department of Surgery, University Hospital of Larissa, Larissa 41110, Greece
| | - Konstantinos Tepetes
- Department of General Surgery, University Hospital of Larissa, Larissa 41110, Greece
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Sun Y, Li Y, Liu Z, Peng T, Wang C, Wu H, Gou S. Stent placement for the prevention of clinically-relevant postoperative pancreatic fistula following pancreaticojejunostomy: A systematic review and meta-analysis. Am J Surg 2024; 234:122-128. [PMID: 38594142 DOI: 10.1016/j.amjsurg.2024.04.002] [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: 01/26/2024] [Revised: 03/18/2024] [Accepted: 04/02/2024] [Indexed: 04/11/2024]
Abstract
OBJECTIVES There remains a lack of consensus regarding the benefits of stent placement following pancreaticojejunostomy in terms of clinically relevant postoperative pancreatic fistulas (CR-POPFs). This study was aimed at analyzing the effects of stent placement, stent technique (internal and external), stent size, and dilation of the main pancreatic duct on CR-POPFs. METHODS Our study comprised a systematic review and meta-analysis of randomized controlled trials involving patients undergoing pancreaticojejunostomy. The primary outcome was defined as the incidence of CR-POPFs. Additionally, subgroup analyses were conducted, and pooled analyses were performed to provide comparative references. RESULTS Twelve randomized controlled trials, including a total of 1117 patients, were included. Compared with no stent placement, stenting did not exhibit a significant association with reduced CR-POPF incidence (odds ratio [OR] = 0.60, 95% CI: 0.34-1.04, P = 0.07). Subgroup analysis revealed that only external stents, and not internal stents, were significantly associated with a reduced CR-POPF incidence compared with no stent placement (OR = 0.53, 95% CI: 0.28-0.99, P = 0.05 vs. OR = 0.92, 95% CI: 0.28-3.05, P = 0.89). Furthermore, stent placement in patients with a main pancreatic duct diameter of ≤3 mm, and not in those with a main pancreatic duct diameter of >3 mm, was associated with a significantly reduced CR-POPF incidence compared with no stent placement (OR = 0.24, 95% CI: 0.07-0.78, P = 0.02 vs. OR = 1.58, 95% CI: 0.41-6.06, P = 0.50). CONCLUSIONS The findings suggest a potential role for external stent placement in the prevention of CR-POPFs after pancreaticojejunostomy, particularly in patients with undilated pancreatic ducts. The reliability of our findings is constrained by the limited number of studies included. PROSPERO REGISTRATION NUMBER CRD42022380103.
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Affiliation(s)
- Ying Sun
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, China; Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Yongfeng Li
- Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, China; Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Zhiqiang Liu
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, China; Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Tao Peng
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, China; Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Chunyou Wang
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, China; Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Heshui Wu
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, China; Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Shanmiao Gou
- Department of Pancreatic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, China; Sino-German Laboratory of Personalized Medicine for Pancreatic Cancer, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, China.
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Büyükkasap AÇ, Dikmen K, Yavuz A, Altıner S, Göbüt H, Emral AC, Bostancı H, Kerem M. Predictive value of drain fluid amylase level on postoperative day one after pancreatic resection for predicting postoperative pancreatic fistula. Turk J Surg 2024; 40:19-27. [PMID: 39036006 PMCID: PMC11257726 DOI: 10.47717/turkjsurg.2024.6292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 01/16/2024] [Indexed: 07/23/2024]
Abstract
Objectives The aim of this study was to evaluate the predictive value of the first postoperative day (POD1) drain fluid amylase in predicting pancreatic fistula formation following pancreaticoduodenectomy (PD). Material and Methods One-hundred and eighty-five prospective patients undergoing PD between April 2014 and April 2018 were studied retrospectively. Cut-off point to predict the development of POPF was determined by median values for drain fluid amylase of 1883 U/L. Patients were classified into two groups according to POD1 drain fluid amylase values: <1883 U/L (Group 1) and ≥1883 U/L (Group 2). Differences between the groups with clinically relevant POPF and without POPF were evaluated. Results The incidence of POPF was 17.2%. POD1 amylase level was the strongest predictor of POPF, with levels of higher than 1883 U/L demonstrating the best accuracy (87.5%), sensitivity (78.1%), specificity (89.5%), positive predictive value (60.9%), and negative predictive value (95.1%). One-hundred and forty-four patients (77.8%) had a POD1 drain amylase level of less than 1883 U/L, and POPF developed in only seven (3.7%) cases, whereas in patients with POD1 drain amylase level of 1883 U/L or higher (n= 41), the POPF rate was 31.4% [OR: 22.24, 95% CI (7.930-62.396), p<0.001]. Conclusion The cut-off point of POD1 drain fluid amylase level (1883 U/L) might predict the clinically relevant POPF with adequate sensitivity and specificity rates in patients undergoing pancreatic resection.
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Affiliation(s)
| | - Kürşat Dikmen
- Department of General Surgery, Gazi University Faculty of Medicine, Ankara, Türkiye
| | - Aydın Yavuz
- Department of General Surgery, Gazi University Faculty of Medicine, Ankara, Türkiye
| | - Saygın Altıner
- Department of General Surgery, Gazi University Faculty of Medicine, Ankara, Türkiye
| | - Hüseyin Göbüt
- Department of General Surgery, Gazi University Faculty of Medicine, Ankara, Türkiye
| | - Ahmet Cihangir Emral
- Department of General Surgery, Gazi University Faculty of Medicine, Ankara, Türkiye
| | - Hasan Bostancı
- Department of General Surgery, Gazi University Faculty of Medicine, Ankara, Türkiye
| | - Mustafa Kerem
- Department of General Surgery, Gazi University Faculty of Medicine, Ankara, Türkiye
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Ocuin LM, Loftus A, Elshami M, Hue JJ, Musonza T, Ammori JB, Winter JM, Hardacre JM. Extended antibiotic therapy is associated with a lower rate of clinically relevant postoperative pancreatic fistula after pancreatoduodenectomy in intermediate- and high-risk patients: A single-institution analysis. Surgery 2024; 175:477-483. [PMID: 37940433 DOI: 10.1016/j.surg.2023.09.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 09/05/2023] [Accepted: 09/26/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula remains a common complication after pancreatoduodenectomy. The fistula risk score is a validated tool to predict the risk of clinically relevant postoperative pancreatic fistula. To mitigate complications, we have implemented an extended antibiotic pathway for patients at increased risk of clinically relevant postoperative pancreatic fistula (fistula risk score ≥3). We report outcomes after pancreatoduodenectomy in patients at increased risk for clinically relevant postoperative pancreatic fistula who received extended antibiotic therapy compared to those who received standard perioperative antibiotics (single dose before incision). METHODS Single-institution analysis of 87 patients who underwent elective pancreatoduodenectomy (2018-2022) with soft gland texture and fistula risk score ≥3 and were treated with (n = 34) or without (n = 53) 10 days of broad-spectrum antibiotics (piperacillin/tazobactam converted to amoxicillin/clavulanic acid at discharge) after surgery. Associations between extended antibiotics and postoperative outcomes were analyzed. RESULTS Baseline clinicodemographic factors were similar between cohorts. Patients who received extended antibiotics had shorter index days (6 vs 8 days, P = .004) and 90-day composite length of stay (8.5 vs 12 days, P = .018). Patients who received extended antibiotics had lower rates of clinically relevant postoperative pancreatic fistula (11.8% vs 37.7%; odds ratio = 0.17, 95% confidence interval: 0.04-0.68), wound infections (8.8% vs 30.2%; odds ratio = 0.08, 95% confidence interval: 0.01-0.50), organ space infections (14.7% vs 43.4%; odds ratio = 0.15, 95% confidence interval: 0.04-0.52), and image-guided drain placement (8.8% vs 34.0%; odds ratio = 0.15, 95% confidence interval: 0.04-0.62). There were no Clostridium difficile infections in the extended antibiotic group. CONCLUSION Extended antibiotic therapy is associated with a lower rate of clinically relevant postoperative pancreatic fistula and associated complications after pancreatoduodenectomy in patients with a fistula risk score ≥3. These results form the basis of a randomized controlled trial (NCT05753735).
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Affiliation(s)
- Lee M Ocuin
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH.
| | - Alexander Loftus
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Mohamedraed Elshami
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jonathan J Hue
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Tashinga Musonza
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - John B Ammori
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jordan M Winter
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jeffrey M Hardacre
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
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11
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Chui JN, Sahni S, Samra JS, Mittal A. Postoperative pancreatitis and pancreatic fistulae: a review of current evidence. HPB (Oxford) 2023; 25:1011-1021. [PMID: 37301633 DOI: 10.1016/j.hpb.2023.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 04/28/2023] [Accepted: 05/09/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Postoperative pancreatic fistula (POPF) represents one of the most severe complications following pancreatic surgery. Despite being a leading cause of morbidity and mortality, its pathophysiology is poorly understood. In recent years, there has been growing evidence to support the role of postoperative or post-pancreatectomy acute pancreatitis (PPAP) in the development of POPF. This article reviews the contemporary literature on POPF pathophysiology, risk factors, and prevention strategies. METHODS A literature search was conducted using electronic databases, including Ovid Medline, EMBASE, and Cochrane Library, to retrieve relevant literature published between 2005 and 2023. A narrative review was planned from the outset. RESULTS A total of 104 studies fulfilled criteria for inclusion. Forty-three studies reported on technical factors predisposing to POPF, including resection and reconstruction technique and adjuncts for anastomotic reinforcement. Thirty-four studies reported on POPF pathophysiology. There is compelling evidence to suggest that PPAP plays a critical role in the development of POPF. The acinar component of the remnant pancreas should be regarded as an intrinsic risk factor; meanwhile, operative stress, remnant hypoperfusion, and inflammation represent common mechanisms for acinar cell injury. CONCLUSIONS The evidence base for PPAP and POPF is evolving. Future POPF prevention strategies should look beyond anastomotic reinforcement and target underlying mechanisms of PPAP development.
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Affiliation(s)
- Juanita N Chui
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, Australia; Faculty of Medical and Health Sciences, The University of Sydney, Sydney, Australia
| | - Sumit Sahni
- Faculty of Medical and Health Sciences, The University of Sydney, Sydney, Australia; Kolling Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Jaswinder S Samra
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, Australia; Faculty of Medical and Health Sciences, The University of Sydney, Sydney, Australia; Australian Pancreatic Centre, Sydney, Australia
| | - Anubhav Mittal
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, Australia; Faculty of Medical and Health Sciences, The University of Sydney, Sydney, Australia; Australian Pancreatic Centre, Sydney, Australia; School of Medicine, The University of Notre Dame, Sydney, Australia.
