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Tsunematsu M, Shirai Y, Hamura R, Haruki K, Furukawa K, Onda S, Matsumoto M, Okui N, Taniai T, Ikegami T. The conventional method of blood-loss calculation can underestimate true blood loss during laparoscopic pancreaticoduodenectomy: a dual-institute experience. Surg Today 2025:10.1007/s00595-025-03040-y. [PMID: 40232398 DOI: 10.1007/s00595-025-03040-y] [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: 11/15/2024] [Accepted: 03/03/2025] [Indexed: 04/16/2025]
Abstract
PURPOSE This study investigated whether blood loss (BL) was. truly less in patients undergoing laparoscopic pancreaticoduodenectomy (LPD) than in those undergoing open pancreaticoduodenectomy (OPD). METHODS A total of 98 patients undergoing pancreaticoduodenectomy between 2021 and 2023 were divided into OPD and LPD groups and compared. Estimated BL was calculated from the perioperative changes in hematocrit, hemoglobin, or red blood cell volume. Actual BL was calculated using the conventional method as the sum of the intraoperative aspirated blood volume and surgical gauze weight. RESULTS Actual BL was significantly lower in the LPD group than in the OPD group (150 [80-350] ml vs. 345 [150-700] ml, p = 0.003). However, there were no significant differences in the estimated BL calculated from the hematocrit (461 [187-626] ml vs. 351 [153-737] ml, p = 0.972), hemoglobin, or red blood cell volume. Estimated BL showed a stronger linear correlation with actual BL in the OPD group (r = 0.447-0.669) than in the LPD group (r = 0.158-0.417). OPD was not a significant factor in the increased estimated BL. CONCLUSIONS The conventional method for calculating the BL in LPD may underestimate the actual loss, highlighting the need for a more accurate method of evaluation.
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Affiliation(s)
- Masashi Tsunematsu
- Department of Digestive Surgery, Saku Central Hospital Advanced Care Center, 3400-28, Nakagomi, Saku, Nagano, 385-0051, Japan.
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan.
| | - Yoshihiro Shirai
- Department of Digestive Surgery, Saku Central Hospital Advanced Care Center, 3400-28, Nakagomi, Saku, Nagano, 385-0051, Japan
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Ryoga Hamura
- Department of Digestive Surgery, Saku Central Hospital Advanced Care Center, 3400-28, Nakagomi, Saku, Nagano, 385-0051, Japan
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Koichiro Haruki
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Kenei Furukawa
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Shinji Onda
- Department of Digestive Surgery, Saku Central Hospital Advanced Care Center, 3400-28, Nakagomi, Saku, Nagano, 385-0051, Japan
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Michinori Matsumoto
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Norimitsu Okui
- Department of Digestive Surgery, Saku Central Hospital Advanced Care Center, 3400-28, Nakagomi, Saku, Nagano, 385-0051, Japan
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Tomohiko Taniai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Toru Ikegami
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
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Alhulaili ZM, Pleijhuis RG, Hoogwater FJH, Nijkamp MW, Klaase JM. Risk stratification of postoperative pancreatic fistula and other complications following pancreatoduodenectomy. How far are we? A scoping review. Langenbecks Arch Surg 2025; 410:62. [PMID: 39915344 PMCID: PMC11802655 DOI: 10.1007/s00423-024-03581-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Accepted: 12/16/2024] [Indexed: 02/09/2025]
Abstract
PURPOSE Pancreatoduodenectomy (PD) is a challenging procedure which is associated with high morbidity rates. This study was performed to make an overview of risk factors included in risk stratification methods both logistic regression models and models based on artificial intelligence algorithms to predict postoperative pancreatic fistula (POPF) and other complications following PD and to provide insight in the extent to which these tools were validated. METHODS Five databases were searched to identify relevant studies. Calculators, equations, nomograms, and artificial intelligence models that addressed POPF and other complications were included. Only PD resections were considered eligible. There was no exclusion of the minimally invasive techniques reporting PD resections. All other pancreatic resections were excluded. RESULTS 90 studies were included. Thirty-five studies were related to POPF, thirty-five studies were related to other complications following PD and twenty studies were related to artificial intelligence predication models after PD. Among the identified risk factors, the most used factors for POPF risk stratification were the main pancreatic duct diameter (MPD) (80%) followed by pancreatic texture (51%), whereas for other complications the most used factors were age (34%) and ASA score (29.4%). Only 26% of the evaluated risk stratification tools for POPF and other complications were externally validated. This percentage was even lower for the risk models using artificial intelligence which was 20%. CONCLUSION The MPD was the most used factor when stratifying the risk of POPF followed by pancreatic texture. Age and ASA score were the most used factors for the stratification of other complications. Insight in clinically relevant risk factors could help surgeons in adapting their surgical strategy and shared decision-making. This study revealed that the focus of research still lies on developing new risk models rather than model validation, hampering clinical implementation of these tools for decision support.
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Affiliation(s)
- Zahraa M Alhulaili
- Department of Hepato-Pancreato- Biliary Surgery and Liver Transplantation University Medical Center Groningen, University of Groningen, 30001 9700 RB, Groningen, Netherlands
| | - Rick G Pleijhuis
- Department of Internal Medicine University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Frederik J H Hoogwater
- Department of Hepato-Pancreato- Biliary Surgery and Liver Transplantation University Medical Center Groningen, University of Groningen, 30001 9700 RB, Groningen, Netherlands
| | - Maarten W Nijkamp
- Department of Hepato-Pancreato- Biliary Surgery and Liver Transplantation University Medical Center Groningen, University of Groningen, 30001 9700 RB, Groningen, Netherlands
| | - Joost M Klaase
- Department of Hepato-Pancreato- Biliary Surgery and Liver Transplantation University Medical Center Groningen, University of Groningen, 30001 9700 RB, Groningen, Netherlands.
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Sasaki T, Takayama Y, Tanaka S, Hamada Y, Nakashima R, Naito S, Kajiwara M, Hasegawa S. Pancreatic extracellular volume fraction on routine contrast-enhanced computed tomography can predict pancreatic fibrosis and postoperative pancreatic fistula. Pancreatology 2025; 25:153-159. [PMID: 39672754 DOI: 10.1016/j.pan.2024.12.003] [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: 09/14/2024] [Revised: 11/25/2024] [Accepted: 12/05/2024] [Indexed: 12/15/2024]
Abstract
BACKGROUND/OBJECTIVES Postoperative pancreatic fistula (POPF) is a critical complication of pancreatectomy, with a higher risk associated with the absence of pancreatic fibrosis. We investigated whether pancreatic extracellular volume fraction (ECV) calculated from preoperative contrast-enhanced computed tomography (CE-CT) images can be used to predict pancreatic fibrosis and POPF. METHODS This retrospective study included patients who underwent CE-CT before pancreatectomy. ECV map was created by subtracting unenhanced from equilibrium-phase images. We assessed the relationship between pancreatic ECV, the histopathological grade of fibrosis at the pancreatic resection margin, and the occurrence of POPF. RESULTS Among the 107 patients included, 66 underwent pancreaticoduodenectomy (PD) and 41 underwent distal pancreatectomy (DP). The median ECV at the pancreatic resection margin was 22.5 %. Pancreatic ECV significantly correlated with the histopathological grade of pancreatic fibrosis (ρ = 0.689; p < 0.001). In PD cases, the ECV was an independent risk factor for all-grade POPF (odds ratio, 0.852; 95 % confidence interval, 0.755-0.934), with excellent predictive capability (area under the curve, 0.912; 95 % confidence interval, 0.842-0.983). In DP cases, pancreatic thickness was the only factor associated with all-grade POPF. CONCLUSIONS Pancreatic ECV obtained from routine CE-CT images accurately predicted the histopathological grade of pancreatic fibrosis and was an independent risk factor for POPF after PD.
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Affiliation(s)
- Takahide Sasaki
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Yukihisa Takayama
- Department of Radiology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Shinji Tanaka
- Department of Radiology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Yoshihiro Hamada
- Department of Pathology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Ryo Nakashima
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Shigetoshi Naito
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Masatoshi Kajiwara
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan.
| | - Suguru Hasegawa
- Department of Gastroenterological Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
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Justo Alonso I, Peralta Fernández-Revuelta P, Marcacuzco Quinto A, Caso Maestro O, Alonso Murillo L, Jiménez-Romero C. Comparison of reconstruction techniques after pancreatoduodenectomy: A single-center retrospective cohort study. Scand J Surg 2025:14574969241312287. [PMID: 39791433 DOI: 10.1177/14574969241312287] [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: 01/12/2025]
Abstract
BACKGROUND There is controversy regarding which is the best reconstruction technique after the pancreatoduodenectomy. Currently, there are no studies comparing the three most frequent reconstruction techniques: Whipple + Roux-en-Y gastrojejunostomy (WRYGJ), pyloric-preserving + Billroth II (PPBII), and Whipple + BII (WBII). METHODS Between 2012 and March 2023, 246 patients underwent pancreaticoduodenectomy with the following type of reconstruction techniques: (1) WRYGJ: 40 patients; (2) PPBII: 118 patients; and (3) WBII: 88 patients. A retrospective comparative study among these groups was performed. RESULTS No significant differences were found among the groups regarding duration of the surgery, the blood volume transfused, or caliber of the Wirsung duct. The size and types of tumors, the degree of differentiation and tumor invasion of the peripancreatic tissue, vascular and neural structures, and lymph nodes were similar among the groups. The rate of R0 resection was lower in WBII (62.5% [55/88]) than in WRYGJ (75% [30/40]) and PPBII (72% [85/118]), but statistically insignificant among the groups (p = 0.232). The incidences of relevant B/C postoperative pancreatic fistula (POPF) were similar among the groups: 7.5% (7/40) in WRYGJ, 17% (20/118) in PPBI, and 26.2% (23/88) in WBII (p = 0.292). In addition, the incidence of B/C delayed gastric emptying (DGE) was higher in WBII (27.3% [24/88]) than in WRYGJ (20% [8/40]) and PPBII (19.5% [23/118]) but statistically insignificance among the groups (p = 0.381). The incidence of medical and surgical complications, intensive care unit and hospital stays, morbimortality at 90 days, and 5-year survival were similar among the groups. Multivariate analysis revealed that POPF grade B/C was a risk factor for DGE grade B/C (odds ratio (OR) = 9.903, 95% confidence interval (CI) = 4.829-20.310; p < 0.001), and a <3-mm Wirsung duct was a risk factor for POPF (OR = 3.604, 95% CI = 1.791-7.254; p < 0.001). CONCLUSION No technique was superior to the others. Only relevant POPF B/C was a risk factor for DGE B/C, and <3 mm Wirsung for a POPF.
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Affiliation(s)
- Iago Justo Alonso
- Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, "Doce de Octubre University Hospital," Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Paola Peralta Fernández-Revuelta
- Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, "Doce de Octubre University Hospital," Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Alberto Marcacuzco Quinto
- Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, "Doce de Octubre University Hospital," Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Oscar Caso Maestro
- Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, "Doce de Octubre University Hospital," Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Laura Alonso Murillo
- Unit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation, "Doce de Octubre University Hospital," Instituto de Investigación (imas12), Department of Surgery, Faculty of Medicine, Complutense University, Madrid, Spain
| | - Carlos Jiménez-Romero
- Carlos Jiménez-RomeroUnit of Hepato-Pancreato-Biliary Surgery and Abdominal Organ Transplantation "Doce de Octubre University Hospital" Department of Surgery Faculty of Medicine Complutense University 6th Floor Carretera Andalucía Km 5,4 28041 Madrid Spain
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Nebbia M, Capretti G, Nappo G, Zerbi A. Updates in the management of postoperative pancreatic fistula. Int J Surg 2024; 110:6135-6144. [PMID: 38518082 PMCID: PMC11487019 DOI: 10.1097/js9.0000000000001395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 03/11/2024] [Indexed: 03/24/2024]
Abstract
Postoperative pancreatic fistula (POPF) remains a common and dreaded complication after pancreatic resections and is associated with increased morbidity and mortality. Over the years, several different strategies have been investigated to prevent and mitigate POPF. However, when a POPF occurs, a consensus on the optimal management strategy of grade B and grade C POPF is still lacking, and the current management strategy is often based on local expertise and driven by patient's condition. Nevertheless, whereas the incidence of POPF after pancreatic surgery has remained stable, the overall mortality related to this complication has decreased over the years. This reflects an improvement in the management of this complication, which has become increasingly conservative. The aim of this review is to provide an updated evidence-based overview on the management strategies of POPF for surgeons and physicians in the clinical practice.
