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Maharjan P, Regmee S, Adhikari SD, Pahari R, Ghimire R, Maharjan DK, Shrestha SK, Thapa PB. Chyle leak following root of mesentery dissection in pancreaticoduodenectomy with inferior infracolic superior mesenteric artery first approach. World J Clin Cases 2025; 13:97887. [PMID: 40094116 PMCID: PMC11670012 DOI: 10.12998/wjcc.v13.i8.97887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 11/02/2024] [Accepted: 11/20/2024] [Indexed: 12/04/2024] Open
Abstract
BACKGROUND The root of mesentery dissection is one of the critical maneuvers, especially in borderline resectable pancreatic head cancer. Intra-abdominal chyle leak (CL) including chylous ascites may ensue in up to 10% of patients after pancreatic resections. Globally recognized superior mesenteric artery (SMA) first approaches are invariably performed. The mesenteric dissection through the inferior infracolic approach has been discussed in this study emphasizing its post-operative impact on CL which is the cornerstone of this study. AIM To assess incidence, risk factors, clinical impact of CL following root of mesentery dissection, and the different treatment modalities. METHODS This is a retrospective study incorporating the patients who underwent dissection of the root of mesentery with inferior infracolic SMA first approach pancreatoduodenectomy for the ventral body and uncinate mass of pancreas in the Department of Gastrointestinal and General Surgery of Kathmandu Medical College and Teaching Hospital from January 1, 2021 to February 28, 2024. Intraoperative findings and postoperative outcomes were analyzed. RESULTS In three years, ten patients underwent root of mesentery dissection with inferior infracolic SMA first approach pancreatoduodenectomy. The mean age was 67.6 years with a male-to-female ratio of 4:5. CL was seen in four patients. With virtue of CL, Clavien-Dindo grade II or higher morbidity was observed in four patients. Two patients had a hospital stay of more than 20 days with the former having a delayed gastric emptying and the latter with long-term total parenteral nutrition requirement. The mean operative time was 330 minutes. Curative resection was achieved in 100% of the patients. The mean duration of the intensive care unit and hospital stay were 2.55 ± 1.45 days and 15.7 ± 5.32 days, respectively. CONCLUSION Root of mesentery dissection with lymphadenectomy and vascular resection correlated with occurrence of CL. After complete curative resection, these were managed with total parenteral nutrition without adversely impacting outcome.
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Affiliation(s)
- Prabir Maharjan
- Department of Gastrointestinal and General Surgery, Kathmandu Medical College and Teaching Hospital, Kathmandu 44600, Nepal
| | - Sujan Regmee
- Department of Gastrointestinal and General Surgery, Kathmandu Medical College and Teaching Hospital, Kathmandu 44600, Nepal
| | - Spandan D Adhikari
- Department of Gastrointestinal and General Surgery, Kathmandu Medical College and Teaching Hospital, Kathmandu 44600, Nepal
| | - Rabin Pahari
- Department of Gastrointestinal and General Surgery, Kathmandu Medical College and Teaching Hospital, Kathmandu 44600, Nepal
| | - Roshan Ghimire
- Department of Gastrointestinal and General Surgery, Kathmandu Medical College and Teaching Hospital, Kathmandu 44600, Nepal
| | - Dhiresh K Maharjan
- Department of Gastrointestinal and General Surgery, Kathmandu Medical College and Teaching Hospital, Kathmandu 44600, Nepal
| | - Suman K Shrestha
- Department of Gastrointestinal and General Surgery, Kathmandu Medical College and Teaching Hospital, Kathmandu 44600, Nepal
| | - Prabin B Thapa
- Department of Gastrointestinal and General Surgery, Kathmandu Medical College and Teaching Hospital, Kathmandu 44600, Nepal
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Li T, Lin C, Zhao B, Li Z, Zhao Y, Han X, Dai M, Guo J, Wang W. Venous resection increases risk of chyle leak after total pancreatectomy for pancreatic tumors. World J Surg Oncol 2024; 22:174. [PMID: 38943154 PMCID: PMC11214213 DOI: 10.1186/s12957-024-03451-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 06/16/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND Existing research on chyle leak (CL) after pancreatic surgery is mostly focused on pancreaticoduodenectomy and lacks investigation on total pancreatectomy (TP). This study aimed to explore potential risk factors of CL and develop a predictive model for patients with pancreatic tumor undergoing TP. METHODS This retrospective study enrolled 90 consecutive patients undergoing TP from January 2015 to December 2023 at Peking Union Medical College Hospital. According to the inclusion criteria, 79 patients were finally included in the following analysis. The LASSO regression and multivariate logistic regression analysis were performed to identify risk factors associated with CL and construct a predictive nomogram. Then, the ROC analysis, calibration curve, decision curve analysis (DCA), and clinical impact curve (CIC) were performed to assess its discrimination, accuracy, and efficacy. Due to the small sample size, we