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12
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Kalayarasan R, Himaja M, Ramesh A, Kokila K. Radiological parameters to predict pancreatic texture: Current evidence and future perspectives. World J Radiol 2023; 15:170-181. [PMID: 37424737 PMCID: PMC10324497 DOI: 10.4329/wjr.v15.i6.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/03/2023] [Accepted: 06/14/2023] [Indexed: 06/28/2023] Open
Abstract
Preoperative prediction of the postoperative pancreatic fistula risk is critical in the current era of minimally invasive pancreatic surgeries to tailor perioperative management, thereby minimizing postoperative morbidity. Pancreatic duct diameter can be readily measured by any routine imaging used to diagnose pancreatic disease. However, radiological evaluation of pancreatic texture, an important determinant of pancreatic fistula, has not been widely used to predict the risk of postoperative pancreatic fistula. Qualitative and quantitative assessment of pancreatic fibrosis and fat fraction provides the basis for predicting pancreatic texture. Traditionally computed tomography has been utilized in identifying and characterizing pancreatic lesions and background parenchymal pathologies. With the increasing utilisation of endoscopic ultrasound and magnetic resonance imaging for evaluating pancreatic pathologies, elastography is emerging as a promising tool for predicting pancreatic texture. Also, recent studies have shown that early surgery for chronic pancreatitis is associated with better pain relief and preservation of pancreatic function. Pancreatic texture assessment can allow early diagnosis of chronic pancreatitis, facilitating early intervention. The present review outlines the current evidence in utilizing various imaging modalities for determining the pancreatic texture based on different parameters and image sequences. However, multidisciplinary investigations using strong radiologic-pathologic correlation are needed to standardize and establish the role of these non-invasive diagnostic tools in predicting pancreatic texture.
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Affiliation(s)
- Raja Kalayarasan
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Mandalapu Himaja
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Ananthakrishnan Ramesh
- Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Kathirvel Kokila
- Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
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13
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Balzano G, Zerbi A, Aleotti F, Capretti G, Melzi R, Pecorelli N, Mercalli A, Nano R, Magistretti P, Gavazzi F, De Cobelli F, Poretti D, Scavini M, Molinari C, Partelli S, Crippa S, Maffi P, Falconi M, Piemonti L. Total Pancreatectomy With Islet Autotransplantation as an Alternative to High-risk Pancreatojejunostomy After Pancreaticoduodenectomy: A Prospective Randomized Trial. Ann Surg 2023; 277:894-903. [PMID: 36177837 PMCID: PMC10174105 DOI: 10.1097/sla.0000000000005713] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare pancreaticoduodenectomy (PD) and total pancreatectomy (TP) with islet autotransplantation (IAT) in patients at high risk of postoperative pancreatic fistula (POPF). BACKGROUND Criteria to predict the risk of POPF occurrence after PD are available. However, even when a high risk of POPF is predicted, TP is not currently accepted as an alternative to PD, because of its severe consequences on glycaemic control. Combining IAT with TP may mitigate such consequences. METHODS Randomized, open-label, controlled, bicentric trial (NCT01346098). Candidates for PD at high-risk pancreatic anastomosis (ie, soft pancreas and duct diameter ≤3 mm) were randomly assigned (1:1) to undergo either PD or TP-IAT. The primary endpoint was the incidence of complications within 90 days after surgery. RESULTS Between 2010 and 2019, 61 patients were assigned to PD (n=31) or TP-IAT (n=30). In the intention-to-treat analysis, morbidity rate was 90·3% after PD and 60% after TP-IAT ( P =0.008). According to complications' severity, PD was associated with an increased risk of grade ≥2 [odds ratio (OR)=7.64 (95% CI: 1.35-43.3), P =0.022], while the OR for grade ≥3 complications was 2.82 (95% CI: 0.86-9.24, P =0.086). After TP-IAT, the postoperative stay was shorter [median: 10.5 vs 16.0 days; P <0.001). No differences were observed in disease-free survival, site of recurrence, disease-specific survival, and overall survival. TP-IAT was associated with a higher risk of diabetes [hazard ratio=9.1 (95% CI: 3.76-21.9), P <0.0001], but most patients maintained good metabolic control and showed sustained C-peptide production over time. CONCLUSIONS TP-IAT may become the standard treatment in candidates for PD, when a high risk of POPF is predicted.
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Affiliation(s)
- Gianpaolo Balzano
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alessandro Zerbi
- Department of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Francesca Aleotti
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Giovanni Capretti
- Department of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Raffella Melzi
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Nicolò Pecorelli
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alessia Mercalli
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Rita Nano
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Paola Magistretti
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesca Gavazzi
- Department of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Francesco De Cobelli
- Department of Radiology, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Dario Poretti
- Department of Radiology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Marina Scavini
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Chiara Molinari
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Stefano Partelli
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Stefano Crippa
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Paola Maffi
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Massimo Falconi
- Department of Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Lorenzo Piemonti
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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14
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Gurram RP, S L H, Gnanasekaran S, Choudhury SR, Pottakkat B, Raja K. External pancreatic ductal stenting in minimally invasive pancreatoduodenectomy: How to do it? Ann Hepatobiliary Pancreat Surg 2023; 27:211-216. [PMID: 36859362 PMCID: PMC10201057 DOI: 10.14701/ahbps.22-098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 12/11/2022] [Accepted: 12/14/2022] [Indexed: 03/03/2023] Open
Abstract
It has been shown that external pancreatic ductal stenting (EPDS) can reduce the incidence of clinically relevant postoperative pancreatic fistula. Although studies have described EPDS in open pancreaticoduodenectomy (PD), EPDS in minimally invasive PD has not been reported yet. Thus, the objective of this study was to describe the technique of EPDS in minimally invasive PD. The procedure was performed either laparoscopically or using a robot. Once PD was completed, key steps included triple enterotomy, threading of silk-suture through all enterotomies and exteriorization, completing posterior layer of pancreaticojejunostomy (PJ), railroading stent through preplaced silk-suture, intubation of stent into the pancreatic duct, completion of PJ, followed by hepaticojejunostomy and parietalization of jejunum at the stent exit site. EPDS in PD through a minimally invasive approach can be performed safely in selected cases with either a small-sized pancreatic duct or a soft pancreas.
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Affiliation(s)
- Ram Prakash Gurram
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Harilal S L
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Senthil Gnanasekaran
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Satyaprakash Ray Choudhury
- Department of Surgical Gastroenterology, Siksha O Anusandhan University Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Odisha, India
| | - Biju Pottakkat
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Kalayarasan Raja
- Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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15
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Bellotti R, Cardini B, Strolz CJ, Stättner S, Oberhuber R, Braunwarth E, Resch T, Scheidl S, Margreiter C, Schneeberger S, Öfner D, Maglione M. Single Center, Propensity Score Matching Analysis of Different Reconstruction Techniques following Pancreatoduodenectomy. J Clin Med 2023; 12:3318. [PMID: 37176758 PMCID: PMC10179219 DOI: 10.3390/jcm12093318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Pancreatoduodenectomy is still hampered by significant morbidity. So far, there is no universally accepted technique aimed at minimizing postoperative complications. Herein, we compare three different reconstruction techniques. METHODS This is a retrospective study of a prospectively maintained database including 283 patients operated between January 2010 and December 2020. Three reconstruction techniques were compared: (1) the Neuhaus-style telescope pancreatojejunostomy, (2) the pancreatogastrostomy, and (3) the modified Blumgart-style, duct-to-mucosa pancreatojejunostomy. The primary endpoint consisted in determining the rates of clinically relevant postoperative pancreatic fistulas (CR-POPF); the secondary endpoints included 90 days morbidity and mortality rates. A propensity score matching analysis was used. RESULTS Rates of CR-POPF did not differ significantly between the groups (Neuhaus-style pancreatojejunostomy 16%, pancreatogastrostomy 17%, modified Blumgart-style pancreatojejunostomy 15%), neither in the unmatched nor in the matched analysis (p = 0.993 and p = 0.901, respectively). Similarly, no significant differences could be observed with regard to major morbidity (unmatched p = 0.596, matched p = 0.188) and mortality rates (unmatched p = 0.371, matched p = 0.209) within the first 90 days following surgery. Propensity-score matching analyses revealed, however, a higher occurrence of post-pancreatectomy hemorrhage after pancreatogastrostomy (p = 0.015). CONCLUSION Similar CR-POPF rates suggest no crucial role of the applied reconstruction technique. Increased incidence of intraluminal post-pancreatectomy hemorrhages following pancreatogastrostomy demands awareness for meticulous hemostasis.
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Affiliation(s)
- Ruben Bellotti
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Benno Cardini
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Carola J. Strolz
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Stefan Stättner
- Department of General, Visceral and Vascular Surgery, Salzkammergut Hospital, 4840 Vöcklabruck, Austria
| | - Rupert Oberhuber
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Eva Braunwarth
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Thomas Resch
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Stefan Scheidl
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Christian Margreiter
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Dietmar Öfner
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
| | - Manuel Maglione
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria; (R.B.)
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16
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Giuliani T, Perri G, Kang R, Marchegiani G. Current Perioperative Care in Pancreatoduodenectomy: A Step-by-Step Surgical Roadmap from First Visit to Discharge. Cancers (Basel) 2023; 15:2499. [PMID: 37173964 PMCID: PMC10177600 DOI: 10.3390/cancers15092499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 04/23/2023] [Accepted: 04/23/2023] [Indexed: 05/15/2023] Open
Abstract
Pancreaticoduodenectomy (PD) is a mainstay in the management of periampullary tumors. Treatment algorithms increasingly employ a multimodal strategy, which includes neoadjuvant and adjuvant therapies. However, the successful treatment of a patient is contingent on the execution of a complex operation, whereby minimizing postoperative complications and optimizing a fast and complete recovery are crucial to the overall success. In this setting, risk reduction and benchmarking the quality of care are essential frameworks through which modern perioperative PD care must be delivered. The postoperative course is primarily influenced by pancreatic fistulas, but other patient- and hospital-associated factors, such as frailty and the ability to rescue from complications, also affect the outcomes. A comprehensive understanding of the factors influencing surgical outcomes allows the clinician to risk stratify the patient, thereby facilitating a frank discussion of the morbidity and mortality of PD. Further, such an understanding allows the clinician to practice based on the most up-to-date evidence. This review intends to provide clinicians with a roadmap to the perioperative PD pathway. We review key considerations in the pre-, intra-, and post-operative periods.
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Affiliation(s)
- Tommaso Giuliani
- Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; (T.G.); (R.K.)
| | | | - Ravinder Kang
- Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; (T.G.); (R.K.)
| | - Giovanni Marchegiani
- Verona University Hospital, 37134 Verona, Italy;
- Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padua, 35122 Padua, Italy
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17
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Pagnanelli M, De Gaetano F, Nappo G, Capretti G, Costantino ML, Zerbi A. The Choice of the Most Appropriate Suture Threads for Pancreatic Anastomoses on the Basis of Their Mechanical Characteristics. Biomedicines 2023; 11:biomedicines11041055. [PMID: 37189673 DOI: 10.3390/biomedicines11041055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/11/2023] [Accepted: 03/13/2023] [Indexed: 04/03/2023] Open
Abstract
The choice of the most appropriate suture threads for pancreatic anastomoses may play an important role in reducing the incidence of post-operative pancreatic fistula (POPF). The literature on this topic is still not conclusive. The aim of this study was to analyze the mechanical characteristics of suture materials to find the best suture threads for pancreatic anastomoses. A single-axial electromagnetic actuation machine was used to obtain the stress–deformation relationship curves and to measure both the ultimate tensile strength (UTS) and the Young’s modulus at the 0–3% deformation range (E0–3) of four different suture materials (Poliglecaprone 25, Polydioxanone, Polyglactin 910, and Polypropylene) at baseline and after incubation in saline solution, bile, and pancreatic juice for 1, 3, and 7 days. Polydioxanone and Polypropylene showed stable values of UTS and E0–3 in all conditions. Polyglactin 910 presented significant UTS and E0–3 variations between different time intervals in all types of liquids analyzed. Poliglecaprone 25 lost half of its strength in all biological liquids analyzed but maintained low E0–3 values, which could reduce the risk of lacerations of soft tissues. These results suggest that Polydioxanone and Poliglecaprone 25 could be the best suture materials to use for pancreatic anastomoses. In vivo experiments will be organized to obtain further confirmations of this in vitro evidence.