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Affiliation(s)
- Martina Nebbia
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Manzoni, Rozzano
| | - Giovanni Capretti
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Manzoni, Rozzano
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, Pieve Emanuele, Milan, Italy
| | - Gennaro Nappo
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Manzoni, Rozzano
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, Pieve Emanuele, Milan, Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, IRCCS Humanitas Research Hospital, Via Manzoni, Rozzano
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, Pieve Emanuele, Milan, Italy
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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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Hao X, Li Y, Liu L, Bai J, Liu J, Jiang C, Zheng L. Is duct-to-mucosa pancreaticojejunostomy necessary after pancreaticoduodenectomy: A meta-analysis of randomized controlled trials. Heliyon 2024; 10:e33156. [PMID: 39040391 PMCID: PMC11260976 DOI: 10.1016/j.heliyon.2024.e33156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 06/11/2024] [Accepted: 06/14/2024] [Indexed: 07/24/2024] Open
Abstract
The incidence of postoperative pancreatic fistula is influenced by the effectiveness of the pancreaticojejunostomy, and the most suitable pancreaticojejunostomy for pancreaticoduodenectomy remains uncertain. Since grade A postoperative pancreatic fistula is no longer considered a true fistula, the purpose of this meta-analysis was to compare the effectiveness of duct-to-mucosa anastomosis and invagination anastomosis in reducing the incidence of grade B/C postoperative pancreatic fistula. The meta-analysis was conducted using software Review Manager 5.3, and the fixed-effect model was employed for pooled statistic calculations. The Cochrane Collaboration Risk of Bias Tool was utilized for quality assessment. Ten randomized controlled trials from Embase, Web of Science, MEDLINE, and the Cochrane Library (1990.01-2022.10) including 1471 patients, met the inclusion criteria. This meta-analysis has been registered on PROSPERO with the registration number CRD42023491673. The incidence of grade B/C fistula was significantly lower in the invagination group (7.7 %) compared to the duct-to-mucosa group (12.8 %, mostly Cattell manner)(RR = 1.65, 95%CI: 1.14-2.39, P = 0.008; heterogeneity: P = 0.008, I2 = 68 %),heterogeneity among the results was addressed through sensitivity analysis. In patients with a soft pancreas, the incidence of grade B/C fistula was significantly lower in those who underwent invagination anastomosis (10 %) compared to those who underwent duct-to-mucosa anastomosis (41.9 %)(RR = 4.19, 95%CI: 1.33-13.25, P = 0.01).No significant differences were observed in terms of the occurrence of grade B/C fistula in firm pancreas, postoperative mortality, other major postoperative complications, anastomosis time, and postoperative bile leak. Therefore, we concluded that invagination anastomosis is significantly superior to duct-to-mucosa anastomosis in reducing the incidence of grade B/C fistula, especially in patients with a soft pancreas.
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Affiliation(s)
- Xiaofei Hao
- Fourth Outpatient Department, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Yi Li
- Section for Day Surgery, Department of General Surgery, The Third People's Hospital of Chengdu & The Affiliated Hospital of Southwest Jiaotong University, Chengdu, Sichuan, China
| | - Lin Liu
- Fourth Outpatient Department, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Jian Bai
- Fourth Outpatient Department, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Jia Liu
- Fourth Outpatient Department, The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Cuinan Jiang
- Section for HepatoPancreatoBiliary Surgery, Department of General Surgery, The Third People's Hospital of Chengdu & The Affiliated Hospital of Southwest Jiaotong University, Chengdu, Sichuan, China
| | - Lu Zheng
- Department of Hepatobiliary Surgery, the Second Affiliated Hospital of Army Medical University, Chongqing, China
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Kimura N, Ishido K, Wakiya T, Nagase H, Odagiri T, Wakasa Y, Hakamada K. Revealing the role of early peripancreatic bacterial contamination and Enterococcus faecalis in pancreatic fistula development after pancreaticoduodenectomy: Implications for useful antibiotic prophylaxis-An observational cohort study. Pancreatology 2024; 24:630-642. [PMID: 38508910 DOI: 10.1016/j.pan.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/26/2024] [Accepted: 03/13/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Peripancreatic bacterial contamination (PBC) is a critical factor contributing to the development of clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD). Controlling pathogenic bacteria is essential in preventing CR-POPF; however, the precise relationship between specific bacteria and CR-POPF remains unclear. This study aimed to investigate the relationship between PBC and CR-POPF after PD, with a focus on identifying potentially causative bacteria. METHODS This prospective observational study enrolled 370 patients who underwent PD. Microbial cultures were routinely collected from peripancreatic drain fluid on postoperative days (PODs) 1, 3, and 6. Predictive factors for CR-POPF and the bacteria involved in PBC were investigated. RESULTS CR-POPF occurred in 86 (23.2%) patients. In multivariate analysis, PBC on POD1 (Odds ratio [OR] = 3.59; P = 0.005) was one of the main independent predictive factors for CR-POPF, while prophylactic use of antibiotics other than piperacillin/tazobactam independently influenced PBC on POD1 (OR = 2.95; P = 0.010). Notably, Enterococcus spp., particularly Enterococcus faecalis, were significantly isolated from PBC in patients with CR-POPF compared to those without CR-POPF on PODs 1 and 3 (P < 0.001), and they displayed high resistance to all cephalosporins. CONCLUSIONS Early PBC plays a pivotal role in the development of CR-POPF following PD. Prophylactic antibiotic administration, specifically targeting Enterococcus faecalis, may effectively mitigate early PBC and subsequently reduce the risk of CR-POPF. This research sheds light on the importance of bacterial control strategies in preventing CR-POPF after PD.
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Affiliation(s)
- Norihisa Kimura
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan.
| | - Keinosuke Ishido
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan
| | - Taiichi Wakiya
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan
| | - Hayato Nagase
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan
| | - Tadashi Odagiri
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan
| | - Yusuke Wakasa
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan
| | - Kenichi Hakamada
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan
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Cannas S, Casciani F, Vollmer CM. Extending Quality Improvement for Pancreatoduodenectomy Within the High-Volume Setting: The Experience Factor. Ann Surg 2024; 279:1036-1045. [PMID: 37522844 DOI: 10.1097/sla.0000000000006060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
OBJECTIVE To analyze the association of a surgeon's experience with postoperative outcomes of pancreatoduodenectomies (PDs) when stratified by Fistula Risk Score (FRS). BACKGROUND Centralization is now well-established for pancreatic surgery. Nevertheless, the benefits of individual surgeon's experience in high-volume settings remain undefined. METHODS Pancreatoduodenectomies performed by 82 surgeons across 18 international specialty institutions (median: 140 PD/year) were analyzed. Surgeon cumulative PD volume was linked with postoperative outcomes through multivariable models, adjusted for patient/operative characteristics and the FRS. Then, surgeon experience was also stratified by the 10, previously defined, most clinically impactful scenarios for clinically relevant pancreatic fistula (CR-POPF) development. RESULTS Of 8189 PDs, 18.7% suffered severe complications (Accordion≥3), 4.8% were reoperated upon and 2.2% expired. Although the most experienced surgeons (top-quartile; >525 career PDs) more often operated on riskier cases, their experience was significantly associated with declines in CR-POPF ( P <0.001), severe complications ( P =0.008), reoperations ( P <0.001), and length of stay (LOS) ( P <0.001)-accentuated even more in the most impactful FRS scenarios (2830 patients). Risk-adjusted models indicate male sex, increasing age, ASA class, and FRS, but not surgeon experience, as being associated with severe complications, failure-to-rescue, and mortality. Instead, upper-echelon experience demonstrates significant reductions in CR-POPF (OR 0.66), reoperations (OR 0.64), and LOS (OR 0.65) in moderate-to-high fistula risk circumstances (FRS≥3, 68% of cases). CONCLUSIONS At specialty institutions, major morbidity, mortality, and failure-to-rescue are primarily associated with baseline patient characteristics, while cumulative surgical experience impacts pancreatic fistula occurrence and its attendant effects for most higher-risk pancreatoduodenectomies. These data also suggest an extended proficiency curve exists for this operation.
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Affiliation(s)
- Samuele Cannas
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Fabio Casciani
- Unit of General and Pancreatic Surgery, The Pancreas Institute, University of Verona, Italy
| | - Charles M Vollmer
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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10
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Sok C, Sandhu S, Shah H, Ajay PS, Russell MC, Cardona K, Maegawa F, Maithel SK, Sarmiento J, Goyal S, Kooby DA, Shah MM. Simple Preoperative Imaging Measurements Predict Postoperative Pancreatic Fistula After Pancreatoduodenectomy. Ann Surg Oncol 2024; 31:1898-1905. [PMID: 37968411 PMCID: PMC10922305 DOI: 10.1245/s10434-023-14564-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/22/2023] [Indexed: 11/17/2023]
Abstract
OBJECTIVE Postoperative pancreatic fistula is a potentially devastating complication after pancreatoduodenectomy (PD). The purpose of this study was to identify features on preoperative computed tomography (CT) imaging that correlate with an increased risk of postoperative pancreatic fistula (POPF). METHODS Patients who underwent PD at our high-volume pancreatic surgery center from 2019 to 2021 were included if CT imaging was available within 8 weeks of surgical intervention. Pancreatic neck thickness (PNT), abdominal wall thickness (AWT), and intra-abdominal distance from pancreas to peritoneum (PTP) were measured by two board-certified radiologists who were blinded to the clinical outcomes. Radiographic measurements, as well as preoperative patient characteristics and intraoperative data, were assessed with univariate and multivariable analysis (MVA) to determine risk for clinically relevant POPF (CR-POPF, grades B and C). RESULTS A total of 204 patients met inclusion criteria. Median PTP was 5.8 cm, AWT 1.9 cm, and PNT 1.3 cm. CR-POPF occurred in 33 of 204 (16.2%) patients. MVA revealed PTP > 5.8 cm (odds ratio [OR] 2.86, p = 0.023), PNT > 1.3 cm (OR 2.43, p = 0.047), soft pancreas consistency (OR 3.47, p = 0.012), and pancreatic duct size ≤ 3.0 mm (OR 4.55, p = 0.01) as independent risk factors for CR-POPF after PD. AWT and obesity were not associated with increased risk of CR-POPF. Patients with PTP > 5.8 cm or PNT > 1.3 cm were significantly more likely to suffer a major complication after PD (39.6% vs. 22.3% and 40% vs. 22.1%, p < 0.008). CONCLUSIONS Patients with a thick pancreatic neck and increased intra-abdominal girth have a heightened risk of CR-POPF after pancreatoduodenectomy, and they experience more serious postoperative complications. We defined a simple CT scan-based measurement tool to identify patients at increased risk of CR-POPF.
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Affiliation(s)
- Caitlin Sok
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Sameer Sandhu
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Hardik Shah
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Pranay S Ajay
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Maria C Russell
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Felipe Maegawa
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Juan Sarmiento
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Subir Goyal
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health of Emory University, Atlanta, GA, USA
| | - David A Kooby
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA
| | - Mihir M Shah
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine/Winship Cancer Institute, Atlanta, GA, USA.
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11
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Watanabe G, Ishizawa T, Kuriki Y, Kamiya M, Ichida A, Kawaguchi Y, Akamatsu N, Kaneko J, Arita J, Kokudo N, Urano Y, Hasegawa K. Evaluation of pancreatic chymotrypsin activity for on-site prediction of clinically relevant postoperative pancreatic fistula. Pancreatology 2024; 24:169-177. [PMID: 38061979 DOI: 10.1016/j.pan.2023.11.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/14/2023] [Accepted: 11/23/2023] [Indexed: 01/27/2024]
Abstract
OBJECTIVES Although the risk of complications due to postoperative pancreatic fistula (POPF) have been evaluated based on the amylase level in drained ascitic fluid, this method has much room for improvement regarding diagnostic accuracy and facility of the measurement. This study aimed to investigate the clinical value of measuring pancreatic chymotrypsin activity for rapid and accurate prediction of POPF after pancreaticoduodenectomy. METHODS In 52 consecutive patients undergoing pancreaticoduodenectomy, the chymotrypsin activity in pancreatic juice was measured by calculating the increase in fluorescence intensity during the first 5 min after activation with an enzyme-activatable fluorophore. The predictive value for clinically relevant POPF (CR-POPF) was compared between this technique and the conventional method based on the amylase level. RESULTS According to receiver operating characteristic analyses, pancreatic chymotrypsin activity on postoperative day (POD) 3 measured with a multiplate reader had the highest predictive value for CR-POPF (area under the curve [AUC], 0.752; P < 0.001), yielding 77.8 % sensitivity and 68.8 % specificity. The AUC and sensitivity/specificity of the amylase level in ascitic fluid on POD 3 were 0.695 (P = 0.053) and 77.8 %/41.2 %, respectively. Multivariable analysis identified high pancreatic chymotrypsin activity on POD 3 as an independent risk factor for CR-POPF. Measurement of pancreatic chymotrypsin activity with a prototype portable fluorescence photometer could significantly predict CR-POPF (AUC, 0.731; P = 0.010). CONCLUSION Measurement of pancreatic chymotrypsin activity enabled accurate and rapid prediction of CR-POPF after pancreaticoduodenectomy. This can help surgeons to implement appropriate drain management at the patient's bedside without delay.