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18
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Codjia T, Roussel E, Papet E, Pinson J, Monge M, Tortajada P, Tuech JJ, Schwarz L. Can the Realization of an External Wirsungostomy be an Option for High-Risk Pancreatic Anastomosis After Pancreaticoduodenectomy? World J Surg 2023; 47:1533-1539. [PMID: 36884081 DOI: 10.1007/s00268-023-06927-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (POPF) occurs in 15-20% of patients after pancreaticoduodenectomy (PD) and reintervention in the setting of Grade C POPF remains associated with a mortality rate of up to 25%. In patients at high risk of POPF, PD with external wirsungostomy (EW) could be a safe alternative that avoids pancreatico-enteric anastomosis while preserving the remnant pancreas. METHODS Of the 155 consecutive patients who underwent PD from November 2015 to December 2020, 10 patients were managed using an EW, all with a fistula risk score (FRS) ≥ 7 and BMI ≥30 kg/m2, and/or major associated abdominal surgery. The pancreatic duct was cannulated with a polyethylene tube to allow good external drainage of the pancreatic fluid. We retrospectively analyzed postoperative complications and endocrine and exocrine insufficiencies. RESULTS The median alternative FRS was 36.9% [22.1-45.2]. There was no postoperative death. The 90-day overall severe complication (grade ≥3) rate was 30% (n = 3 patients), no patient required reoperation, and 2 hospital readmissions occurred. 3 patients experienced Grade B POPF (30%), managed using image-guided drainage for 2 patients. The external pancreatic drain was removed after a median drainage time of 75 days [63-80]. Two patients presented with late symptoms (> 6 months) warranting interventional management (pancreaticojejunostomy and transgastric drainage). Six patients experienced significant weight loss (> 2 kg) 3 months after surgery. One year after surgery, 4 patients still complained of diarrhea and were treated with transit-delaying drugs. One patient presented new-onset diabetes one year after surgery, and 1 of the 4 patients with preexisting diabetes experienced worsening disease. CONCLUSION EW after PD might be a solution to reduce post-operative mortality following PD in high-risk patients.
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Affiliation(s)
- Tatiana Codjia
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France
| | - Edouard Roussel
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France
| | - Eloise Papet
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France
| | - Jean Pinson
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France
| | - Matthieu Monge
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France
| | - Pauline Tortajada
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France
| | - Jean-Jacques Tuech
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France
- Department of Genomic and Personalized Medicine in Cancer and Neurological Disorders, Rouen University Hospital, UNIROUEN, UMR 1245 INSERM, Normandie ROUEN University, 76000, Rouen, France
| | - Lilian Schwarz
- Department of Digestive Surgery, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France.
- Department of Genomic and Personalized Medicine in Cancer and Neurological Disorders, Rouen University Hospital, UNIROUEN, UMR 1245 INSERM, Normandie ROUEN University, 76000, Rouen, France.
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19
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Xu SB, Jia CK. External drainage of the pancreatic duct in pancreatojejunostomy for preventing postoperative pancreatic fistula: Efficacy and side effects. J Surg Oncol 2023; 127:504-507. [PMID: 36416048 DOI: 10.1002/jso.27126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 10/08/2022] [Indexed: 11/24/2022]
Affiliation(s)
- Sun-Bing Xu
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
| | - Chang-Ku Jia
- Department of Hepatobiliary and Pancreatic Surgery, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China
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20
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Schuh F, Mihaljevic AL, Probst P, Trudeau MT, Müller PC, Marchegiani G, Besselink MG, Uzunoglu F, Izbicki JR, Falconi M, Castillo CFD, Adham M, Z'graggen K, Friess H, Werner J, Weitz J, Strobel O, Hackert T, Radenkovic D, Kelemen D, Wolfgang C, Miao YI, Shrikhande SV, Lillemoe KD, Dervenis C, Bassi C, Neoptolemos JP, Diener MK, Vollmer CM, Büchler MW. A Simple Classification of Pancreatic Duct Size and Texture Predicts Postoperative Pancreatic Fistula: A classification of the International Study Group of Pancreatic Surgery. Ann Surg 2023; 277:e597-e608. [PMID: 33914473 PMCID: PMC9891297 DOI: 10.1097/sla.0000000000004855] [Citation(s) in RCA: 114] [Impact Index Per Article: 57.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The aim of this study was to develop a classification system for pancreas-associated risk factors in pancreatoduodenectomy (PD). SUMMARY BACKGROUND DATA Postoperative pancreatic fistula (POPF) is the most relevant PD-associated complication. A simple standardized surgical reporting system based on pancreas-associated risk factors is lacking. METHODS A systematic literature search was conducted to identify studies investigating clinically relevant (CR) POPF (CR-POPF) and pancreas-associated risk factors after PD. A meta-analysis of CR-POPF rate for texture of the pancreas (soft vs not-soft) and main pancreatic duct (MPD) diameter was performed using the Mantel-Haenszel method. Based on the results, the International Study Group of Pancreatic Surgery (ISGPS) proposes the following classification: A, not-soft (hard) texture and MPD >3 mm; B, not-soft (hard) texture and MPD ≤3 mm; C, soft texture and MPD >3 mm; D, soft texture and MPD ≤3 mm. The classification was evaluated in a multi-institutional, international cohort. RESULTS Of the 2917 articles identified, 108 studies were included in the analyses. Soft pancreatic texture was significantly associated with the development of CR-POPF [odds ratio (OR) 4.24, 95% confidence interval (CI) 3.67-4.89, P < 0.01) following PD. Similarly, MPD diameter ≤3 mm significantly increased CR-POPF risk compared with >3 mm diameter MPDs (OR 3.66, 95% CI 2.62-5.12, P < 0.01). The proposed 4-stage system was confirmed in an independent cohort of 5533 patients with CR-POPF rates of 3.5%, 6.2%, 16.6%, and 23.2% for type A-D, respectively ( P < 0.001). CONCLUSION For future pancreatic surgical outcomes studies, the ISGPS recommends reporting these risk factors according to the proposed classification system for better comparability of results.
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Affiliation(s)
- Fabian Schuh
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - André L Mihaljevic
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Maxwell T Trudeau
- Department of Surgery, The University of Pennsylvania, Philadelphia, PA
| | | | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Faik Uzunoglu
- Department of General, Visceral and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, ''Vita-Salute'' University, Milan, Italy
| | | | - Mustapha Adham
- Department of Digestive & HPB Surgery, Hospital Edouard Herriot, Lyon, France
| | | | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, School of Medicine, Technische Universität München, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplantation Surgery, Ludwig Maximilians-University, Munich, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Dejan Radenkovic
- Clinic for Digestive Surgery, Clinical Center of Serbia and School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dezso Kelemen
- Department of Surgery, University of Pécs, Medical School, Pécs, Hungary
| | - Christopher Wolfgang
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Y I Miao
- Pancreas Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, P.R. China
| | | | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital and the Harvard Medical School, Boston, MA
| | | | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - John P Neoptolemos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
- The Study Center of the German Surgical Society (SDGC), University of Heidelberg, Heidelberg, Germany
| | - Charles M Vollmer
- Department of Surgery, The University of Pennsylvania, Philadelphia, PA
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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21
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Kazantsev GB, Spitzer AL, Peng PD, Ramirez RM, Chang CK, Tsai S, Aldakkak M, Huyser MR, Dominguez DA. Pancreaticogastrostomy as a fistula mitigating strategy for a high-risk pancreatic anastomosis following pancreaticoduodenectomy. HPB (Oxford) 2023; 25:124-135. [PMID: 36323594 DOI: 10.1016/j.hpb.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 09/19/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD) has been associated with soft gland texture and/or small pancreatic duct. We hypothesized that selective use of pancreaticogastrostomy (PG) over pancreaticojejunostomy (PJ) in those scenarios would decrease the rate of CR-POPF. METHODS Review of prospective database of all PD's performed at a single institution between 2009 and 2019 was performed. The pancreatic remnant was deemed "high risk" if soft gland and/or small duct were present. RESULTS PJ was performed in 199 (147 "low-risk" and 52 "high-risk") cases, and 110 patients (all "high-risk") had a PG. Overall CR-POPF rate was 11.9% with no difference between the groups. Risk-stratified analysis within PJ group showed CR-POPF rate of 5.4% versus 36% in "low-risk" versus "high risk" scenarios, respectively; the use of PG significantly decreased CR-POPF rate (9.1%, p < 0.0001). Gastrointestinal bleeding was more likely to occur following PG than PJ. Soft gland texture and gastrointestinal bleeding were the strongest predictors of CR-POPF in PJ and PG groups, respectively. CONCLUSION Selective use of PG after PD in "high-risk" scenarios mitigates the risk of CR-POPF. Increased rate of gastrointestinal bleeding calls for further refinement of the technique and heightened postoperative vigilance.
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Affiliation(s)
- George B Kazantsev
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA 94611, USA.
| | - Austin L Spitzer
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA 94611, USA
| | - Peter D Peng
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA 94611, USA
| | - Rene M Ramirez
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA 94611, USA
| | - Ching-Kuo Chang
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA 94611, USA
| | - Susan Tsai
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mohammed Aldakkak
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michelle R Huyser
- Department of Surgery, University of California San Francisco, East Bay, Oakland, CA, USA
| | - Dana A Dominguez
- Department of Surgery, University of California San Francisco, East Bay, Oakland, CA, USA
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22
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Yi JH, Li ZS, Hu LH. Pancreatic duct stents. J Dig Dis 2022; 23:675-686. [PMID: 36776138 DOI: 10.1111/1751-2980.13158] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 02/03/2023] [Accepted: 02/08/2023] [Indexed: 02/14/2023]
Abstract
Pancreatic duct stenting using endoscopy or surgery is widely used for the management of benign and malignant pancreatic diseases. Endoscopic pancreatic stents are mainly used to relieve pain caused by chronic pancreatitis and pancreas divisum, and to treat pancreatic duct disruption and stenotic pancreaticointestinal anastomosis after surgery. They are also used to prevent postendoscopic retrograde cholangiopancreatography pancreatitis and postoperative pancreatic fistula, treat pancreatic cancer, and locate radiolucent stones. Recent advances in endoscopic techniques, such as endoscopic ultrasonography and balloon enteroscopy, and newly designed stents have broadened the indications for pancreatic duct stenting. In this review we outlined the types, insertion procedures, efficacy, and complications of endoscopic pancreatic duct stent placement, and summarized the applications of pancreatic duct stents in surgery.
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Affiliation(s)
- Jin Hui Yi
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Zhao Shen Li
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, Shanghai, China
| | - Liang Hao Hu
- Department of Gastroenterology, First Affiliated Hospital of Naval Medical University, Shanghai, China
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23
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Houghton EJ, Rubio JS. Surgical management of the postoperative complications of hepato-pancreato-biliary surgery. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2022. [DOI: 10.18528/ijgii220041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Eduardo Javier Houghton
- Teaching and Research Department, DAICIM Foundation, Buenos Aires, Argentina
- Surgery Division, B. Rivadavia Hospital, Buenos Aires, Argentina
- Department of Surgery, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Juan Santiago Rubio
- Solid Organ Transplant Service, Hospital de Alta Complejidad en Red El Cruce Dr. Néstor Carlos Kirchner, Buenos Aires, Argentina
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24
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Miyamoto R, Takahashi A, Ogasawara A, Ogura T, Kitamura K, Ishida H, Matsudaira S, Nozu S, Kawashima Y. Three-dimensional simulation of the pancreatic parenchyma, pancreatic duct and vascular arrangement in pancreatic surgery using a deep learning algorithm. PLoS One 2022; 17:e0276600. [PMID: 36306322 PMCID: PMC9616217 DOI: 10.1371/journal.pone.0276600] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 10/10/2022] [Indexed: 11/25/2022] Open
Abstract
Three-dimensional surgical simulation, already in use for hepatic surgery, can be used in pancreatic surgery. However, some problems still need to be overcome to achieve more precise pancreatic surgical simulation. The present study evaluates the performance of SYNAPSE VINCENT® (version 6.6, Fujifilm Medical Co., Ltd., Tokyo, Japan) in the semiautomated surgical simulation of the pancreatic parenchyma, pancreatic ducts, and peripancreatic vessels using an artificial intelligence (AI) engine designed with deep learning algorithms. One-hundred pancreatic cancer patients and a control group of 100 nonpancreatic cancer patients were enrolled. The evaluation methods for visualizing the extraction were compared using the Dice coefficient (DC). In the pancreatic cancer patients, tumor size, position, and stagewise correlations with the pancreatic parenchymal DC were analyzed. The relationship between the pancreatic duct diameter and the DC, and between the manually and AI-measured diameters of the pancreatic duct were analyzed. In the pancreatic cancer/control groups, the pancreatic parenchymal DC and pancreatic duct extraction were 0.83/0.86 and 0.84/0.77. The DC of the arteries (portal veins/veins) and associated sensitivity and specificity were 0.89/0.88 (0.89/0.88), 0.85/0.83 (0.85/0.82), and 0.82/0.81 (0.84/0.81), respectively. No correlations were observed between pancreatic parenchymal DC and tumor size, position, or stage. No correlation was observed between the pancreatic duct diameter and the DC. A positive correlation (r = 0.61, p<0.001) was observed between the manually and AI-measured diameters of the pancreatic duct. Extraction of the pancreatic parenchyma, pancreatic duct, and surrounding vessels with the SYNAPSE VINCENT® AI engine assumed to be useful as surgical simulation.
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Affiliation(s)
- Ryoichi Miyamoto
- Department of Gastroenterological Surgery, Saitama Cancer Center, Kita-Adachi-gun, Saitama, Japan
- * E-mail:
| | - Amane Takahashi
- Department of Gastroenterological Surgery, Saitama Cancer Center, Kita-Adachi-gun, Saitama, Japan
| | - Aya Ogasawara
- Imaging Technology Center, Fujifilm Corporation, Minato-ku, Tokyo, Japan
| | - Toshiro Ogura
- Department of Gastroenterological Surgery, Saitama Cancer Center, Kita-Adachi-gun, Saitama, Japan
| | - Kei Kitamura
- Department of Gastroenterological Surgery, Saitama Cancer Center, Kita-Adachi-gun, Saitama, Japan
| | - Hiroyuki Ishida
- Department of Gastroenterological Surgery, Saitama Cancer Center, Kita-Adachi-gun, Saitama, Japan
| | - Shinichi Matsudaira
- Department of Gastroenterological Surgery, Saitama Cancer Center, Kita-Adachi-gun, Saitama, Japan
| | - Satoshi Nozu
- Department of Radiology, Saitama Cancer Center, Kita-Adachi-gun, Saitama, Japan
| | - Yoshiyuki Kawashima
- Department of Gastroenterological Surgery, Saitama Cancer Center, Kita-Adachi-gun, Saitama, Japan
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25
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ALKURT EG, DURAK D, TUTAN MB, ŞAHİN F, ŞAHİNER İT. The effect of duct width and pancreatic gland structure on pancreatic fistula rates in patients who underwent pancreaticoduodenectomy for pancreatic cancer. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2022. [DOI: 10.32322/jhsm.1119708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction: One of the most important causes of morbidity in pancreaticoduodenectomy (PD) surgery is pancreatic anastomosis leakage. There is a possibility of pancreatic fistula even in the most experienced hands. After PD, pancreatic fistula occurs between 10% and 20% in various series. This study aims to evaluate the effects of pancreatic duct size and pancreatic tissue on the development of pancreatic fistula after PD is performed in our center.
Material and Method: Pancreatic duct size was categorized as small <3 mm and large >3 mm. Pancreatic gland tissue was categorized as a soft, medium, and hard. These variables were calculated preoperatively with the help of computed tomography (CT), ultrasonography(USG), and Endoscopic ultrasound (EUS), and postoperative pathology results. It was accepted that the 24-hour flow rate of the drain behind the pancreatic anastomosis was more than 50 ml during 3 days after PD and/or the amylase concentration of the drain content measured at 3 different times was 3 times higher than the serum amylase concentration.
Results: A total of 90 patients were included in the study, anastomotic leakage was not observed in 63 (70%) of 90 patients, and leakage was observed in 27 (30%) patients. The mean age was 71.22±10.78 years (p=0.615). There was no statistically significant difference between the ductus diameters between the two groups (p=0.240). There was no statistical difference between the groups formed according to pancreatic duct width. (p=0.059). It was observed that 60.3% of the patients in the non-leakage group had a hard appearance, and this rate was statistically significantly reduced to 29.6% in the patients with leakage (p=0.008).
Conclusion: In summary, our study showed that pancreatic fistula after PD is associated with soft pancreatic parenchyma. The surgeon should consider this risk factor when performing a PD and be more careful to reduce the rate of pancreatic fistula.
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Affiliation(s)
- Ertugrul Gazi ALKURT
- T.C. Hitit University Erol Olçok Training and Resource Hospital, Department of General Surgery
| | - Doğukan DURAK
- University of Health Sciences Bursa Yuksek Ihtisas Training and Research Hospital, Department of General Surgery
| | - Mehmet Berksun TUTAN
- T.C. Hitit University Erol Olçok Training and Resource Hospital, Department of General Surgery
| | - Fatih ŞAHİN
- T.C. Hitit University Erol Olçok Training and Resource Hospital, Department of General Surgery
| | - İbrahim Tayfun ŞAHİNER
- T.C. Hitit University Erol Olçok Training and Resource Hospital, Department of General Surgery
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26
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Sulieman I, Elaffandi A, Elmoghazy W, Khalaf H. USE of Biodegradable STENTS in Pancreaticoduodenectomy: Initial Experience. Surg Innov 2022:15533506221123355. [PMID: 36148813 DOI: 10.1177/15533506221123355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. Plastic stents have been used to avoid postoperative pancreatic fistula (POPF) following Whipple's Pancreaticoduodenectomy (WPD), but they may cause some stent-related complications. Biodegradable stents have been recently introduced and might be a safe alternative. Here we present our initial experience with their use. Methods. Between March 1, 2020, and September 30, 2020, ten (10) consecutive patients underwent WPD. They all had conventional two-layer pancreaticojejunostomy with the placement of an internal biodegradable stent. They were assessed for technical feasibility, pancreatic leak, and stent-related complications. Results. The use of biodegradable stents was technically feasible in all patients, despite some difficulties in insertion due to stent stiffness and design. After a median follow-up period of 124 days, none of the patients suffered POPF. One patient had a biochemical pancreatic leak with no clinical significance. The median hospital stay was 7 days, and there were no stent-related complications. Conclusion. Biodegradable stents are technically feasible and safe in WPD with good short-term outcomes. They might provide a better alternative to plastic stents and their potential complications. Larger long-term studies are needed to validate efficacy and safety. Few modifications of the stent's design might be needed to facilitate use in open surgery.
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Affiliation(s)
- Ibnouf Sulieman
- Department of Surgery, Division of Organ Transplant, 36977Hamad General Hospital, Doha, Qatar
| | - Ahmed Elaffandi
- Department of Surgery, Division of Organ Transplant, 36977Hamad General Hospital, Doha, Qatar.,Department of Surgical Oncology, National Cancer Institute, 36977Cairo University, Egypt
| | - Walid Elmoghazy
- Department of Surgery, Division of Organ Transplant, 36977Hamad General Hospital, Doha, Qatar.,Department of Surgery, 36977Sohag University, Sohag, Egypt
| | - Hatem Khalaf
- Department of Surgery, Division of Organ Transplant, 36977Hamad General Hospital, Doha, Qatar.,Department of Surgery, College of Medicine, 36977Qatar University, Qatar
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27
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He R, Yin T, Pan S, Wang M, Zhang H, Qin R. One hundred most cited article related to pancreaticoduodenectomy surgery: A bibliometric analysis. Int J Surg 2022; 104:106775. [PMID: 35840048 DOI: 10.1016/j.ijsu.2022.106775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 06/30/2022] [Accepted: 07/07/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND In light of the challenges associated with pancreaticoduodenectomy (PD) and recent key improvements, this bibliometric analysis aimed to analyze the 100 top-cited (T100) articles related to PD surgery to widen the awareness of relevant research on this procedure. METHODS The term "pancreaticoduodenectomy" was used to retrieve articles from the Web of Science Core Collection database. The 100 most cited manuscripts in the English language were identified and further analyzed by their countries of origin, publication journals, authors, and themes. RESULTS A thorough literature search was performed on the Web of Science until April 2020. The total number of citations for the T100 articles ranged from 227 to 3029. The T100 articles came from 18 different countries, with the USA accounting for the plurality (n = 72). Professor J.L. Cameron from Johns Hopkins Medicine USA published the most articles (n = 22), including one as the first author and two as a co-author. Furthermore, Johns Hopkins Medicine, USA, published the most articles on PD surgery (n = 24), with a total citation count of 14,151. The journal Annals of Surgery published 40 of the T100 articles, with 15,847 citations and an average citation count of 396. Among the T100 articles, the citation frequency following the year of publication showed a parabolic trend, with citations peaking in the 9th year following publication. CONCLUSION Our study identified and analyzed the T100 articles in PD surgery. The USA was the dominant country regarding articles, researchers, and institutions. The citations of the articles peaked in the 9th year after publication.
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Affiliation(s)
- Ruizhi He
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, China
| | - Taoyuan Yin
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, China; Department of Epidemiology and Biostatistics and State Key Laboratory of Environment Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Shutao Pan
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, China
| | - Min Wang
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, China
| | - Hang Zhang
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, China
| | - Renyi Qin
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, 430030, China.