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Affiliation(s)
- Genki Watanabe
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takeaki Ishizawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yugo Kuriki
- Laboratory of Chemistry and Biology, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan
| | - Mako Kamiya
- Laboratory of Chemical Biology and Molecular Imaging, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akihiko Ichida
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshikuni Kawaguchi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nobuhisa Akamatsu
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Kaneko
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Arita
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Norihiro Kokudo
- Department of Surgery, National Center for Global-Health and Medicine, Tokyo, Japan
| | - Yasuteru Urano
- Laboratory of Chemistry and Biology, Graduate School of Pharmaceutical Sciences, The University of Tokyo, Tokyo, Japan; Laboratory of Chemical Biology and Molecular Imaging, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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12
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Schouten TJ, Henry AC, Smits FJ, Besselink MG, Bonsing BA, Bosscha K, Busch OR, van Dam RM, van Eijck CH, Festen S, Groot Koerkamp B, van der Harst E, de Hingh IHJT, Kazemier G, Liem MSL, de Meijer VE, Patijn GA, Roos D, Schreinemakers JMJ, Stommel MWJ, Wit F, Daamen LA, Molenaar IQ, van Santvoort HC. Risk Models for Developing Pancreatic Fistula After Pancreatoduodenectomy: Validation in a Nationwide Prospective Cohort. Ann Surg 2023; 278:1001-1008. [PMID: 36804843 DOI: 10.1097/sla.0000000000005824] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
OBJECTIVE To evaluate the performance of published fistula risk models by external validation, and to identify independent risk factors for postoperative pancreatic fistula (POPF). BACKGROUND Multiple risk models have been developed to predict POPF after pancreatoduodenectomy. External validation in high-quality prospective cohorts is, however, lacking or only performed for individual models. METHODS A post hoc analysis of data from the stepped-wedge cluster cluster-randomized Care After Pancreatic Resection According to an Algorithm for Early Detection and Minimally Invasive Management of Pancreatic Fistula versus Current Practice (PORSCH) trial was performed. Included were all patients undergoing pancreatoduodenectomy in the Netherlands (January 2018-November 2019). Risk models on POPF were identified by a systematic literature search. Model performance was evaluated by calculating the area under the receiver operating curves (AUC) and calibration plots. Multivariable logistic regression was performed to identify independent risk factors associated with clinically relevant POPF. RESULTS Overall, 1358 patients undergoing pancreatoduodenectomy were included, of whom 341 patients (25%) developed clinically relevant POPF. Fourteen risk models for POPF were evaluated, with AUCs ranging from 0.62 to 0.70. The updated alternative fistula risk score had an AUC of 0.70 (95% confidence intervals [CI]: 0.69-0.72). The alternative fistula risk score demonstrated an AUC of 0.70 (95% CI: 0.689-0.71), whilst an AUC of 0.70 (95% CI: 0.699-0.71) was also found for the model by Petrova and colleagues. Soft pancreatic texture, pathology other than pancreatic ductal adenocarcinoma or chronic pancreatitis, small pancreatic duct diameter, higher body mass index, minimally invasive resection and male sex were identified as independent predictors of POPF. CONCLUSION Published risk models predicting clinically relevant POPF after pancreatoduodenectomy have a moderate predictive accuracy. Their clinical applicability to identify high-risk patients and guide treatment strategies is therefore questionable.
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Affiliation(s)
- Thijs J Schouten
- Departments of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
| | - Anne Claire Henry
- Departments of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
| | - Francina J Smits
- Departments of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center, Amsterdam, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center, Amsterdam, The Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht UMC+, Maastricht, The Netherlands
- Department of General and Visceral Surgery, University Hospital Aachen, Aachen, Germany
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Sebastiaan Festen
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Ignace H J T de Hingh
- GROW - School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Geert Kazemier
- Cancer Center, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Mike S L Liem
- Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala, Zwolle, The Netherlands
| | - Daphne Roos
- Department of Surgery, Reinier de Graaf Hospital, Delft, The Netherlands
| | | | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Fennie Wit
- Department of Surgery, Tjongerschans, Heerenveen, The Netherlands
- Department of Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Lois A Daamen
- Departments of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
- Imaging Division, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Izaak Q Molenaar
- Departments of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Departments of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St. Antonius Hospital Nieuwegein, Utrecht University, Utrecht, The Netherlands
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13
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Ashraf Ganjouei A, Romero-Hernandez F, Wang JJ, Casey M, Frye W, Hoffman D, Hirose K, Nakakura E, Corvera C, Maker AV, Kirkwood KS, Alseidi A, Adam MA. A Machine Learning Approach to Predict Postoperative Pancreatic Fistula After Pancreaticoduodenectomy Using Only Preoperatively Known Data. Ann Surg Oncol 2023; 30:7738-7747. [PMID: 37550449 DOI: 10.1245/s10434-023-14041-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/14/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Clinically-relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD) is a major postoperative complication and the primary determinant of surgical outcomes. However, the majority of current risk calculators utilize intraoperative and postoperative variables, limiting their utility in the preoperative setting. Therefore, we aimed to develop a user-friendly risk calculator to predict CR-POPF following PD using state-of-the-art machine learning (ML) algorithms and only preoperatively known variables. METHODS Adult patients undergoing elective PD for non-metastatic pancreatic cancer were identified from the ACS-NSQIP targeted pancreatectomy dataset (2014-2019). The primary endpoint was development of CR-POPF (grade B or C). Secondary endpoints included discharge to facility, 30-day mortality, and a composite of overall and significant complications. Four models (logistic regression, neural network, random forest, and XGBoost) were trained, validated and a user-friendly risk calculator was then developed. RESULTS Of the 8666 patients who underwent elective PD, 13% (n = 1160) developed CR-POPF. XGBoost was the best performing model (AUC = 0.72), and the top five preoperative variables associated with CR-POPF were non-adenocarcinoma histology, lack of neoadjuvant chemotherapy, pancreatic duct size less than 3 mm, higher BMI, and higher preoperative serum creatinine. Model performance for 30-day mortality, discharge to a facility, and overall and significant complications ranged from AUC 0.62-0.78. CONCLUSIONS In this study, we developed and validated an ML model using only preoperatively known variables to predict CR-POPF following PD. The risk calculator can be used in the preoperative setting to inform clinical decision-making and patient counseling.
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Affiliation(s)
| | | | - Jaeyun Jane Wang
- Department of Surgery, University of California, San Francisco, USA
| | - Megan Casey
- School of Medicine, University of California, San Francisco, USA
| | - Willow Frye
- School of Medicine, University of California, San Francisco, USA
| | - Daniel Hoffman
- Department of Surgery, University of California, San Francisco, USA
| | - Kenzo Hirose
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA
| | - Eric Nakakura
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA
| | - Carlos Corvera
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA
| | - Ajay V Maker
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA
| | - Kimberly S Kirkwood
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA
| | - Adnan Alseidi
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA
| | - Mohamed A Adam
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, CA, USA.
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14
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Angrisani M, Meniconi RL, Sandini M, Colasanti M, Ferretti S, Guglielmo N, Berardi G, Mariano G, Usai S, Braga M, Gianotti L, Ettorre GM. External validation of scores predicting postoperative fistula after pancreatogastrostomy for pancreatoduodenectomy reconstruction. A single center experience. Pancreatology 2023; 23:852-857. [PMID: 37827971 DOI: 10.1016/j.pan.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 09/23/2023] [Accepted: 10/05/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) is the most frequent complication of pancreatic surgery and can be fatal. Selection and stratification of patients according to the risk of POPF are important for the perioperative management. Predictive metrics have been developed and validated in pancreatojejunostomy. Aim of this study is to assess whether the most used prognostic scores can be predictive of fistula following Wirsung-pancreaticogastrostomy (WPG) for pancreatoduodenectomy (PD)reconstruction. METHOD This single-center prospective observational study included 212 PDs between January 2008 and October 2022 with a standardized WPG. All component variables of the six scores were separately validated in our cohort. The overall predictive ability of the six fistula scores was measured and compared with the receiver operating characteristics curves (ROC) method and expressed by the area under the ROC-curve (AUC). Univariate and multivariate logistic regression analyses were performed considering all risk factors in the scores in order to identify variables independently correlated with POPF in the WPG. RESULTS CR-POPF occurred in 36 of 212 (17 %) patients. All scores showed poor prognostic stratification for the development of CR-POPF. The occurrence of CR-POPF was associated with nine factors: male gender (p = 0.003); BMI (kg/m2) (p = 0.005); ASA (%) (p = 0.003); Soft pancreatic texture (%) (p = 0.003), Pathology (p = 0.008); MPD (p = 0.011); EBL (mL) (p = 0.021); Preop. Bilirubin (mg/dl) (p = 0.038); Preop. Glucose (mg/dl) (p = 0.0369). Male gender (OR: 5.54, CI 1.41-21.3) and soft consistency of the remnant pancreas (OR: 3.83, CI 1.14-12.8) were the only independent prognostic factors on multivariate analysis. CONCLUSIONS Our study including exclusively pancreatogastrostomies failed to validate the most used predictive scores for POPF. We found that only male gender and soft pancreatic texture are associated with POPF. Specific predictive scores following pancreatogasgtrostomy are needed.
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Affiliation(s)
- Marco Angrisani
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy; School of Medicine and Surgery, University of Milano-Bicocca, and HPB Unit, IRCCS San Gerardo Hospital, Monza, Italy.
| | - Roberto Luca Meniconi
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Marta Sandini
- Department of Medical, Surgical, and Neurologic Sciences, University of Siena, Siena, Italy
| | - Marco Colasanti
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Stefano Ferretti
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Nicola Guglielmo
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Giammauro Berardi
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Germano Mariano
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Sofia Usai
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Marco Braga
- School of Medicine and Surgery, University of Milano-Bicocca, and HPB Unit, IRCCS San Gerardo Hospital, Monza, Italy
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milano-Bicocca, and HPB Unit, IRCCS San Gerardo Hospital, Monza, Italy
| | - Giuseppe Maria Ettorre
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
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15
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Alhulaili ZM, Linnemann RJ, Dascau L, Pleijhuis RG, Klaase JM. A Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis analysis to evaluate the quality of reporting of postoperative pancreatic fistula prediction models after pancreatoduodenectomy: A systematic review. Surgery 2023; 174:684-691. [PMID: 37296054 DOI: 10.1016/j.surg.2023.04.058] [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: 10/02/2022] [Revised: 03/06/2023] [Accepted: 04/27/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula is a frequent and potentially lethal complication after pancreatoduodenectomy. Several models have been developed to predict postoperative pancreatic fistula risk. This study was performed to evaluate the quality of reporting of postoperative pancreatic fistula prediction models after pancreatoduodenectomy using the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) checklist that provides guidelines on reporting prediction models to enhance transparency and to help in the decision-making regarding the implementation of the appropriate risk models into clinical practice. METHODS Studies that described prediction models to predict postoperative pancreatic fistula after pancreatoduodenectomy were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The TRIPOD checklist was used to evaluate the adherence rate. The area under the curve and other performance measures were extracted if reported. A quadrant matrix chart is created to plot the area under the curve against TRIPOD adherence rate to find models with a combination of above-average TRIPOD adherence and area under the curve. RESULTS In total, 52 predictive models were included (23 development, 15 external validation, 4 incremental value, and 10 development and external validation). No risk model achieved 100% adherence to the TRIPOD. The mean adherence rate was 65%. Most authors failed to report on missing data and actions to blind assessment of predictors. Thirteen models had an above-average performance for TRIPOD checklist adherence and area under the curve. CONCLUSION Although the average TRIPOD adherence rate for postoperative pancreatic fistula models after pancreatoduodenectomy was 65%, higher compared to other published models, it does not meet TRIPOD standards for transparency. This study identified 13 models that performed above average in TRIPOD adherence and area under the curve, which could be the appropriate models to be used in clinical practice.