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28
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Guo C, Xie B, Guo D. Does pancreatic duct stent placement lead to decreased postoperative pancreatic fistula rates after pancreaticoduodenectomy? A meta-analysis. Int J Surg 2022; 103:106707. [PMID: 35697324 DOI: 10.1016/j.ijsu.2022.106707] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/20/2022] [Accepted: 05/25/2022] [Indexed: 01/02/2023]
Abstract
PURPOSE To evaluate the effectiveness of pancreatic duct stent placement for preventing postoperative pancreatic fistula after pancreaticoduodenectomy. METHODS PubMed, the Cochrane Central Register of Controlled Trials, Embase and ClinicalTrials.gov databases were searched up to February 26, 2022. Studies comparing outcomes following pancreaticoduodenectomy with or without pancreatic duct stents were included. The primary outcome measured was postoperative pancreatic fistula rate, and secondary outcomes were in-hospital mortality rate, reoperation rate, delayed gastric emptying rate and wound infection rate. RESULTS Seven RCTs involving 847 patients met the inclusion criteria. No statistically significant difference between the stent group and non-stent group was detected in the incidence of postoperative pancreatic fistula (RR = 0.85, 95%CI: 0.57-1.26, P = 0.41), in-hospital mortality, reoperation, delayed gastric emptying rate and wound infection. Subgroup analyses revealed that use of an external stent significantly reduced the incidence of pancreatic fistula (RR = 0.61, 95%CI: 0.43-0.86, P = 0.005). CONCLUSIONS Our preliminary results from this systematic review and meta-analysis revealed that pancreatic duct stents did not reduce the risk of POPF and other complications after pancreaticoduodenectomy compared with no stents. External stents were associated with a reduced POPF rate compared with no stents. Large-scale RCTs are required to assess the effectiveness and assist in clarifying the real role of pancreatic duct stents with respect to the POPF rates after pancreaticoduodenectomy.
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Affiliation(s)
- Chenchen Guo
- Department of General Surgery, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, 230001, China.
| | - Bin Xie
- Anhui Normal University, Wuhu, Anhui, 241000, China
| | - Diandian Guo
- School of Medicine, Southeast University, Nanjing, 210009, China
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29
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Lim CSH, Chui JN, Sharma V, Samra JS, Mittal A. Construction of a pancreatojejunostomy with an external stent: A technical description. J Surg Oncol 2022; 125:976-981. [PMID: 35099826 DOI: 10.1002/jso.26808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 12/30/2021] [Accepted: 01/18/2022] [Indexed: 02/04/2023]
Affiliation(s)
- Christopher S H Lim
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Juanita N Chui
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Varsha Sharma
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Jaswinder S Samra
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Australian Pancreatic Centre, Sydney, Australia
| | - Anubhav Mittal
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Australian Pancreatic Centre, Sydney, Australia.,Notre Dame University of Australia, Fremantle, Western Australia, Australia
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30
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Trudeau MT, Casciani F, Ecker BL, Maggino L, Seykora TF, Puri P, McMillan MT, Miller B, Pratt WB, Asbun HJ, Ball CG, Bassi C, Behrman SW, Berger AC, Bloomston MP, Callery MP, Castillo CFD, Christein JD, Dillhoff ME, Dickson EJ, Dixon E, Fisher WE, House MG, Hughes SJ, Kent TS, Malleo G, Salem RR, Wolfgang CL, Zureikat AH, Vollmer CM. The Fistula Risk Score Catalog: Toward Precision Medicine for Pancreatic Fistula After Pancreatoduodenectomy. Ann Surg 2022; 275:e463-e472. [PMID: 32541227 DOI: 10.1097/sla.0000000000004068] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE This study aims to present a full spectrum of individual patient presentations of pancreatic fistula risk, and to define the utility of mitigation strategies amongst some of the most prevalent, and vulnerable scenarios surgeons encounter. BACKGROUND The FRS has been utilized to identify technical strategies associated with reduced CR-POPF incidence across various risk strata. However, risk-stratification using the FRS has never been investigated with greater granularity. By deriving all possible combinations of FRS elements, individualized risk assessment could be utilized for precision medicine purposes. METHODS FRS profiles and outcomes of 5533 PDs were accrued from 17 international institutions (2003-2019). The FRS was used to derive 80 unique combinations of patient "scenarios." Risk-matched analyses were conducted using a Bonferroni adjustment to identify scenarios with increased vulnerability for CR-POPF occurrence. Subsequently, these scenarios were analyzed using multivariable regression to explore optimal mitigation approaches. RESULTS The overall CR-POPF rate was 13.6%. All 80 possible scenarios were encountered, with the most frequent being scenario #1 (8.1%) - the only negligible-risk scenario (CR-POPF rate = 0.7%). The moderate-risk zone had the most scenarios (50), patients (N = 3246), CR-POPFs (65.2%), and greatest non-zero discrepancy in CR-POPF rates between scenarios (18-fold). In the risk-matched analysis, 2 scenarios (#59 and 60) displayed increased vulnerability for CR-POPF relative to the moderate-risk zone (both P < 0.001). Multivariable analysis revealed factors associated with CR-POPF in these scenarios: pancreaticogastrostomy reconstruction [odds ratio (OR) 4.67], omission of drain placement (OR 5.51), and prophylactic octreotide (OR 3.09). When comparing the utilization of best practice strategies to patients who did not have these conjointly utilized, there was a significant decrease in CR-POPF (10.7% vs 35.5%, P < 0.001; OR 0.20, 95% confidence interval 0.12-0.33). CONCLUSION Through this data, a comprehensive fistula risk catalog has been created and the most clinically-impactful scenarios have been discerned. Focusing on individual scenarios provides a practical way to approach precision medicine, allowing for more directed and efficient management of CR-POPF.
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Affiliation(s)
- Maxwell T Trudeau
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Fabio Casciani
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona, Italy
| | - Brett L Ecker
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Laura Maggino
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona, Italy
| | - Thomas F Seykora
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Priya Puri
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Matthew T McMillan
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Benjamin Miller
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Wande B Pratt
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | | | - Claudio Bassi
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona, Italy
| | | | - Adam C Berger
- Jefferson Medical College, Philadelphia, Pennsylvania
| | | | - Mark P Callery
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | - John D Christein
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Mary E Dillhoff
- The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Euan J Dickson
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, UK
| | | | | | - Michael G House
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Steven J Hughes
- University of Florida College of Medicine, Jacksonville, Florida
| | - Tara S Kent
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Verona, Italy
| | | | | | - Amer H Zureikat
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Charles M Vollmer
- Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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OUP accepted manuscript. Br J Surg 2022; 109:812-821. [DOI: 10.1093/bjs/znac074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/07/2021] [Accepted: 02/23/2022] [Indexed: 11/13/2022]
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Zhou L, Xiao WM, Li CP, Gao YW, Gong WJ, Lu GT. Impact of Fatty Pancreas on Postoperative Pancreatic Fistulae: A Meta-Analysis. Front Oncol 2021; 11:622282. [PMID: 34926236 PMCID: PMC8671996 DOI: 10.3389/fonc.2021.622282] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 11/11/2021] [Indexed: 12/24/2022] Open
Abstract
Background Soft pancreas is widely recognized as an important risk factor for the development of postoperative pancreatic fistula (POPF). Although fatty pancreas (FP) has not been formally defined as a cause of pancreatic fistula, existing research has shown that it can increase the incidence of POPF by increasing pancreatic tenderness; therefore, it may be a potential risk factor. This study aimed to discern whether FP was associated with POPF. Method Two reviewers independently performed literature searches from five electronic databases. According to the established inclusion criteria, we extracted necessary data from the studies that met the criteria for further analysis. We pooled the odds ratios (ORs) from individual studies using a random-effects model to investigate the associations between POPF and the prognosis of FP. Result A total of 11 studies involving 2484 individuals were included. The pooled prevalence of POPF was 18% (95% CI: 12-24%). Body mass index (BMI) was associated with a significantly increased risk of POPF (OR=3.55; 95% CI: 1.83, 6.86; P=0.0002; I²=0). FP was obviously associated with the occurrence of POPF (OR=3.75; 95% CI: 1.64, 8.58; P=0.002; I²=78). Conclusion FP is closely associated with the development of POPF, and the early identification of these high-risk patients can help to reduce the incidence of POPF. Systematic Review Registration The Registration URL link is (https://www.crd.york.ac.uk/PROSPERO/). The ID is "CRD42021265141".
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Affiliation(s)
- Lu Zhou
- Pancreatic Center, Department of Gastroenterology, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China.,Department of Gastroenterology, Jingmen No. 2 People's Hospital, Hubei, China
| | - Wei-Ming Xiao
- Pancreatic Center, Department of Gastroenterology, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China.,Institute of digestive diseases, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
| | - Cheng-Peng Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Hepato-Pancreato-Biliary Surgery, Peking University Cancer Hospital & Institute, Beijing, China
| | - Yi-Wen Gao
- Pancreatic Center, Department of Gastroenterology, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China.,School of Nursing, Yangzhou University, Yangzhou, China
| | - Wei-Juan Gong
- Pancreatic Center, Department of Gastroenterology, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China.,School of Nursing, Yangzhou University, Yangzhou, China
| | - Guo-Tao Lu
- Pancreatic Center, Department of Gastroenterology, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China.,Institute of digestive diseases, The Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China
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He CC, Wu MD, Wang CH. Impact of internal and external drainage of the pancreatic duct on pancreatic fistula after pancreaticoduodenectomy: A meta-analysis. Shijie Huaren Xiaohua Zazhi 2021; 29:1341-1348. [DOI: 10.11569/wcjd.v29.i23.1341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Based on the domestic and foreign research on the impact of internal and external drainage of the pancreatic duct on pancreatic fistula after pancreaticoduodenectomy (PD), we conducted a meta-analysis to provide doctors with evidence on its applications in clinical work.
AIM To systematically evaluate the effect of internal and external drainage of the pancreatic duct on pancreatic fistula after PD.
METHODS PubMed, Embase, Cochrane, CNKI, CBM, Wanfang, and VIP were searched for randomized controlled and retrospective studies on internal and external drainage after PD resection from 2016 to 2021. According to the inclusion and exclusion criteria, the literature was selected, the data were extracted, and the literature quality was evaluated. Rev Man 5.3 software was used for meta-analysis.
RESULTS A total of four retrospective studies with 1213 patients were included. The results of meta-analysis showed that there was no significant difference in the improvement of clinically relevant pancreatic fistula after PD between internal and external drainage [odds ratio (OR) = 1.42, 95% confidence interval (CI): 0.84-2.40, P = 0.19]. Sensitivity analysis suggested that there was no heterogeneity among the studies (P = 0.33, I2 = 8.7%). The difference was statistically significant after pooling the results using the fixed-effects model (OR = 1.83, 95%CI: 1.12-2.99, P = 0.02). External drainage can reduce the incidence of postoperative clinically related pancreatic fistula. Subgroup analysis showed that there was no difference in the improvement of grade B (OR = 0.95, 95%CI: 0.64-1.40, P = 0.78] or grade C pancreatic fistula (OR = 1.58, 95%CI: 0.81- 3.09, P = 0.18).
CONCLUSION External drainage of the supporting duct can reduce the incidence of clinically relevant pancreatic fistula after surgery, but there is no difference in the improvement of grades B and C pancreatic fistula. Further research is required to verify our findings.