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Affiliation(s)
- Zahraa M Alhulaili
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Ralph J Linnemann
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Larisa Dascau
- Department of Surgery, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Rick G Pleijhuis
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Joost M Klaase
- Department of Hepato-Pancreato-Biliary Surgery and Liver Transplantation, University of Groningen, University Medical Center Groningen, the Netherlands.
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16
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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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17
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ÖZŞAY O, AYDIN MC, ÇELİK SC, KARABULUT K, YÜRÜKER SS. Serum amylase on postoperative day one is a strong predictor of pancreatic fistula after pancreaticoduodenectomy: a retrospective cohort. Turk J Med Sci 2023; 53:1271-1280. [PMID: 38813023 PMCID: PMC10763807 DOI: 10.55730/1300-0144.5693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 10/26/2023] [Accepted: 08/11/2023] [Indexed: 05/31/2024] Open
Abstract
Background/aim Early identification of patients at risk for developing postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) may facilitate drain management. In this context, it was aimed to examine the efficiency of the serum amylase (SA) value on postoperative day (PoD) 1 in predicting the occurrence of POPF. Materials and methods A total of 132 patients who underwent PD were studied. Occurrences of POPF were classified according to the International Study Group on Pancreatic Fistula classification as a biochemical leak (BL) or clinically relevant grade b/c POPF (CR-POPF). Receiver operating characteristic analysis identified a threshold value of SA on PoD 1 associated with POPF formation. Results Overall, 66 (50%) patients had POPF, including 51 (38.7%) with BL and 15 with CR-POPF (11.3%). The threshold value of SA associated with the development of POPF was 120 IU/L (odds ratio [OR]: 3.20; p = 0.002). In the multivariate analysis, independent POPF risk factors were SA ≥120 IU/L, soft pancreatic texture, and high-risk pathology (i.e., duodenal, biliary, ampullary, islet cell, and benign tumors); SA ≥120 IU/L outperformed soft pancreatic texture and high-risk pathology in predicting POPF, respectively (OR: 2.22; p = 0.004 vs. OR: 1.37; p = 0.012 vs. OR: 1.35; p = 0.018). In a subset analysis according to gland texture (soft vs. hard), patients with soft pancreatic texture exhibited a significantly higher incidence of POPF (63.4% vs. 34.4%) and SA ≥120 IU/L (52.1% vs. 27.9%); SA <120 IU/L had a negative predictive value of 82.5% for developing POPF in patients with hard pancreatic texture (OR: 4.28, p = 0.028). Conclusion A SA value ≥120 IU/L on the day after PD, which is the strongest predictor for POPF, can be used as a biomarker of the occurrence of POPF. The advantage of SA measurement is that it can contribute to identifying suitable patients for early drain removal.
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Affiliation(s)
- Oğuzhan ÖZŞAY
- Department of Gastrointestinal Surgery, Faculty of Medicine, Ondokuz Mayıs University, Samsun,
Turkiye
| | - Mehmet Can AYDIN
- Department of Gastrointestinal Surgery, Faculty of Medicine, Ondokuz Mayıs University, Samsun,
Turkiye
| | - Salih Can ÇELİK
- Department of Gastrointestinal Surgery, Ordu State Hospital, Ordu,
Turkiye
| | - Kağan KARABULUT
- Department of General Surgery, Faculty of Medicine, Ondokuz Mayıs University, Samsun,
Turkiye
| | - Saim Savaş YÜRÜKER
- Department of General Surgery, Faculty of Medicine, Ondokuz Mayıs University, Samsun,
Turkiye
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18
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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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19
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Blunck CK, Vickers SM, Wang TN, Dudeja V, Reddy S, Rose JB. Adjusting Drain Fluid Amylase for Drain Volume Does Not Improve Pancreatic Fistula Prediction. J Surg Res 2023; 284:312-317. [PMID: 36634411 DOI: 10.1016/j.jss.2022.11.030] [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: 01/12/2022] [Revised: 09/22/2022] [Accepted: 11/16/2022] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Drain fluid amylase (DFA) levels have been used to predict clinically relevant postoperative pancreatic fistula (CR-POPF) and guide postoperative drain management. Optimal DFA cutoff thresholds vary between studies, thereby prompting investigation of an alternative assessment technique. As DFA measurements could, in theory, be distorted by variations in ascites fluid production, we hypothesized that adjusting DFA for volume corrected drain fluid amylase (vDFA) would improve CR-POPF predictive models. METHODS A single-institution retrospective cohort study of patients, who underwent pancreatoduodenectomies (PD) and distal pancreatectomies (DP) between 2013 and 2019, was performed. DFAs and vDFAs were measured on postoperative day (POD) 3. Clinicopathologic variables were compared between cohorts by univariable and multivariable analyses and Receiver operating characteristic (ROC) curves. RESULTS Patients developing a CR-POPF were more likely to be male and have elevated DFA, vDFA, and body mass index (BMI). vDFA use did not contribute to a superior CR-POPF predictive model compared to DFA-a finding consistent on subanalysis of surgery type PD versus DP. In CR-POPF predictive models, DFA, vDFA, and male sex significantly improved CR-POPF predictive models when considering both surgery subtypes, while only DFA and vDFA significantly improved models when cohorts were segregated by surgery type. CONCLUSIONS Postoperative DFA remains a preferred method of predicting CR-POPF as the proposed vDFA assessment technique only adds complexity without increased discriminability.
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Affiliation(s)
| | - Selwyn M Vickers
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Thomas N Wang
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Vikas Dudeja
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Sushanth Reddy
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - J Bart Rose
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama.
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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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Lv TR, Wang JM, Ma WJ, Hu YF, Dai YS, Jin YW, Li FY. The consistencies and inconsistencies between distal cholangiocarcinoma and pancreatic ductal adenocarcinoma: A systematic review and meta-analysis. Front Oncol 2022; 12:1042493. [PMID: 36578941 PMCID: PMC9791204 DOI: 10.3389/fonc.2022.1042493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/09/2022] [Indexed: 12/14/2022] Open
Abstract
Objective To evaluate the consistencies and inconsistencies between distal cholangiocarcinoma (DCCA) and pancreatic ductal adenocarcinoma (PDCA) regarding their biological features and long-term prognosis. Methods PubMed, the Cochrane Library, and EMBASE were searched to find comparative studies between DCCA and PDCA. RevMan5.3 and Stata 13.0 software were used for the statistical analyses. Results Eleven studies with 4,698 patients with DCCA and 100,629 patients with PDCA were identified. Pooled results indicated that patients with DCCA had a significantly higher rate of preoperative jaundice (p = 0.0003). Lymphatic metastasis (p < 0.00001), vascular invasion (p < 0.0001), and peri-neural invasion (p = 0.005) were more frequently detected in patients with PDCA. After curative pancreaticoduodenectomy (PD), a significantly higher R0 rate (p < 0.0001) and significantly smaller tumor size (p < 0.00001) were detected in patients with DCCA. Patients with DCCA had a more favorable overall survival (OS) (p < 0.00001) and disease-free survival (DFS) (p = 0.005) than patients with PDCA. However, postoperative morbidities (p = 0.02), especially postoperative pancreatic fistula (POPF) (p < 0.00001), more frequently occurred in DCCA. Conclusion Patients with DCCA had more favorable tumor pathological features and long-term prognosis than patients with PDCA. An early diagnosis more frequently occurred in patients with DCCA. However, postoperative complications, especially POPF, were more frequently observed in patients with DCCA.
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Affiliation(s)
| | | | | | | | | | | | - Fu-Yu Li
- *Correspondence: Yan-Wen Jin, ; Fu-Yu Li,
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23
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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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24
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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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25
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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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Zhang B, Yuan Q, Li S, Xu Z, Chen X, Li L, Shang D. Risk factors of clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy: A systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e29757. [PMID: 35776984 PMCID: PMC9239615 DOI: 10.1097/md.0000000000029757] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) is a common and troublesome complication after pancreatoduodenectomy (PD). We conducted a systematic review and meta-analysis to identify the risk factors of CR-POPF after PD. METHODS We searched PubMed, EMBASE, and Cochrane Library databases for studies related to risk factors of CR-POPF after PD. Odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were extracted from the included studies, then a meta-analysis was conducted. If necessary, sensitivity analysis would be performed by changing the effect model or excluding 1 study at a time. Publication bias was assessed by funnel plot and Begg test and Egger test. RESULTS A total of 27 studies with 24,740 patients were included, and CR-POPF occurred in 3843 patients (incidence = 17%, 95% CI: 16%-19%). Male (OR = 1.56, 95% CI: 1.42-1.70), body mass index >25 kg/m2 (OR = 1.98, 95% CI: 1.23-3.18), pancreatic duct diameter <3 mm (OR = 1.87, 95% CI: 1.66-2.12), soft pancreatic texture (OR = 3.49, 95% CI: 2.61-4.67), and blood transfusion (OR = 3.10, 95% CI: 2.01-4.77) can significantly increase the risk of CR-POPF. Pancreatic adenocarcinoma (OR = 0.54, 95% CI: 0.47-0.61), vascular resection (OR = 0.57, 95% CI: 0.39-0.83), and preoperative chemoradiotherapy (OR = 0.68, 95% CI: 0.57-0.81) can significantly decrease the factor of CR-POPF. Diabetes mellitus was not statistically associated with CR-POPF (OR = 0.66, 95% CI: 0.40-1.08). However, the analysis of body mass index, pancreatic texture, and diabetes mellitus had a high heterogeneity, then sensitivity analysis was performed, and the result after sensitivity analysis showed diabetes mellitus can significantly decrease the risk of CR-POPF. There was no significant publication bias in this meta-analysis. CONCLUSIONS The current review assessed the effects of different factors on CR-POPF. This can provide a basis for the prevention and management of CR-POPF. Effective interventions targeting the above risk factors should be investigated in future studies for decreasing the occurrence of CR-POPF.
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Affiliation(s)
- Biao Zhang
- Department of General Surgery, Clinical Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Institute of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China
| | - Qihang Yuan
- Department of General Surgery, Clinical Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Institute of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China
| | - Shuang Li
- Department of General Surgery, Clinical Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Institute of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China
| | - Zhaohui Xu
- Department of Hernia and Colorectal Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Xu Chen
- Department of General Surgery, Clinical Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Institute of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China
| | - Lunxu Li
- Department of General Surgery, Clinical Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Institute of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China
| | - Dong Shang
- Department of General Surgery, Clinical Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
- Institute of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China
- *Correspondence: Dong Shang, Department of General Surgery, Clinical Laboratory of Integrative Medicine, The First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, Xigang District, Dalian 116011, Liaoning, China ()
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Wei ZG, Liang CJ, Du Y, Zhang YP, Liu Y. Learning curve for a surgeon in robotic pancreaticoduodenectomy through a "G"-shaped approach: A cumulative sum analysis. World J Clin Cases 2022; 10:4357-4367. [PMID: 35663072 PMCID: PMC9125268 DOI: 10.12998/wjcc.v10.i14.4357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 10/19/2021] [Accepted: 03/24/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Robotic pancreaticoduodenectomy (RPD) can achieve similar surgical results to open and PD; however, RPD has a long learning curve and operation time (OT). To address this issue, we have summarized a surgical path to shorten the surgical learning curve and OT. AIM To investigate the effective learning curve of a "G"-shaped surgical approach in RPD for patients. METHODS A total of 60 patients, who received "G"-shaped RPD (GRPD) by a single surgeon in the First Hospital of Shanxi Medical University from May 2017 to April 2020, were included in this study. The OT, demographic data, intraoperative blood loss, complications, hospitalization time, and pathological results were recorded, and the cumulative sum (CUSUM) analysis was performed to evaluate the learning curve for GRPD. RESULTS According to the CUSUM analysis, the learning curve for GRPD was grouped into two phases: The early and late phases. The OT was 480 ± 81.65 min vs 331 ± 76.54 min, hospitalization time was 22 ± 4.53 d vs 17 ± 6.08 d, and blood loss was 308 ± 54.78 mL vs 169.2 ± 35.33 mL in the respective groups. Complications, including pancreatic fistula, bile leakage, reoperation rate, postoperative death, and delayed gastric emptying, were significantly decreased after this surgical technique. CONCLUSION GRPD can improve the learning curve and operative time, providing a new method for shortening the RPD learning curve.
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Affiliation(s)
- Zhi-Gang Wei
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| | - Chao-Jie Liang
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Shanxi Medical University, Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| | - Yang Du
- Operating Room, The First Hospital of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| | - Yong-Ping Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital/First Clinical Medical College of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
| | - Yu Liu
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital/First Clinical Medical College of Shanxi Medical University, Taiyuan 030001, Shanxi Province, China
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Niu C, Chen Q, Liu S, Zhang W, Jiang P, Liu Y. Clinical validation of the risk scoring systems of postoperative pancreatic fistula after laparoscopic pancreatoduodenectomy in Chinese cohorts: A single-center retrospective study. Surgery 2022; 171:1051-1057. [PMID: 34511238 DOI: 10.1016/j.surg.2021.08.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 07/15/2021] [Accepted: 08/09/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although several prediction models for the occurrence of clinically relevant postoperative pancreatic fistula after laparoscopic pancreatoduodenectomy exist, most were established using Western cohorts. The utility of these models using a Chinese cohort has not been validated widely. The aim of this study was to validate the original Fistula Risk Score, the alternative Fistula Risk Score, and the updated alternative Fistula Risk Score for patients undergoing laparoscopic pancreatoduodenectomy in a large-scale Chinese cohort externally. METHODS Three clinically relevant postoperative pancreatic fistula risk models were selected for external validation with our database. Primary outcome was grade B/C postoperative pancreatic fistula (clinically relevant postoperative pancreatic fistula). Performance was measured based on sensitivity, specificity, positive and negative predictive value, positive and negative likelihood ratio, and area under the curve. The original Fistula Risk Score was also compared with the alternative Fistula Risk Score and the updated alternative Fistula Risk Score. RESULTS Of the 400 patients who underwent laparoscopic pancreatoduodenectomy, 60 (15.00%) developed clinically relevant postoperative pancreatic fistula. For the original Fistula Risk Score, the alternative Fistula Risk Score, and the updated alternative Fistula Risk Score, the sensitivity was 65.00%, 90.00%, and 90.00%; the specificity was 43.53%, 44.12%, and 37.65%; the positive predictive value was 16.88%, 22.13%, and 20.30%; the negative predictive value was 87.57%, 96.15%, and 95.52%; positive likelihood ratio was 1.151, 1.611, and 1.443; negative likelihood ratio was 0.804, 0.227, and 0.266, respectively. The area under the curve values were 0.608 (95% confidence interval 0.573-0.649), 0.733 (95% confidence interval 0.692-0.797), and 0.720 (95% confidence interval 0.688-0.763) on the original Fistula Risk Score, the alternative Fistula Risk Score, and the updated alternative Fistula Risk Score (P < .05). CONCLUSION The alternative Fistula Risk Score and the updated alternative Fistula Risk Score had similarly good predictive utility. The original Fistula Risk Score performed less well. We recommended to use the alternative Fistula Risk Score and the updated alternative Fistula Risk Score to predict occurrence of clinically relevant postoperative pancreatic fistula after laparoscopic pancreatoduodenectomy when applied to a Chinese cohort.
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Affiliation(s)
- Chunyuan Niu
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun, Jilin, P.R. China. https://twitter.com/
| | - Qingmin Chen
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun, Jilin, P.R. China. https://twitter.com/
| | - Songyang Liu
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun, Jilin, P.R. China. https://twitter.com/
| | - Wei Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun, Jilin, P.R. China. https://twitter.com/
| | - Peiqiang Jiang
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun, Jilin, P.R. China. https://twitter.com/
| | - Yahui Liu
- Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, Changchun, Jilin, P.R. China.
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The effect of hospital volume on mortality, morbidity and dissected lymph nodes in pancreaticoduodenectomy for periampullary region tumors. JOURNAL OF SURGERY AND MEDICINE 2022. [DOI: 10.28982/josam.1076643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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External validation of four Pancreatic Fistula Risk Score models in the Deep South US: Do racial disparities affect pancreatic fistula prediction? Am J Surg 2022; 224:557-561. [DOI: 10.1016/j.amjsurg.2022.02.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/08/2022] [Accepted: 02/14/2022] [Indexed: 11/18/2022]
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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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Takchi R, Cos H, Williams GA, Woolsey C, Hammill CW, Fields RC, Strasberg SM, Hawkins WG, Sanford DE. Enhanced recovery pathway after open pancreaticoduodenectomy reduces postoperative length of hospital stay without reducing composite length of stay. HPB (Oxford) 2022; 24:65-71. [PMID: 34183246 PMCID: PMC9446414 DOI: 10.1016/j.hpb.2021.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/25/2021] [Accepted: 05/27/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND/PURPOSE There is no data regarding the impact of enhanced recovery pathways (ERP) on composite length of stay (CLOS) after procedures with increased risk of morbidity and mortality, such as pancreaticoduodenectomy. METHODS Patients undergoing open pancreaticoduodenectomy before and after implementation of ERP were prospectively followed for 90 days after surgery and complications were severity graded using the Modified Accordion Grading System. A retrospective analysis of patient outcomes were compared before and after instituting ERP. 1:1 propensity score matching was used to compare ERP patient outcomes to those of matched pre-ERP patients. CLOS is defined as postoperative length of hospital stay (PLOS) plus readmission length of hospital stay within 90 days after surgery. RESULTS 494 patients underwent open pancreaticoduodenectomy - 359 pre-ERP and 135 ERP. In a 1:1 propensity-score-matched analysis of 110 matched pairs, ERP patients had significantly decreased superficial surgical site infections (5.5% vs 15.5% p = 0.015) and significantly increased rates of urinary retention (29.1% vs 7.3% p < 0.0001) compared to matched pre-ERP patients. However, overall complication rate and 90-day readmission rate were not significantly different between matched groups. Propensity score-matched ERP patients had significantly decreased PLOS (7 days vs 8 days p = 0.046) compared to matched pre-ERP patients, but CLOS was not significantly different (9 days vs 9.5 days p = 0.615). CONCLUSION ERP may reduce PLOS but might not impact the total postoperative time spent in the hospital (i.e. CLOS) within 90 days after pancreaticoduodenectomy.
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Affiliation(s)
- Rony Takchi
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Heidy Cos
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Gregory A Williams
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Cheryl Woolsey
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Chet W Hammill
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Ryan C Fields
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Steven M Strasberg
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - William G Hawkins
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Dominic E Sanford
- Department of Surgery, Barnes-Jewish Hospital and the Alvin J. Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO, USA.
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Jin J, Xiong G, Wang X, Peng F, Zhu F, Wang M, Qin R. The Impact of Preoperative and Postoperative Malnutrition on Outcomes for Ampullary Carcinoma After Pancreaticoduodenectomy. Front Oncol 2021; 11:748341. [PMID: 34917503 PMCID: PMC8669645 DOI: 10.3389/fonc.2021.748341] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 11/08/2021] [Indexed: 12/23/2022] Open
Abstract
Purpose The aim of this study was to investigate the effect of preoperative and postoperative malnutrition on postoperative short- and long-term outcomes for ampullary carcinoma after pancreatoduodenectomy (PD). Methods Data were collected retrospectively from 511 patients with ampullary carcinoma who underwent PD between June 2012 and June 2019. Nutritional status before and at 3, 6, and 12 months after operation was assessed by the scored Patient-Generated Subjective Global Assessment (PG-SGA). The patients were classified into well-nourished, moderately malnourished, and severely malnourished group according to the PG-SGA score. Propensity score matching (PSM) was performed to adjust baseline characteristics between preoperative group A (well-nourished and moderately malnourished group) and group B (severely malnourished group). After PSM, clinicopathological variables and postoperative complications were compared between the two groups. Univariate and multivariate Cox analysis was also conducted to investigate the prognostic factors of overall survival of patients with ampullary carcinoma who underwent PD. Results Preoperatively, 122 (23.9%) patients were classified into well-nourished group, 189 (37.0%) into moderately malnourished group, and 200 (39.1%) into severely malnourished group. After PSM analysis, the incidence of overall postoperative complications was higher in group B than that in group A (50.5% vs. 32.5%, p < 0.001). Multivariate Cox proportional hazards regression model showed that severe malnutrition (PG-SGA score >9 scores) before operation [hazard ratio (HR) = 1.508; 95% CI, 1.103–2.061; p = 0.01] and at 6 months (HR = 4.148; 95% CI, 2.523–6.820; p < 0.001) and 12 months (HR = 5.272; 95% CI, 3.630–7.656; p < 0.001) after operation was an independent prognostic factor of patients who underwent PD for ampullary carcinoma. Conclusions Severe malnutrition before and at 6 and 12 months after operation significantly affects the long-term survival of patients with ampullary carcinoma who underwent PD. Additionally, the preoperative malnutrition was closely related to postoperative complications.
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Affiliation(s)
- Jikuan Jin
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guangbing Xiong
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoxiang Wang
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Feng Peng
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Feng Zhu
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Min Wang
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Renyi Qin
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Lee KF, Wong KKC, Lo EYJ, Kung JWC, Lok HT, Chong CCN, Wong J, Lai PBS, Ng KKC. What is the pancreatic duct size limit for a safe duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy? A retrospective study. Ann Hepatobiliary Pancreat Surg 2021; 26:84-90. [PMID: 34903678 PMCID: PMC8901978 DOI: 10.14701/ahbps.21-054] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 08/12/2021] [Accepted: 09/06/2021] [Indexed: 11/17/2022] Open
Abstract
Backgrounds/Aims Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) remains a dreadful complication. Duct-to-mucosa pancreaticojejunostomy (DTMPJ) is a commonly performed anastomosis after PD. This study aims to evaluate whether there is a size limit of pancreatic duct below which POPF rate increases significantly after DTMPJ. Methods A retrospective study was performed from a database with prospectively collected data on consecutive patients undergoing DTMPJ. Results Between the years 2003 and 2019, a total of 288 patients with DTMPJ were recruited. POPF occurred in 56.3% of the patients, of which 43.8% were biochemical leak, 8.7% were grade B, and 1.4% were grade C. Overall operative morbidity was 51.4%, of which 19.1% were major complications. Five patients (1.7%) died within 90 days of operation. Patients with grade B/C POPF had significantly soft pancreas (p < 0.001), smaller duct size (p = 0.031), and a diagnosis of carcinoma of the pancreas (p = 0.027). When a clinically significant POPF rate was analysed based on the pancreatic duct diameter, pancreatic duct size ≤ 1 mm had the highest POPF rate (35.7%). There was a significant difference in POPF rate between adjacent ductal diameter ≤ 1 mm and > 1 mm to 2 mm (35.7% vs 13.3%; p = 0.040). Multivariable analysis showed that for the soft pancreas, pancreatic duct diameter ≤ 1 mm was the only significant predictive factor for POPF (p = 0.027). Conclusions DTMPJ can be safely performed for pancreatic duct > 1 mm without significantly increased POPF risk.
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Affiliation(s)
- Kit-Fai Lee
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Kandy Kam Cheung Wong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Eugene Yee Juen Lo
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Janet Wui Cheung Kung
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Hon-Ting Lok
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Charing Ching Ning Chong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - John Wong
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Paul Bo San Lai
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Kelvin Kwok Chai Ng
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
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Mohamed A, Nicolais L, Fitzgerald TL. Revisiting the Pancreatic Fistula Risk Score: Clinical Nomogram Accurately Assesses Risk. Am Surg 2021:31348211047471. [PMID: 34633224 DOI: 10.1177/00031348211047471] [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
OBJECTIVES Surgeons have created numerous iterations of the pancreatic fistula risk score (FRS) to predict risk for clinically relevant postoperative pancreatic fistula (CR-POPF). The multitude of often conflicting models makes it difficult for surgeons to apply data in clinical practice. METHODS We conducted a retrospective cohort study utilizing National Surgical Quality Improvement Program data from 2015 to 2018. The study included patients undergoing pancreaticoduodenectomy. Missing data were resolved with multiple imputations. RESULTS The study included 5975 patients; 1018 (17%) had a CR-POPF. On multivariate analysis, male sex (odds ratio (OR) 1.60 CI: 1.29-1.98 P < .001), obesity (OR 1.65 CI: 1.31-2.08 P < .001), and soft gland texture (OR 3.21 CI: 2.45-4.23 P < .001) were all associated with increased odds of a CR-POPF. Variables not associated with CR-POPF included diabetes, preoperative bilirubin, preoperative albumin, and American Society of Anesthesiologists (ASA) classification. On multivariate analysis, duct diameter >6 mm (OR .52 CI: .34-.77 P = .001), pancreatic adenocarcinoma pathology (OR .67 CI: .53-.84 P < .001), and neoadjuvant treatment (OR .71 CI: .51-.98 P = .042) were all associated with decreased odds of a CR-POPF. We constructed a clinically relevant nomogram from this model known as the Portland FRS. Model characteristics were superior to previously published FRS models. The area under the curve (AUC) for the Portland FRS was .72 (CI: .704-.737). In comparison, AUCs for the Alternative and Seoul FRS were .70 and .64, respectively. CONCLUSION Utilizing readily available clinical data, the Portland FRS can accurately predict the risk for pancreatic fistula. The nomogram may assist surgeons in patient counseling and perioperative management.