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Affiliation(s)
- Chen-Chen He
- China Medical University, Shenyang 110000, Liaoning Province, China
| | - Ming-Dong Wu
- China Medical University, Shenyang 110000, Liaoning Province, China
| | - Chun-Hui Wang
- Department of Hepatological Surgery, General Hospital of Northern Theater Command, Shenyang 110000, Liaoning Province, China
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Hong SS, Chong JU, Hwang HK, Lee WJ, Kang CM. Laparoscopic pancreaticoduodenectomy reduces incidence of clinically relevant postoperative pancreatic fistula in soft pancreas with a smaller than 2 mm pancreatic duct. Surg Endosc 2021; 35:7094-7103. [PMID: 33398573 DOI: 10.1007/s00464-020-08226-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 12/03/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Soft pancreas with small pancreatic duct is a known risk factor for postoperative pancreatic fistula (POPF). This study demonstrated the safety and feasibility of laparoscopic duct-to-mucosa pancreaticojejunostomy (PJ) and compared perioperative outcomes of laparoscopic pancreaticoduodenectomy (LPD) and open pancreaticoduodenectomy (OPD) in patients with soft pancreas and small pancreatic duct. METHODS From January 2014 to December 2019, 183 patients underwent LPD and 91 patients underwent OPD by a single surgeon. Data on patients with soft pancreas and combined small pancreatic duct (≤ 2 mm) were retrospectively reviewed. Clinicopathologic characteristics, and perioperative outcomes were compared between LPD and OPD. We evaluated risk factors affecting clinically relevant POPF (CR-POPF). We also correlated calculated risks of POPF and CR-POPF between the two groups. RESULTS We compared 62 patients in the LPD group and 34 patients in the OPD group. Perioperative outcomes showed less blood loss, shorter hospital stays, and less postoperative pain score on postoperative day (POD)#1 and #5 in LPD compared with OPD. Postoperative complications showed no differences between LPD and OPD. LPD group showed significantly reduced CR-POPF rates compared to the OPD group (LPD 11.3% vs. OPD 29.4%, p = 0.026). Multivariate analysis identified obesity (BMI ≥ 25), thick pancreas parenchyma and open surgery as independent predicting factors for CR-POPF. The LPD group showed less CR-POPF than the OPD group according to POPF risk groups. This difference was more prominent in a high-risk group. CONCLUSION With appropriate laparoscopic technique, LPD is feasible and safe and reduces CR-POPF in soft pancreas with a small pancreatic duct.
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Affiliation(s)
- Seung Soo Hong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-Ro, Seodaemun-Ku, Seoul, 03722, Korea
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Jae Uk Chong
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Ho Kyoung Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-Ro, Seodaemun-Ku, Seoul, 03722, Korea
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Woo Jung Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-Ro, Seodaemun-Ku, Seoul, 03722, Korea
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea
| | - Chang Moo Kang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, 50 Yonsei-Ro, Seodaemun-Ku, Seoul, 03722, Korea.
- Pancreatobiliary Cancer Center, Yonsei Cancer Center, Severance Hospital, Seoul, Korea.
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Fukuhara S, Kato M, Iwasaki E, Machida Y, Tamagawa H, Kawasaki S, Sasaki M, Kiguchi Y, Takatori Y, Matsuura N, Nakayama A, Ogata H, Kanai T, Yahagi N. External drainage of bile and pancreatic juice after endoscopic submucosal dissection for duodenal neoplasm: Feasibility study (with video). Dig Endosc 2021; 33:977-984. [PMID: 33258135 DOI: 10.1111/den.13907] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 11/23/2020] [Accepted: 11/26/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic submucosal dissection (ESD) for superficial duodenal epithelial tumors (SDETs) is technically difficult and has a high risk of adverse events. Endoscopic nasobiliary and nasopancreatic duct drainage (ENBPD) may reduce the risk of delayed adverse events by preventing exposure of the post-ESD mucosal defect to bile and pancreatic juice. This study was performed to evaluate the safety and feasibility of ENBPD after duodenal ESD. METHODS Patients who underwent ESD for SDETs from July 2010 to March 2020 were included. We collected data on the success rate of ENBPD, adverse events due to insertion of a side-viewing endoscope, and pancreatitis after ENBPD. We also collected the clinical outcomes of duodenal ESD, including the incidence rate of delayed adverse events (defined as bleeding or perforation found after the endoscopic procedure). RESULTS Among 70 patients without complete closure of the post-ESD mucosal defect, ENBPD was successfully performed in all 25 patients including 21 cases inserted immediately after ESD and four cases inserted later. There were no adverse events associated with ENBPD procedure intraoperatively, while pancreatitis after ENBPD occurred in four patients (16.0%). No patients who underwent immediate ENBPD required intervention for an intra-abdominal abscess or delayed perforation, whereas 3 of 49 patients (6.1%) who did not undergo immediate ENBPD required surgery or drainage of an abscess. CONCLUSIONS Endoscopic nasobiliary and nasopancreatic duct drainage is technically feasible and might provide effective prophylaxis for delayed adverse events, even if a large mucosal defect is present after ESD.
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Affiliation(s)
- Seiichiro Fukuhara
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Motohiko Kato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yujiro Machida
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hiroki Tamagawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shintaro Kawasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Motoki Sasaki
- Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiyuki Kiguchi
- Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Yusaku Takatori
- Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Noriko Matsuura
- Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Atsushi Nakayama
- Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Naohisa Yahagi
- Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
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Yu J, Ren CY, Wang J, Cui W, Zhang JJ, Wang YJ. Establishment of risk prediction model of postoperative pancreatic fistula after pancreatoduodenectomy: 2016 edition of definition and grading system of pancreatic fistula: a single center experience with 223 cases. World J Surg Oncol 2021; 19:257. [PMID: 34461923 PMCID: PMC8404268 DOI: 10.1186/s12957-021-02372-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 08/12/2021] [Indexed: 01/30/2023] Open
Abstract
Objective To establish a risk prediction model for pancreatic fistula according to the pancreatic fistula standards of the 2016 edition. Methods Clinical data from 223 patients with PD admitted to Tianjin Third Central Hospital from January 2016 to December 2020 were retrospectively analyzed. Patients were divided into modeling (January 2016 to December 2018) and validation (January 2019 to December 2020) sets according to the time of admission. The risk factors for postoperative pancreatic fistula (POPF) were screened by univariate and multivariate logistic regression analyses, and a risk prediction model for POPF was established in the modeling set. This score was tested in the validation set. Results Logistic regression analysis showed that the main pancreatic duct index and CT value were independent risk factors according to the 2016 pancreatic fistula grading standard, based on which a risk prediction model for POPF was established. Receiver operating characteristic curve analysis showed that the area under the curve was 0.775 in the modeling set and 0.848 in the validation set. Conclusion The main pancreatic duct index and CT value of the pancreas are closely related to the occurrence of pancreatic fistula after PD, and the established risk prediction model for pancreatic fistula has good prediction accuracy.
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Affiliation(s)
- Jun Yu
- Department of Hepatobiliary Surgery, Third Central Hospital of Tianjin, Tianjin, China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Third Central Hospital of Tianjin, Tianjin, China.,Artificial Cell Engineering Technology Research Center of Public Health Ministry, Third Central Hospital of Tianjin, 83 Jintang Road, Tianjin, 300170, China
| | - Chao-Yi Ren
- Department of Hepatobiliary Surgery, Third Central Hospital of Tianjin, Tianjin, China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Third Central Hospital of Tianjin, Tianjin, China.,Artificial Cell Engineering Technology Research Center of Public Health Ministry, Third Central Hospital of Tianjin, 83 Jintang Road, Tianjin, 300170, China
| | - Jun Wang
- Department of Hepatobiliary Surgery, Third Central Hospital of Tianjin, Tianjin, China
| | - Wei Cui
- Department of Hepatobiliary Surgery, Third Central Hospital of Tianjin, Tianjin, China.,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Third Central Hospital of Tianjin, Tianjin, China
| | - Jin-Juan Zhang
- Department of Hepatobiliary Surgery, Third Central Hospital of Tianjin, Tianjin, China.,Artificial Cell Engineering Technology Research Center of Public Health Ministry, Third Central Hospital of Tianjin, 83 Jintang Road, Tianjin, 300170, China
| | - Yi-Jun Wang
- Department of Hepatobiliary Surgery, Third Central Hospital of Tianjin, Tianjin, China. .,Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Third Central Hospital of Tianjin, Tianjin, China. .,Artificial Cell Engineering Technology Research Center of Public Health Ministry, Third Central Hospital of Tianjin, 83 Jintang Road, Tianjin, 300170, China.
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Park JH, Park J, Park Y, Kang JM, Ryu DS, Kyung J, Jang JK, Hwang C, Shim IK, Song HY, Yang SG, Kim SC. Acetazolamide-eluting biodegradable tubular stent prevents pancreaticojejunal anastomotic leakage. J Control Release 2021; 335:650-659. [PMID: 34118337 DOI: 10.1016/j.jconrel.2021.06.010] [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: 12/15/2020] [Revised: 05/23/2021] [Accepted: 06/08/2021] [Indexed: 10/21/2022]
Abstract
Postoperative pancreatic fistula at the early stage can lead to auto-digestion, which may delay the recovery of the pancreaticojejunal (PJ) anastomosis. The efficacy and safety of an acetazolamide-eluting biodegradable tubular stent (AZ-BTS) for the prevention of self-digestion and intra-abdominal inflammatory diseases caused by pancreatic juice leakage after PJ anastomosis in a porcine model were investigated. The AZ-BTS was successfully fabricated using a multiple dip-coating process. Then, the drug amount and release profile were analyzed. The therapeutic effects of AZ were examined in vitro using two kinds of pancreatic cancer cell lines, AsPC-1 and PANC-1. The efficacy of AZ-BTS was assessed in a porcine PJ leakage model, with animals were each assigned to a leakage group, a BTS group and an AZ-BTS group. The overall mortality rates in these three groups were 44.4%, 16.6%, and 0%, respectively. Mean α-amylase concentrations were significantly higher in the leakage and BTS groups than in the AZ-BTS group on day 2-5 (p < 0.05 each all). The luminal diameters and areas of the pancreatic duct were significantly larger in the leakage group than in the BTS and AZ-BTS groups (p < 0.05 each all). These findings indicate that AZ-BTS can significantly suppress intra-abdominal inflammatory diseases caused by pancreatic juice leakage and also prevent late stricture formation at the PJ anastomotic site in a porcine model.
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Affiliation(s)
- Jung-Hoon Park
- Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - Jieun Park
- Department of Biomedical Science, BK21 FOUR Program in Biomedical Science and Engineering, Inha University College of Medicine, 366 Seohae-Daero, Jung-Gu, Incheon 22332, Republic of Korea
| | - Yejong Park
- Division of Hepatobiliary Pancreas Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Jeon Min Kang
- Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - Dae Sung Ryu
- Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - Jeongsu Kyung
- Department of Biomedical Science, BK21 FOUR Program in Biomedical Science and Engineering, Inha University College of Medicine, 366 Seohae-Daero, Jung-Gu, Incheon 22332, Republic of Korea
| | - Jong Keon Jang
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Changmo Hwang
- Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - In Kyong Shim
- Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea; Asan Medical Institute of Convergence Science and Technology (AMIST), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - Ho-Young Song
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea; Department of Radiology, UT Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Su-Geun Yang
- Department of Biomedical Science, BK21 FOUR Program in Biomedical Science and Engineering, Inha University College of Medicine, 366 Seohae-Daero, Jung-Gu, Incheon 22332, Republic of Korea.
| | - Song Cheol Kim
- Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea; Division of Hepatobiliary Pancreas Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea; Asan Medical Institute of Convergence Science and Technology (AMIST), Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea.