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Affiliation(s)
- Abdimajid Mohamed
- Division of Surgical Oncology, 12261Tufts University School of Medicine, Boston, MA, USA
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Capretti G, Bonifacio C, De Palma C, Nebbia M, Giannitto C, Cancian P, Laino ME, Balzarini L, Papanikolaou N, Savevski V, Zerbi A. A machine learning risk model based on preoperative computed tomography scan to predict postoperative outcomes after pancreatoduodenectomy. Updates Surg 2021; 74:235-243. [PMID: 34596836 DOI: 10.1007/s13304-021-01174-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/20/2021] [Indexed: 11/09/2022]
Abstract
Clinically relevant postoperative pancreatic fistula (CR-POPF) is a life-threatening complication following pancreaticoduodenectomy (PD). Individualized preoperative risk assessment could improve clinical management and prevent or mitigate adverse outcomes. The aim of this study is to develop a machine learning risk model to predict occurrence of CR-POPF after PD from preoperative computed tomography (CT) scans. A total of 100 preoperative high-quality CT scans of consecutive patients who underwent pancreaticoduodenectomy in our institution between 2011 and 2019 were analyzed. Radiomic and morphological features extracted from CT scans related to pancreatic anatomy and patient characteristics were included as variables. These data were then assessed by a machine learning classifier to assess the risk of developing CR-POPF. Among the 100 patients evaluated, 20 had CR-POPF. The predictive model based on logistic regression demonstrated specificity of 0.824 (0.133) and sensitivity of 0.571 (0.337), with an AUC of 0.807 (0.155), PPV of 0.468 (0.310) and NPV of 0.890 (0.084). The performance of the model minimally decreased utilizing a random forest approach, with specificity of 0.914 (0.106), sensitivity of 0.424 (0.346), AUC of 0.749 (0.209), PPV of 0.502 (0.414) and NPV of 0.869 (0.076). Interestingly, using the same data, the model was also able to predict postoperative overall complications and a postoperative length of stay over the median with AUCs of 0.690 (0.209) and 0.709 (0.160), respectively. These findings suggest that preoperative CT scans evaluated by machine learning may provide a novel set of information to help clinicians choose a tailored therapeutic pathway in patients candidated to pancreatoduodenectomy.
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Affiliation(s)
- Giovanni Capretti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089, Rozzano, MI, Italy
| | - Cristiana Bonifacio
- Department of Diagnostic and Interventional Radiology, Humanitas Clinical and Research Center-IRCCS, Via A. Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Crescenzo De Palma
- Artificial Intelligence Center, Humanitas Clinical and Research Center-IRCCS, Via A. Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Martina Nebbia
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
| | - Caterina Giannitto
- Department of Diagnostic and Interventional Radiology, Humanitas Clinical and Research Center-IRCCS, Via A. Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Pierandrea Cancian
- Artificial Intelligence Center, Humanitas Clinical and Research Center-IRCCS, Via A. Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Maria Elena Laino
- Artificial Intelligence Center, Humanitas Clinical and Research Center-IRCCS, Via A. Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Luca Balzarini
- Department of Diagnostic and Interventional Radiology, Humanitas Clinical and Research Center-IRCCS, Via A. Manzoni 56, Rozzano, 20089, Milan, Italy
| | | | - Victor Savevski
- Artificial Intelligence Center, Humanitas Clinical and Research Center-IRCCS, Via A. Manzoni 56, Rozzano, 20089, Milan, Italy.
| | - Alessandro Zerbi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20090, Milan, Italy
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS, Via Manzoni 56, 20089, Rozzano, MI, Italy
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Vollmer CM. Moving toward prediction with purpose. Surgery 2021; 170:1602-1603. [PMID: 34482989 DOI: 10.1016/j.surg.2021.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 08/04/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
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Acher AW, Stahl C, Barrett JR, Schwartz PB, Aiken T, Ronnekleiv-Kelly S, Minter RM, Leverson G, Weber SM, Abbott DE. Clinical and Cost Profile of Controlled Grade B Postoperative Pancreatic Fistula: Rationale for Their Consideration as Low Risk. J Gastrointest Surg 2021; 25:2336-2343. [PMID: 33555526 DOI: 10.1007/s11605-021-04928-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 01/15/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Despite standardization, the 2016 ISGPF criteria are limited by their wider applicability and oversimplification of grade B POPF. This work applied the 2016 ISGPF grading criteria within a US academic cancer center to verify clinical and fiscal distinctions and sought to improve grading criteria for grade B POPF. METHODS The 2008-2018 cost and NSQIP data from pancreaticoduodenectomy to postoperative day 90 were merged. All POPFs were coded by 2016 ISGPF criteria. The Clavien-Dindo Classification (CD) defined complication severity. On sub-analyses, grade B POPFs were divided into those with adequate drainage and those requiring additional drainage. Chi-square, ANOVA, and Fisher's least significant difference test were employed. RESULTS Two hundred thirty-two patients were in the final analyses, 72 (31%) of whom had POPFs: 16 (7%) biochemical leaks, 54 (23%) grade B (28% required additional drainage), and 2 (1%) grade C. There was no significant difference in length of stay, CD, readmission, or cost in patients without a POPF, with biochemical leak or grade B POPF. On sub-analyses, 92% of adequately drained grade B POPFs had CD 1-2 and readmission equivalent to patients without POPF (p > 0.05). One hundred percent of grade B POPF requiring drainage had CD 3-4a, and 67% were readmitted. Cost was significantly increased in grade B POPF requiring additional drainage (p = 0.02) and grade C POPF (p < 0.01). CONCLUSIONS This analysis did not confirm an incremental increase in morbidity and cost with POPF grade. Sub-analyses enabled accurate clinical and cost distinctions in grade B POPF; adequately drained grade B POPF are low risk and clinically insignificant.
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Affiliation(s)
- Alexandra W Acher
- Department of General Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53792, USA. .,Clinical Science Center, 600 Highland Avenue, Box 7375, Madison, WI, 53792, USA.
| | - Christopher Stahl
- Department of General Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53792, USA
| | - James R Barrett
- Department of General Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53792, USA
| | - Patrick B Schwartz
- Department of General Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53792, USA
| | - Taylor Aiken
- Department of General Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53792, USA
| | - Sean Ronnekleiv-Kelly
- Department of General Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53792, USA
| | - Rebecca M Minter
- Department of General Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53792, USA
| | - Glen Leverson
- Department of General Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53792, USA
| | - Sharon M Weber
- Department of General Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53792, USA
| | - Daniel E Abbott
- Department of General Surgery, Division of Surgical Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI, 53792, USA
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Kiguchi G, Sugioka A, Uchida Y, Yoshikawa J, Nakauchi M, Kojima M, Tanahashi Y, Takahara T, Yasuda A, Suda K, Kato Y, Uyama I. Wrapping double-mattress anastomosis for pancreaticojejunostomy in minimally invasive pancreaticoduodenectomy can significantly reduce postoperative pancreatic fistula rate compared with conventional pancreaticojejunostomy in open surgery: An analysis of a propensity score-matched sample. Surg Oncol 2021; 38:101577. [PMID: 33887674 DOI: 10.1016/j.suronc.2021.101577] [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: 01/06/2021] [Revised: 03/29/2021] [Accepted: 04/01/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Minimally invasive pancreaticoduodenectomy (MIPD), including laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD), is technically demanding because of pancreaticojejunostomy (PJ). Postoperative pancreatic fistula (POPF) is the most serious complication of MIPD and open pancreaticoduodenectomy (OPD). Contrary to expectations, conventional PJ in MIPD did not improve POPF rate and length of hospital stay. High POPF rates are attributed to technical issues encountered during MIPD, which include motion restriction and insufficient water tightness. Therefore, we developed wrapping double-mattress anastomosis, the Kiguchi method, which is a novel PJ technique that can improve MIPD. Herein, we describe the Kiguchi method for PJ in MIPD and compare the outcomes between this technique and conventional PJ in OPD. METHODS The current retrospective study included 83 patients in whom the complete obstruction of the main pancreatic duct by pancreatic tumors was absent on preoperative imaging. This research was performed from September 2016 to August 2020 at Fujita Health University Hospital. All patients were evaluated as having a soft pancreatic texture, which is the most important factor associated with POPF development. Briefly, 50 patients underwent OPD with conventional PJ (OPD group). Meanwhile, 33 patients, including 15 and 18 who had LPD and RPD, respectively, underwent MIPD using the Kiguchi method (MIPD group). After a 1:1 propensity score matching, 30 patients in the OPD group were matched to 30 patients in the MIPD group. RESULTS The patients' preoperative data did not differ. The grade B/C POPF rate was significantly lower in the MIPD group than in the OPD group (6.7% vs 40.0%, p = 0.002). The MIPD group had a significantly shorter median length of hospital stay than the OPD group (24 vs 30 days, p = 0.004). CONCLUSION The novel Kiguchi method in MIPD significantly reduced the POPF rate in patients without complete obstruction of the main pancreatic duct.
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Affiliation(s)
- Gozo Kiguchi
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan.
| | - Atsushi Sugioka
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Yuichiro Uchida
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Junichi Yoshikawa
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Masaya Nakauchi
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Masayuki Kojima
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Yoshinao Tanahashi
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Takeshi Takahara
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Akira Yasuda
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Koichi Suda
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Yutaro Kato
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Ichiro Uyama
- Department of Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
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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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Park LJ, Baker L, Smith H, Lemke M, Davis A, Abou-Khalil J, Martel G, Balaa FK, Bertens KA. Passive Versus Active Intra-Abdominal Drainage Following Pancreatic Resection: Does A Superior Drainage System Exist? A Systematic Review and Meta-Analysis. World J Surg 2021; 45:2895-2910. [PMID: 34046692 DOI: 10.1007/s00268-021-06158-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2021] [Indexed: 12/14/2022]
Abstract
Postoperative pancreatic fistula (POPF) is a major source of morbidity following pancreatic resection. Surgically placed drains under suction or gravity are routinely used to help mitigate the complications associated with POPF. Controversy exists as to whether one of these drain management strategies is superior. The objective was to identify and compare the incidence of POPF, adverse events, and resource utilization associated with passive gravity (PG) versus active suction (AS) drainage following pancreatic resection. MEDLINE, EMBASE, CINAHL, and Cochrane Library databases were searched from inception to May 18, 2020. Outcomes of interest included POPF, post-pancreatectomy hemorrhage (PPH), surgical site infection (SSI), other major morbidity, and resource utilization. Descriptive qualitative and pooled quantitative meta-analyses were performed. One randomized control trial and five cohort studies involving 10 663 patients were included. Meta-analysis found no difference in the odds of developing POPF between AS and PG (p = 0.78). There were no differences in other endpoints including PPH (p = 0.58), SSI (wound p = 0.21, organ space p = 0.05), major morbidity (p = 0.71), or resource utilization (p = 0.72). The risk of POPF or other adverse outcomes is not impacted by drain management following pancreatic resection. Based on current evidence, a suggestion cannot be made to support the use of one drain over another at this time. There is a trend toward increased intra-abdominal wound infections with AS drains (p = 0.05) that merits further investigation.
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Affiliation(s)
- Lily J Park
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - Laura Baker
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Heather Smith
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada
| | - Madeline Lemke
- Division of General Surgery, Department of Surgery, Western University, London, Canada
| | - Alexandra Davis
- Liver and Pancreas Surgical Unit, Division of General Surgery, The Ottawa Hospital, CCW1667b, 501 Smyth Road, Ottawa, K1H 8L6, Canada
| | - Jad Abou-Khalil
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada.,Liver and Pancreas Surgical Unit, Division of General Surgery, The Ottawa Hospital, CCW1667b, 501 Smyth Road, Ottawa, K1H 8L6, Canada
| | - Guillaume Martel
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada.,Liver and Pancreas Surgical Unit, Division of General Surgery, The Ottawa Hospital, CCW1667b, 501 Smyth Road, Ottawa, K1H 8L6, Canada
| | - Fady K Balaa
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada.,Liver and Pancreas Surgical Unit, Division of General Surgery, The Ottawa Hospital, CCW1667b, 501 Smyth Road, Ottawa, K1H 8L6, Canada
| | - Kimberly A Bertens
- Division of General Surgery, Department of Surgery, University of Ottawa, Ottawa, Canada. .,Liver and Pancreas Surgical Unit, Division of General Surgery, The Ottawa Hospital, CCW1667b, 501 Smyth Road, Ottawa, K1H 8L6, Canada.
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Kuscher S, Kiehl T, Kronberger IE, Moser P, Maier H, Maier S, Hautz T, Öfner D, Schneeberger S, Troppmair J. Distal Pancreatic Resection with Splenectomy in the Rat: A Pancreatic Fistula Model to Investigate Postsurgical Damage? Eur Surg Res 2021; 62:97-104. [PMID: 34023826 DOI: 10.1159/000515867] [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: 01/28/2021] [Accepted: 03/15/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is a major complication in pancreatic surgery and can cause considerable postoperative morbidity. Advanced surgical-technical approaches to prevent POPF did not yield a substantial improvement. To investigate innovative treatments, experimental animal models of distal pancreatic resection and pancreaticoduodenectomy are of fundamental importance. After a failed attempt to replicate a previously described rat model for pancreatic fistula induction, we proceeded to distal pancreatic resection with splenectomy to provoke pancreatic leakage and generate a suitable animal model. METHODS Distal pancreatic resection with splenectomy was performed in 40 rats. The rats were sacrificed on postoperative day (POD) 1, 2, 4, 6, 8, or 10, and the abdominal cavity was explored. Ascites probes were collected pre- and postoperatively for the detection of pancreas amylase and lipase. Tissue samples from the naïve pancreas (POD 0) and the postoperatively harvested remnant were evaluated histologically. The extent of necrosis was determined, and samples were examined for neutrophil infiltration. TUNEL staining served for the verification of necrosis in distinct cases. Immunohistochemistry of Ki67, von Willebrand factor, and CD68 was performed to evaluate proliferation, blood-vessel sprouting, and macrophage invasion. RESULTS The rats showed no clinical symptoms or severe complications in the postoperative course up to 10 days. Abdominal exploration revealed adhesions in the upper abdomen, but no intra-abdominal fluid accumulations were found. Signs of inflammation and tissue damage were evident at the pancreatic resection margin on histological examination whereas the naïve pancreatic tissue was widely unaffected. Statistically significant differences were seen between the preoperative and postoperative extent of necrosis, the presence of neutrophil infiltrate, and levels of ascitic amylase and lipase. Immunohistochemical staining on Ki67, von Willebrand factor, and CD68 did not reveal any workable results on nonstatistical examination, and it was therefore not considered for further analyses. CONCLUSION Creating a functional animal model of pancreatic fistula that reflects the clinical and pathophysiological impact of pancreatic leakage in humans has not been achieved. Our approach of left pancreatic resection recapitulated inflammation and tissue damage, early events in the development of fistulas, and it could be suitable for the experimental testing of novel targeting methods.
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Affiliation(s)
- Stefanie Kuscher
- Daniel Swarovski Research Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria.,Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Tobias Kiehl
- Daniel Swarovski Research Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Irmgard Elisabeth Kronberger
- Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Patrizia Moser
- INNPATH, Institute of Pathology, Tirol Kliniken Innsbruck, Innsbruck, Austria
| | - Hans Maier
- INNPATH, Institute of Pathology, Tirol Kliniken Innsbruck, Innsbruck, Austria
| | - Sarah Maier
- Department of Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Innsbruck, Austria
| | - Theresa Hautz
- Daniel Swarovski Research Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Dietmar Öfner
- Daniel Swarovski Research Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria.,Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schneeberger
- Daniel Swarovski Research Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria.,Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Jakob Troppmair
- Daniel Swarovski Research Laboratory, Department of Visceral, Transplant and Thoracic Surgery, Center of Operative Medicine, Medical University of Innsbruck, Innsbruck, Austria
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Kamarajah SK, Bundred JR, Lin A, Halle-Smith J, Pande R, Sutcliffe R, Harrison EM, Roberts KJ. Systematic review and meta-analysis of factors associated with post-operative pancreatic fistula following pancreatoduodenectomy. ANZ J Surg 2021; 91:810-821. [PMID: 33135873 DOI: 10.1111/ans.16408] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/05/2020] [Accepted: 10/11/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Many studies have explored factors relating to post-operative pancreatic fistula (POPF); however, the original definition (All-POPF) was revised to include only 'clinically relevant' (CR) POPF. This study identified variables associated with the two International Study Group on Pancreatic Surgery definitions to identify which variables are more strongly associated with CR-POPF. METHODS A systematic review identified all studies reporting risk factors for POPF (using both International Study Group on Pancreatic Fistula definitions) following pancreatoduodenectomy. The primary outcome was factors associated with CR-POPF. Meta-analyses (random effects models) of pre-, intra- and post-operative factors associated with POPF in more than two studies were included. RESULTS Among 52 774 patients All-POPF (n = 69 studies) and CR-POPF (n = 53 studies) affected 27% (95% confidence interval (CI95% ) 23-30) and 19% (CI95% 17-22), respectively. Of the 176 factors, 24 and 17 were associated with All- and CR-POPF, respectively. Absence of pre-operative pancreatitis, presence of renal disease, no pre-operative neoadjuvant therapy, use of post-operative somatostatin analogues, absence of associated venous or arterial resection were associated with CR-POPF but not All-POPF. CONCLUSION In conclusion this study demonstrates wide variation in reported rates of POPF and that several risk factors associated with CR-POPF are not used within risk prediction models. Data from this study can be used to shape future studies, research and audit across ethnic and geographic boundaries in POPF following pancreatoduodenectomy.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle University NHS Trust Hospitals, Newcastle-Upon-Tyne, UK
- Institute of Cellular Medicine, University of Newcastle, Newcastle-Upon-Tyne, UK
| | - James R Bundred
- Department of Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Aaron Lin
- Department of Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - James Halle-Smith
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Rupaly Pande
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Robert Sutcliffe
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | - Keith J Roberts
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Clinical Surgery, Edinburgh Royal Infirmary, Edinburgh, UK
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Kumar S, Chandra A, Madhavan SM, Kumar D, Chauhan S, Pandey A, Masood S. Predictors and Outcomes of Pancreatic Fistula Following Pancreaticoduodenectomy: a Dual Center Experience. Indian J Surg Oncol 2021; 12:22-30. [PMID: 33814828 DOI: 10.1007/s13193-020-01195-3] [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: 04/26/2020] [Accepted: 08/19/2020] [Indexed: 01/04/2023] Open
Abstract
Fistula following leaked pancreatico-enteric anastomosis is a common, potentially lethal complication of pancreaticoduodenectomy (PD). Early assessment and prediction of its occurrence can improve postoperative outcomes. Various perioperative factors were analyzed for its contribution to clinically relevant postoperative pancreatic fistula (crPOPF). Also, the difference in clinical outcomes of patients with and without fistula was studied. Sixty-seven patients undergoing PD for malignancies were analyzed during 3-year period in a dual-institutional study. Various preoperative, intraoperative, and postoperative factors were assessed. The incidence and severity of POPF and its association with the development of other post-PD complications were observed. Patients with and without POPF were divided into groups and compared with univariate and multivariate analyses, to identify significant contributing factors. Clinically relevant POPF was present in 20.9% cases. crPOPF contributed to delayed gastric emptying, albeit insignificant (p = 0.403), but was significantly associated with increased incidence of post-pancreatectomy hemorrhagic (p = 0.005) and infectious complications (p = 0.013). Soft pancreas (p = 0.024), intraoperative blood loss (p = 0.045), blood transfusion (p = 0.024), and fistula risk score (p = 0.001) were significant predictors of crPOPF. First postoperative day (POD1) drain fluid amylase (DFA) values at cut-off of 1336 U/L (AUC = 0.871; p < 0.001) significantly predicted crPOPF with good sensitivity and specificity. POD1 DFA was only factor significant on multivariate analysis (p = 0.014). There was no significant difference in overall survival between groups. crPOPF results in significant post-pancreatectomy hemorrhagic and septic complications, along with increased mortality. It can be accurately predicted by several preoperative and intraoperative factors. POD1 DFA can independently predict crPOPF development.
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Affiliation(s)
- Suneed Kumar
- Department of Surgical Gastroenterology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh 226010 India
| | - Abhijit Chandra
- Department of Surgical Gastroenterology, King George Medical University, Lucknow, Uttar Pradesh India
| | - Shibumon M Madhavan
- Department of Surgical Gastroenterology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh 226010 India
| | - Dinesh Kumar
- Department of Surgical Gastroenterology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh 226010 India
| | - Smita Chauhan
- Department of Surgical Gastroenterology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh 226010 India
| | - Anshuman Pandey
- Department of Surgical Gastroenterology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh 226010 India
| | - Shakeel Masood
- Department of Surgical Gastroenterology, Dr. Ram Manohar Lohia Institute of Medical Sciences, Vibhuti Khand, Gomti Nagar, Lucknow, Uttar Pradesh 226010 India
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Singh K, Kaman L, Tandup C, Raypattanaik N, Dahiya D, Behera A. Internal stenting across the pancreaticojejunostomy anastomosis and main pancreatic duct after pancreaticoduodenectomy. POLISH JOURNAL OF SURGERY 2021; 93:1-5. [PMID: 33949332 DOI: 10.5604/01.3001.0014.7225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula is associated with high morbidity and mortality. Studies have reported internal stenting of the pancreaticojejunostomy anastomosis to reduce postoperative pancreatic fistula, but it is still controversial. MATERIALS AND METHODS Fifty patients undergoing elective pancreaticoduodenectomy, were included. Patients were divided into 2 groups in randomized fashion; Group A (n-25) without internal stenting across the pancreaticojejunostomy anastomosis and Group B (n-25) with internal stenting of the pancreaticojejunostomy anastomosis. Primary endpoint was the occurrence of postoperative pancreatic fistula. RESULT Both the groups were comparable in demographics, co morbidities, pathologies, pancreatic texture and pancreatic duct diameter. Out of 50 patients studied, total 23(46.0%) patients developed postoperative pancreatic fistula. Ten (40%) in group A and 13 (52%) in group B (p 0.156). Sixteen patients (32%) developed Grade A and 7 (14%) patients had Grade B postoperative pancreatic fistula. In group A, 6 patients developed grade A and 4 patients developed grade B postoperative pancreatic fistula. In group B, 10 patients developed grade A and 3 patients developed grade B postoperative pancreatic fistula. There was no Grade C fistula. All patients had satisfactory recovery on conservative management. Eight patients (16%) developed delayed gastric emptying [5 in group A and 3 in group B; p-0.366]. Six patients developed superficial surgical site infection (2 in group A and 4 in group B; p-0.445). The length of hospital stay was comparable in two groups. There was no mortality. CONCLUSION Internal stenting of pancreaticojejunostomy anastomosis does not decrease the rate of postoperative pancreatic fistula after pancreaticoduodenectomy.