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Pros and pitfalls of externalized trans-anastomotic stent as a mitigation strategy of POPF: a prospective risk-stratified observational series. HPB (Oxford) 2021; 23:1046-1053. [PMID: 33221160 DOI: 10.1016/j.hpb.2020.10.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 09/30/2020] [Accepted: 10/02/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Several advantages and pitfalls have been related to externalized trans-anastomotic stents (ETS) after pancreaticoduodenectomy. The purpose of this study was to investigate the effect of an ETS effect in a risk-stratified setting. METHODS Data from patients at either intermediate- or high-risk for postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy were prospectively analyzed from January 2016 to December 2019. Outcomes included POPF rate, mean complication burden (ACB), and complications related to ETS malfunction. RESULTS A total of 540 patients met the inclusion criteria. Following an intention-to-treat analysis, there was no difference in terms of POPF and the ACB in the intermediate (22 vs.29%, p = 0.148; 0.38 vs.0.24, p = 0.082) and high-risk categories (58 vs.37%, p = 0.103; 0.33 vs.0.33, p = 0.478) comparing PJ to PJ-ETS. Excluding patients experiencing ETS malfunction (n = 45, 22%), ETS was associated with a significantly reduced ACB in the intermediate-risk (0.38 vs.0.26, p = 0.009) and POPF rate in the high-risk category (58 vs.32%, p = 0.033). In patients with ETS malfunction an increased rate of severe morbidity (Clavien-Dindo ≥ III, 33 vs.19%, p = 0.044) was observed as compared to patients with functioning ETS. CONCLUSION ETS provides crucial advantages for prevention and mitigation of POPF depending on risk setting and its correct functioning. ETS malfunction is not uncommon and increases morbidity. Improving ETS design and fixing technique might lead to better outcomes.
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Jiménez Romero C, Alonso Murillo L, Rioja Conde P, Marcacuzco Quinto A, Caso Maestro Ó, Nutu A, Pérez Moreiras I, Justo Alonso I. Pancreaticoduodenectomy and external Wirsung stenting: Our outcomes in 80 cases. Cir Esp 2021; 99:440-449. [PMID: 34103272 DOI: 10.1016/j.cireng.2021.05.011] [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: 03/02/2020] [Accepted: 07/12/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION There is controversy regarding the ideal pancreaticojejunostomy technique after pancreaticoduodenectomy. Many authors consider the external Wirsung stenting technique to be associated with a low incidence of fistula, morbidity and mortality. We analyse our experience with this technique. PATIENTS AND METHODS A retrospective analysis of the morbidity and mortality of a series of 80 consecutive patients who had been treated surgically over a 6.5-year period for pancreatic head or periampullary tumors, performing pancreaticoduodenectomy and pancreaticojejunostomy with external Wirsung duct stenting. RESULTS Mean patient age was 68.3 ± 9 years, and the resectability rate was 78%. The texture of the pancreas was soft in 51.2% of patients and hard in 48.8%. Pylorus-preserving resection was performed in 43.8%. Adenocarcinoma was the most frequent tumor (68.8%), and R0 was confirmed in 70% of patients. Biochemical fistula was observed in 11.2%, pancreatic fistula grade B in 12.5% and C in 2.5%, whereas the abdominal reoperation rate was 10%. Median postoperative hospital stay was 16 days, and postoperative and 90-day mortality was 2.5%. Delayed gastric emptying was observed in 36.3% of patients, de novo diabetes in 12.5%, and exocrine insufficiency in 3. Patient survival rates after 1, 3 and 5 years were 80.2%, 53.6% and 19.2%, respectively. CONCLUSIONS Although our low rates of postoperative complications and mortality using external Wirsung duct stenting coincides with other more numerous recent series, it is necessary to perform a comparative analysis with other techniques, including more cases, to choose the best reconstruction technique after pancreaticoduodenectomy.
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Affiliation(s)
- Carlos Jiménez Romero
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | - Laura Alonso Murillo
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Paula Rioja Conde
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Alberto Marcacuzco Quinto
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Óscar Caso Maestro
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Anisa Nutu
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Iago Justo Alonso
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Madrid, Spain
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Wongta K, Tangsirapat V. Surgical outcomes of combined modified Blumgart pancreaticojejunostomy and long internal pancreatic duct stent for pancreaticoduodenectomy. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2021.100346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Honselmann KC, Antoine C, Frohneberg L, Deichmann S, Bolm L, Braun R, Lapshyn H, Petrova E, Keck T, Wellner U, Bausch D. A simple nomogram for early postoperative risk prediction of clinically relevant pancreatic fistula after pancreatoduodenectomy. Langenbecks Arch Surg 2021; 406:2343-2355. [PMID: 34009458 PMCID: PMC8578094 DOI: 10.1007/s00423-021-02184-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 04/28/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE Postoperative pancreatic fistulae (POPF) present a serious and life-threatening complication after pancreatic head resections (PD). Therefore, reliable risk stratification to identify those at risk is urgently needed. The aim of this study was to identify postoperative laboratory parameters for the prediction of POPF in the early postoperative period. METHODS One hundred eighty-two patients who underwent PD from 2012 until 2017 were retrospectively analyzed. Multivariate logistic regression was performed using the GLM (general linear model) method for model building. Two nomograms were created based on the GLM models of postoperative day one and postoperative day one to five. A cohort of 48 patients operated between 2018 and 2019 served as internal validation. RESULTS Clinically relevant pancreatic fistulae (CR-POPF) were present in 16% (n = 29) of patients. Patients with CR-POPF experienced significantly more insufficiencies of gastroenterostomies, delayed gastric emptying, and more extraluminal bleeding than patients without CR-POPF. Multivariate analysis revealed multiple postoperative predictive models, the best one including ASA, main pancreatic duct diameter, operation time, and serum lipase as well as leucocytes on day one. This model was able to predict CR-POPF with an accuracy of 90% and an AUC of 0.903. Two nomograms were created for easier use. CONCLUSION Clinically relevant fistula can be predicted using simple laboratory and clinical parameters. Not serum amylase, but serum lipase is an independent predictor of CR-POPF. Our simple nomograms may help in the identification of patients for early postoperative interventions.
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Affiliation(s)
- K C Honselmann
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - C Antoine
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - L Frohneberg
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - S Deichmann
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - L Bolm
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - R Braun
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - H Lapshyn
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - E Petrova
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - T Keck
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - U Wellner
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany
| | - D Bausch
- Department of Surgery, University Cancer Center, University Medical Center Schleswig-Holstein, Campus Luebeck, Luebeck, Germany. .,Department of Surgery, Marien Hospital Herne-University Medical Center of the Ruhr-Universität Bochum, Hölkeskampring 40, 44625, Herne, Germany.
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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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Casciani F, Trudeau MT, Asbun HJ, Ball CG, Bassi C, Behrman SW, Berger AC, Bloomston MP, Callery MP, Christein JD, Falconi M, Fernandez-Del Castillo C, Dillhoff ME, Dickson EJ, Dixon E, Fisher WE, House MG, Hughes SJ, Kent TS, Malleo G, Partelli S, Salem RR, Stauffer JA, Wolfgang CL, Zureikat AH, Vollmer CM. Surgeon experience contributes to improved outcomes in pancreatoduodenectomies at high risk for fistula development. Surgery 2021; 169:708-720. [PMID: 33386129 DOI: 10.1016/j.surg.2020.11.022] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 11/12/2020] [Accepted: 11/17/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Pancreatoduodenectomies at high risk for clinically relevant pancreatic fistula are uncommon, yet intimidating, situations. In such scenarios, the impact of individual surgeon experience on outcomes is poorly understood. METHODS The fistula risk score was applied to identify high-risk patients (fistula risk score 7-10) from 7,706 pancreatoduodenectomies performed at 18 international institutions (2003-2020). For each case, surgeon pancreatoduodenectomy career volume and years of practice were linked to intraoperative fistula mitigation strategy adoption and outcomes. Consequently, best operative approaches for clinically relevant pancreatic fistula prevention and best performer profiles were identified through multivariable analysis models. RESULTS Eight hundred and thirty high-risk pancreatoduodenectomies, performed by 64 surgeons, displayed an overall clinically relevant pancreatic fistula rate of 33.7%. Clinically relevant pancreatic fistula rates decreased with escalating surgeon career pancreatoduodenectomy (-49.7%) and career length (-41.2%; both P < .001), as did transfusion and reoperation rates, postoperative morbidity index, and duration of stay. Great experience (≥400 pancreatoduodenectomies performed or ≥21-year-long career) was a significant predictor of clinically relevant pancreatic fistula prevention (odds ratio 0.52, 95% confidence interval 0.35-0.76) and was more often associated with pancreatojejunostomy reconstruction and prophylactic octreotide omission, which were both independently associated with clinically relevant pancreatic fistula reduction. A risk-adjusted performance analysis also correlated with experience. Moreover, minimizing blood loss (≤400 mL) significantly contributed to clinically relevant pancreatic fistula prevention (odds ratio 0.40, 95% confidence interval 0.22-0.74). CONCLUSION Surgeon experience is a key contributor to achieve better outcomes after high-risk pancreatoduodenectomy. Surgeons can improve their performance in these challenging situations by employing pancreatojejunostomy reconstruction, omitting prophylactic octreotide, and minimizing blood loss.
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Affiliation(s)
- Fabio Casciani
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Italy
| | - Maxwell T Trudeau
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Chad G Ball
- Department of Surgery, University of Calgary, Canada
| | - Claudio Bassi
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Italy
| | | | - Adam C Berger
- Department of Surgery, Jefferson Medical College, Philadelphia, PA
| | - Mark P Bloomston
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Mark P Callery
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - John D Christein
- Department of Surgery, University of Alabama at Birmingham School of Medicine, AL
| | | | | | - Mary E Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Euan J Dickson
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, United Kingdom
| | - Elijah Dixon
- Department of Surgery, University of Calgary, Canada
| | | | - Michael G House
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Steven J Hughes
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Tara S Kent
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Giuseppe Malleo
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Italy
| | | | - Ronald R Salem
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | | | | | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
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Jiang Y, Chen Q, Shao Y, Gao Z, Jin M, Gao B, Zhou B, Yan S. The prognostic value of external vs internal pancreatic duct stents after pancreaticoduodenectomy in patients with FRS ≥ 4: a retrospective cohort study. BMC Surg 2021; 21:81. [PMID: 33579250 PMCID: PMC7881586 DOI: 10.1186/s12893-021-01074-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 01/25/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The prognostic value of external vs internal pancreatic duct stents after pancreaticoduodenectomy remains controversial. This study aimed to evaluate the benefits of external and internal stents using the Fistula Risk Score system with regard to the incidence of clinically relevant postoperative pancreatic fistula. METHODS A total of 382 patients who underwent pancreaticoduodenectomy with duct to mucosa pancreaticojejunostomy were retrospectively enrolled from January 2015 to October 2019. The receiver operating characteristic curve was performed for subgroup analysis of the patients at different levels of risk for pancreatic fistula. RESULTS There were no significant differences in terms of pancreatic fistula or other postoperative complications. According to the receiver operating characteristic curve threshold of 3.5, 172 patients with a Fistula Risk Score ≥ 4 and 210 patients with a Fistula Risk Score < 4 were divided into separate groups. The number of valid cases was insufficient to support the subsequent research in patients with a Fistula Risk Score < 4. In patients with a Fistula Risk Score ≥ 4, the use of an external pancreatic duct stent was significantly more effective than the use of an internal stent, especially with regard to the risk for pancreatic fistula (Grade C) (P = 0.039), at ameliorating the incidence of clinically relevant postoperative pancreatic fistula (P = 0.019). Additionally, the incidence of lymphatic leakage was significantly higher in the external stent group compared with the internal stent group (P = 0.040). CONCLUSIONS Compared with internal stents, the use of an external stent could reduce the incidence of clinically relevant postoperative pancreatic fistula in patients with a Fistula Risk Score ≥ 4. More large-scale prospective clinical trials are warranted to further clarify our results.
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Affiliation(s)
- Yuancong Jiang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, China
| | - Qin Chen
- Cancer Institute (Key Laboratory of Cancer Prevention and Intervention, China National Ministry of Education, Key Laboratory of Molecular Biology in Medical Sciences, Zhejiang Province, China), The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yi Shao
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Zhenzhen Gao
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, China
| | - Ming Jin
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, China
| | - Bingqiang Gao
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, China
| | - Bo Zhou
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, China.
| | - Sheng Yan
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, 310009, China.
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Sachs TE, Tseng JF. Landmark Series in Pancreatic Tumors: Anastomotic Techniques and Route of Reconstruction. Ann Surg Oncol 2021; 28:2227-2234. [PMID: 33550501 DOI: 10.1245/s10434-021-09663-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 01/15/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Pancreaticoduodenectomy is one of the more complicated operations that exists in surgery, and is fraught with potential morbidity, the most well-known, and dreaded, of which is the pancreatic leak. While much of the risk associated with pancreatic leak is inherent to the operation, there have been no shortage of techniques employed by surgeons to try to mitigate that risk. METHODS We focused on four topics of greatest conjecture with regard to reconstruction after pancreaticoduodenectomy: (1) the type of anastomosis, (2) the enteral organ to which the pancreas is sewn, (3) whether to preserve the pylorus and (4) whether or not to use anastomotic silastic stents. We identified the most relevant randomized control trials on each topic, which were appropriately powered. RESULTS We identified a total of 15 studies for evaluation, (type of anastomosis: n = 4; enteral organ to which the pancreas is sewn: n = 4; whether to preserve the pylorus, n=3; and whether or not to use anastomotic silastic stents, n = 4). In each group of comparisons, there was no definitive conclusion to be made on superiority of reconstruction. CONCLUSION While clear consensus on how best to reconstruct the anatomy after pancreaticoduodenectomy has not yet been reached, we present the following review in the hope of providing some understanding of the literature for the pancreatic surgeon.
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Affiliation(s)
- Teviah E Sachs
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, USA.
| | - Jennifer F Tseng
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, USA
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Hain E, Challine A, Tzedakis S, Mare A, Martinino A, Fuks D, Adham M, Piessen G, Regimbeau JM, Buc E, Barbier L, Vaillant JC, Jeune F, Sulpice L, Muscari F, Schwarz L, Deguelte S, Sa Cunha A, Truant S, Dousset B, Sauvanet A, Gaujoux S. Study Protocol of the PreFiPS Study: Prevention of Postoperative Pancreatic Fistula by Somatostatin Compared With Octreotide, a Prospective Randomized Controlled Trial. Front Med (Lausanne) 2021; 7:488. [PMID: 33521003 PMCID: PMC7844059 DOI: 10.3389/fmed.2020.00488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 07/17/2020] [Indexed: 11/25/2022] Open
Abstract
Background: Pancreatic fistula (PF), i. e., a failure of the pancreatic anastomosis or closure of the remnant pancreas after distal pancreatectomy, is one of the most feared complications after pancreatic surgery. PF is also one of the most common complications after pancreatic surgery, occurring in about 30% of patients. Prevention of a PF is still a major challenge for surgeons, and various technical and pharmacological interventions have been investigated, with conflicting results. Pancreatic exocrine secretion has been proposed as one of the mechanisms by which PF occurs. Pharmacological prevention using somatostatin or its analogs to inhibit pancreatic exocrine secretion has shown promising results. We can hypothesize that continuous intravenous infusion of somatostatin-14, the natural peptide hormone, associated with 10–50 times stronger affinity with all somatostatin receptor compared with somatostatin analogs, will be associated with an improved PF prevention. Methods: A French comparative randomized open multicentric study comparing somatostatin vs. octreotide in adult patients undergoing pancreaticoduodenectomy (PD) or distal pancreatectomy with or without splenectomy. Patients with neoadjuvant radiation therapy and/or neoadjuvant chemotherapy within 4 weeks before surgery are excluded from the study. The main objective of this study is to compare 90-day grade B or C postoperative PF as defined by the last ISGPF (International Study Group on Pancreatic Fistula) classification between patients who receive perioperative somatostatin and octreotide. In addition, we analyze overall length of stay, readmission rate, cost-effectiveness, and postoperative quality of life after pancreatic surgery in patients undergoing PD. Conclusion: The PreFiPS study aims to evaluate somatostatin vs. octreotide for the prevention of postoperative PF.
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Affiliation(s)
- Elisabeth Hain
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Paris Descartes University, Cochin Hospital, Paris, France
| | - Alexandre Challine
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Paris Descartes University, Cochin Hospital, Paris, France
| | - Stylianos Tzedakis
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Paris Descartes University, Cochin Hospital, Paris, France
| | - Alexandru Mare
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Paris Descartes University, Cochin Hospital, Paris, France
| | - Alessandro Martinino
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Paris Descartes University, Cochin Hospital, Paris, France
| | - David Fuks
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Mustapha Adham
- Chirurgie digestive, HCL-Hôpital Edouard Herriot, Lyon, France
| | - Guillaume Piessen
- Chirurgie digestive et oncologique, Hôpital Claude Huriez, Lille, France
| | | | - Emmanuel Buc
- Chirurgie digestive et oncologie digestive, CHU Estaing, Clermont-Ferrand, France
| | - Louise Barbier
- Chirurgie digestive, Hôpital Trousseau, Chambray-Lès-Tours, France
| | - Jean-Christophe Vaillant
- Chirurgie Digestive et Hépatobiliaire-Transplantation Hépatique, Hôpital La pitié Salpêtrière, Paris, France
| | - Florence Jeune
- Chirurgie Digestive et Hépatobiliaire-Transplantation Hépatique, Hôpital La pitié Salpêtrière, Paris, France
| | - Laurent Sulpice
- Chirurgie Hépatobiliaire et Digestive, Hôpital Universitaire Pontchaillou, Rennes, France
| | - Fabrice Muscari
- Chirurgie Digestive et Transplantation Hépatique, CHU Rangueil, Toulouse, France
| | - Lilian Schwarz
- Chirurgie Digestive, Hôpital Charles Nicolle, Rouen, France
| | - Sophie Deguelte
- Chirurgie Viscérale, Digestive et Endocrinienne, CHU de Reims, Reims, France
| | | | - Stephanie Truant
- Chirurgie digestive et Transplantation, Hôpital Claude Huriez, Lille, France
| | - Bertrand Dousset
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Paris Descartes University, Cochin Hospital, Paris, France
| | - Alain Sauvanet
- Chirurgie hépatobiliaire et transplantation hépatique, Hôpital Beaujon, Clichy, France
| | - Sébastien Gaujoux
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Paris Descartes University, Cochin Hospital, Paris, France
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Turrini O, Delpero JR. External drainage of the main pancreatic duct is a variable technique. Pancreatology 2020; 20:1791-1792. [PMID: 33082107 DOI: 10.1016/j.pan.2020.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/02/2020] [Accepted: 10/08/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Olivier Turrini
- Department of Surgery, Aix-Marseille University, Institut Paoli-Calmettes, CRCM, Marseille, France.
| | - Jean-Robert Delpero
- Department of Surgery, Aix-Marseille University, Institut Paoli-Calmettes, CRCM, Marseille, France
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Drozdov ES, Koshel AP, Rodionova OV, Dibina TV, Klokov SS. [Predictors of external pancreatic fistulae after pancreatic resection]. Khirurgiia (Mosk) 2020:107-114. [PMID: 33210516 DOI: 10.17116/hirurgia2020111107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Despite a significant decrease in postoperative mortality after pancreatic resections in recent years (5.2-15% after pancreatoduodenectomy and about 5% after distal pancreatectomy), incidence of postoperative complications remains high (30-50% and 22-50%, respectively). Postoperative pancreatic fistula is one of the most common and formidable complications. Currently, most authors use the classification proposed by the International Study Group for Pancreatic Fistula (biochemical failure, fistula type B and C). Prediction of the risk of postoperative fistula is still a complex and unresolved problem of modern surgical pancreatology. According to the literature, the main risk factors of postoperative pancreatic fistulae are obesity and high body mass index, concomitant cardiovascular diseases, no neoadjuvant chemo- and radiotherapy, soft pancreatic texture, narrow pancreatic duct, no fibrotic changes in parenchyma, adipose infiltration of the pancreas, advanced intraoperative blood loss, as well as center experience. Most often, magnetic resonance imaging, computed tomography, ultrasound elastography and various multivariate risk assessment systems are used to estimate the risk of pancreatic fistulae. However, a generally accepted technique does not exist. This manuscript is devoted to analysis of risk factors of postoperative pancreatic fistulae and diagnostic methods for assessment of this risk.
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Affiliation(s)
- E S Drozdov
- Siberian State Medical University, Tomsk, Russia.,Tomsk Regional Oncology Hospital, Tomsk, Russia
| | - A P Koshel
- Siberian State Medical University, Tomsk, Russia.,Alperovich Tomsk City Clinical Hospital No. 3, Tomsk, Russia
| | | | | | - S S Klokov
- Siberian State Medical University, Tomsk, Russia.,Zherlov Medical Center, Seversk, Russia
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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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Van Buren G, Vollmer CM. The Landmark Series: Mitigation of the Postoperative Pancreatic Fistula. Ann Surg Oncol 2020; 28:1052-1059. [PMID: 33089395 DOI: 10.1245/s10434-020-09251-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 10/04/2020] [Indexed: 12/14/2022]
Abstract
Pancreatic fistula has been the defining complication and challenge of pancreatic surgery. Better awareness and mitigation of postoperative pancreatic fistulas has led to significant improvements in morbidity and mortality of pancreatic surgery. The definition and management of pancreatic fistulas has sequentially progressed over the last three decades; the literature ranges from retrospective, observational studies to prospective multicenter randomized controlled trials. The landmark literature contributions driving the perioperative management of pancreatic fistulas are detailed in this article.
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Affiliation(s)
- George Van Buren
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Charles M Vollmer
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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