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Affiliation(s)
| | | | | | | | - Divya Dahiya
- Department of Surgery, PGIMER, Chandigarh, India
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46
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Kopljar M, Čoklo M, Krstačić A, Krstačić G, Jeleč V, Zovak M, Pavić R, Kondža G. Validation of a clinical score in predicting pancreatic fistula after pancreaticoduodenectomy. Acta Chir Belg 2021; 121:30-35. [PMID: 31535593 DOI: 10.1080/00015458.2019.1664541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 09/03/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is one of the most severe complications after cephalic pancreaticoduodenectomy, with mortality as high as 30%. Risk scores may help predict the risk of POPF. Multiple external validations substantially improve generalized clinical acceptability of a scoring system. AIM The aim of this study was to externally validate previously described fistula risk score in the prediction of clinically relevant POPF. METHODS All patients who underwent pancreaticoduodenectomy for any indication during a 5-year period were prospectively analyzed. A total of 132 patients were analyzed. RESULTS Of the 132 patients, 44 (33.3%) developed pancreatic fistula, including 12.9% biochemical leaks, 7.6% grade B fistula, and 12.9% grade C fistula. Cut-off point of 4.5 was determined to best separate patients who developed clinically relevant POPF with area under curve of 78% (p = .00003). Sensitivity and specificity for the prediction of clinically relevant POPF with the cut-off value of 4.5 was 70.4 and 74.3%, respectively. Positive predictive value with cut-off value 4.5 was 57.8%, and negative predictive value was 83.4%. CONCLUSION Fistula risk score identified low risk patients with false negative rate of 16.6%. Further external validation studies on large cohorts of patients and with wide case-mix may enable additional refinements of the score model.
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Affiliation(s)
- Mario Kopljar
- Department of Surgery, University Hospital Center "Sestre Milosrdnice", Zagreb, Croatia
- Medical Faculty Osijek, University "Josip Juraj Strossmayer", Osijek, Croatia
| | - Miran Čoklo
- Institute for Anthropological Research, Zagreb, Croatia
| | - Antonija Krstačić
- Medical Faculty Osijek, University "Josip Juraj Strossmayer", Osijek, Croatia
- University of Applied Health Sciences, Zagreb, Croatia
- Clinical Hospital of Traumatology, University Hospital Centre "Sestre Milosrdnice", Zagreb, Croatia
| | - Goran Krstačić
- Medical Faculty Osijek, University "Josip Juraj Strossmayer", Osijek, Croatia
- University of Applied Health Sciences, Zagreb, Croatia
- Institute for Cardiovascular Prevention and Rehabilitation, Zagreb, Croatia
| | - Vjekoslav Jeleč
- Medical Faculty Osijek, University "Josip Juraj Strossmayer", Osijek, Croatia
- Department of Neurosurgery, University Hospital Dubrava, Zagreb, Croatia
| | - Mario Zovak
- Department of Surgery, University Hospital Center "Sestre Milosrdnice", Zagreb, Croatia
| | - Roman Pavić
- Medical Faculty Osijek, University "Josip Juraj Strossmayer", Osijek, Croatia
- Clinical Hospital of Traumatology, University Hospital Centre "Sestre Milosrdnice", Zagreb, Croatia
| | - Goran Kondža
- Medical Faculty Osijek, University "Josip Juraj Strossmayer", Osijek, Croatia
- Department of Abdominal Surgery, University Hospital Center Osijek, Osijek, Croatia
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Assessment of Preoperative Clinicophysiologic Findings as Risk Factors for Postoperative Pancreatic Fistula After Pancreaticoduodenectomy. Int Surg 2021. [DOI: 10.9738/intsurg-d-20-00020.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective
Postoperative pancreatic fistula (POPF) is one of the severe complications that develop after pancreaticoduodenectomy (PD). This study aimed to assess the utility of preoperative clinicophysiologic findings as risk factors for POPF after PD.
Summary of Background Data
We enrolled 350 patients who underwent PD between 2007 and 2012 at Tokyo Women's Medical University.
Methods
In total, 350 patients who underwent PD between 2007 and 2012 were examined retrospectively. All patients were classified into 2 groups as follows: group A (no fistula/biochemical leak group, 289 patients) and group B (grade B/C of POPF group 61 patients). Variables, including operative characteristics, length of stay in hospital, morbidity, mortality, and data regarding preoperative clinicophysiologic parameters, were collected and analyzed as predictors of POPF for univariate and multivariate analyses.
Results
There were 213 male and 137 female patients. The mean age was 65.4 years (range, 21–87 years). Univariate analysis showed that sex (P = 0.047), amylase level (P = 0.032), prognostic nutritional index (PNI; P = 0.001), and C-reactive protein/albumin ratio (P = 0.005) were independent risk factors for POPF. In contrast, multivariate analysis showed that sex (P = 0.045) and PNI (P = 0.012) were independent risk factors for POPF.
Conclusions
Our results show that PNI (≤48.64 U/mL) and male sex were risk factors for POPF after PD, and especially, PNI can be suggested as an effective biomarker for POPF.
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Jin J, Xiong G, Li J, Guo X, Wang M, Li Z, Zhu F, Qin R. Predictive factors of postoperative pancreatic fistula after laparoscopic pancreatoduodenectomy. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:41. [PMID: 33553334 PMCID: PMC7859741 DOI: 10.21037/atm-20-1411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background Clinically relevant postoperative pancreatic fistula (CR-POPF) continues to be a major contributor to morbidity after pancreaticoduodenectomy (PD), but it remains unclear what risk factors can precisely predict the development of CR-POPF after laparoscopic pancreatoduodenectomy (LPD). We thus aimed to identify the risk factors for predicting CR-POPF after LPD. Methods A total of 388 consecutive patients who underwent LPD at our institution between July 2014 and December 2018 were identified. All data, including pre-, intra-, and postoperative risk factors associated with CR-POPF defined by the International Study Group of Pancreatic Fistula, were collected retrospectively. To evaluate the predictive performance of the risk factor models, areas under the receiver operating characteristic curve (ROC) were determined. Results CR-POPF was observed in 31 patients (8.0%) with significant association observed with body mass index (BMI), visceral fat area (VFA), subcutaneous fat area (SFA), total fat area (TFA), intra-abdominal fat thickness, main pancreatic duct width, soft pancreatic texture, operative time, underlying pathology, and albumin (Alb) on postoperative days (POD) 1–3. Multivariate analyses revealed that VFA >82 cm2 [odds ratio (OR) =11.088; P=0.029], main pancreatic duct width <3 mm (OR =7.701; P=0.001), soft pancreatic texture (OR =12.543; P=0.022), and operative time >320 min (OR =6.061; P<0.001) were independent risk factors for CR-POPF after LPD. Areas under the ROC curve (AUC) analysis revealed the pancreatic texture was the strongest single predictor (AUC =0.854) of CR-POPF, and pancreatic texture + pancreatic duct width was the best two-predictor model (AUC =0.904). Meanwhile, our findings indicated an association between the TFA >221 cm2 (OR =8.637; P=0.001) and VFA >82 cm2 (OR =7.009; P<0.001) with soft pancreatic texture. Conclusions Soft pancreatic texture, VFA >82 cm2, main pancreatic duct width <3 mm, and operative time >320 min were independent predictive risk factors of CR-POPF for LPD.
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Affiliation(s)
- Jikuan Jin
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guangbing Xiong
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiali Li
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xingjun Guo
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Min Wang
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhen Li
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Feng Zhu
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Renyi Qin
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Kalev G, Marquardt C, Matzke H, Matovu P, Schiedeck T. The modified Blumgart anastomosis after pancreaticoduodenectomy: a retrospective single center cohort study. Innov Surg Sci 2020; 5:20200021. [PMID: 33506098 PMCID: PMC7790181 DOI: 10.1515/iss-2020-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 11/20/2020] [Indexed: 11/15/2022] Open
Abstract
Objectives The postoperative pancreatic fistula (POPF) is a major complication after pancreatic head resection whereby the technique of the anastomosis is a very influencing factor. The literature describes a possible protective role of the Blumgart anastomosis. Methods Patients after pancreatic head resection with reconstruction through the modified Blumgart anastomosis (a 2 row pancreatic anastomosis through mattress sutures of the parenchyma and duct to mucosa pancreaticojejunostomy, Blumgart-group) were compared with patients after pancreatic head resection and reconstruction through the conventional pancreatojejunostomy (single suture technique of capsule and parenchyma to seromuscularis, PJ-group). The Data were collected retrospectively. Depending on the propensity score matching in a ratio of 1:2 comparison groups were set up. Blumgart-group (n=29) and PJ-group (n=56). The primary end point was the rate of POPF. Secondary goals were duration of operation, length of hospital stay, length of stay on intermediate care units and hospital mortality. Results The rate of POPF (biochemical leak, POPF "grade B" and POPF "grade C") was less in the Blumgart-group, but without statistical relevance (p=0.23). Significantly less was the rate of POPF "grade C" in the Blumgart-group (p=0.03). Regarding the duration of hospital stay, length of stay on intermediate care units and hospital mortality, there was no relevant statistical difference between the groups (p=0.1; p=0.4; p=0.7). The duration of the operation was significantly less in the Blumgart-group (p=0.001). Conclusions The modified Blumgart anastomosis technique may have the potential to decrease major postoperative pancreatic fistula.
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Affiliation(s)
- Georgi Kalev
- Department of General, Visceral, Thoracic and Pediatric Surgery, Ludwigsburg Hospital, Ludwigsburg, Germany
| | - Christoph Marquardt
- Department of General, Visceral, Thoracic and Pediatric Surgery, Ludwigsburg Hospital, Ludwigsburg, Germany
| | - Herbert Matzke
- Department of General, Visceral, Thoracic and Pediatric Surgery, Ludwigsburg Hospital, Ludwigsburg, Germany
| | - Paul Matovu
- Department of General, Visceral, Thoracic and Pediatric Surgery, Ludwigsburg Hospital, Ludwigsburg, Germany
| | - Thomas Schiedeck
- Department of General, Visceral, Thoracic and Pediatric Surgery, Ludwigsburg Hospital, Ludwigsburg, Germany
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Tzedakis S, Sauvanet A, Schiavone R, Razafinimanana M, Cauchy F, Rouet J, Dousset B, Gaujoux S. What should we trust to define, predict and assess pancreatic fistula after pancreatectomy? Pancreatology 2020; 20:1779-1785. [PMID: 33077382 DOI: 10.1016/j.pan.2020.10.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/04/2020] [Accepted: 10/08/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The ISGPF postoperative pancreatic fistula (POPF) definition using amylase drain concentration is widely used. However, the interest of lipase drain concentration, daily drain output and absolute enzyme daily production (concentration x daily drain volume) have been poorly investigated. MATERIAL AND METHODS These predictive on postoperative day (POD) 1, 3, 5 and 7 were analyzed in a development cohort, and subsequently tested in an independent validation cohort. RESULTS Of the 227 patients of the development cohort, 17% developed a biochemical fistula and 34% a POPF (Grade B/C). Strong correlation was found between amylase/lipase drain concentration at all postoperative days (ρ = 0.90; p = 0.001). Amylase and lipase were both significantly higher in patients with a POPF (p < 0.001) presenting an equivalent under the ROC curve area (0.85 vs 0.84; p = 0.466). Combining POD1 and POD3 threefold enzyme cut-off value increased significantly POPF prediction sensibility (97.4% vs 77.8%) and NPV (97.1% vs 86.3%). These results were also confirmed in the validation cohort of 554 patients. Finally, absolute enzyme daily production and daily drain output were significantly higher in patients with a POPF (p < 0.001) but did not add clinical value when compared to drain enzyme concentration. CONCLUSION Lipase is as effective as amylase drain concentration to define POPF. Absolute enzyme daily production or daily drain output do not help to better predict clinically significant POPF occurrence and severity. Lipase and amylase should mainly be used for their negative predictive value to predict the absence of clinically significant POPF and could allow early drain removal and hospital discharge.
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Affiliation(s)
- Stylianos Tzedakis
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Cochin Hospital, APHP, Paris, France
| | - Alain Sauvanet
- Department of Hepato-Pancreato-Biliary Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Hospital Beaujon, APHP, Clichy, France; University of Paris, Paris, France
| | - Roberto Schiavone
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Cochin Hospital, APHP, Paris, France
| | - Meva Razafinimanana
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Cochin Hospital, APHP, Paris, France
| | - François Cauchy
- Department of Hepato-Pancreato-Biliary Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Hospital Beaujon, APHP, Clichy, France; University of Paris, Paris, France
| | - Jérémy Rouet
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Cochin Hospital, APHP, Paris, France; Department of Hepato-Pancreato-Biliary Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Hospital Beaujon, APHP, Clichy, France
| | - Bertrand Dousset
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Cochin Hospital, APHP, Paris, France; University of Paris, Paris, France
| | - Sébastien Gaujoux
- Department of Digestive, Hepato-biliary and Endocrine Surgery, La Pitié-Salpétrière Hospital, APHP, Paris, France; Médecine Sorbonne Université, Paris, France.
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