adopted the bootstrap resampling method with 500 repetitions for validation. Lastly, we plotted and analyzed the trend of postoperative drainage volume in CL patients. RESULTS We revealed that venous resection (OR = 4.352, 95%CI 1.404-14.04, P = 0.011) was an independent risk factor for CL after TP. Prolonged operation time (OR = 1.473, 95%CI 1.015-2.237, P = 0.052) was also associated with an increased incidence of CL. We included these two factors in our prediction model. The area under the curve (AUC) was 0.752 (95%CI 0.622-0.874) after bootstrap. The calibration curve, DCA and CIC showed great accuracy and clinical benefit of our nomogram. In patients with CL, the mean drainage volume was significantly higher in venous resection group and grade B CL group. CONCLUSION Venous resection was an independent risk factor for chyle leak after TP. Patients undergoing vascular resection during TP should be alert for the occurrence of CL after surgery. We then constructed a nomogram consisted of venous resection and operation time to predict the odds of CL in patients undergoing TP.
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Affiliation(s)
- Tianyu Li
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chen Lin
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bangbo Zhao
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zeru Li
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yutong Zhao
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xianlin Han
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Menghua Dai
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Junchao Guo
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Weibin Wang
- Department of General Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Ishii N, Harimoto N, Seki T, Muranushi R, Hagiwara K, Hoshino K, Tsukagoshi M, Watanabe A, Igarashi T, Shibuya K, Araki K, Shirabe K. The impact of lymphangiograpy on chyle leakage treatment duration after pancreatic surgery. Surg Today 2024; 54:651-657. [PMID: 38062229 DOI: 10.1007/s00595-023-02777-8] [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: 08/01/2023] [Accepted: 10/10/2023] [Indexed: 05/21/2024]
Abstract
PURPOSE Chyle leakage (CL) is a common complication in pancreatic surgery. Lymphangiography is a therapeutic option for CL in cases of conservative treatment failure. This study investigated the effect of lymphangiography on the healing time of CL. METHODS We retrospectively evaluated 283 patients who underwent pancreatic resection between January 2016 and June 2022. The risk factors for CL and the treatment period were evaluated according to whether or not lymphangiography was performed. RESULTS Of the 29 patients (10.2%) that had CL, lymphangiography was performed in 6. Malignant disease, the number of harvested lymph nodes, and drain fluid volume on postoperative day 2 were identified as independent risk factors for CL. Lymphangiography was associated with the cumulative healing rate of CL, and patients who underwent lymphangiography had a significantly shorter treatment period. No lymphangiography-related adverse events were observed. CONCLUSION Lymphangiography is a feasible and safe treatment option for CL. The CL treatment period after pancreatic surgery was significantly shorter in patients who underwent lymphangiography than in those who did not. Our results suggest that lymphangiography may contribute to early improvement of persistent CL.
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Affiliation(s)
- Norihiro Ishii
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Norifumi Harimoto
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan.
| | - Takamomi Seki
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Ryo Muranushi
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Kei Hagiwara
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Kouki Hoshino
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Mariko Tsukagoshi
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Akira Watanabe
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Takamichi Igarashi
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Kei Shibuya
- Department of Diagnostic Radiology and Nuclear Medicine, Graduate School of Medicine, Gunma University, Gunma, Japan
| | - Kenichiro Araki
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Ken Shirabe
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
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Wang K, Xiao J, Li L, Li X, Yang Y, Liu Z, Jiang J. The application of a medium-chain fatty diet and enteral nutrition in post-operative chylous leakage: analysis of 63 patients. Front Nutr 2023; 10:1128864. [PMID: 37545584 PMCID: PMC10399236 DOI: 10.3389/fnut.2023.1128864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 06/30/2023] [Indexed: 08/08/2023] Open
Abstract
Background Post-operative chylous leakage (CL) is the pathologic leakage of chylomicron fluid after surgery. This retrospective study was performed to evaluate a uniform oral nutrition management strategy on the post-operative CL. Methods We retrospectively reviewed patients who developed post-operative CL and received consultation from a clinical nutritionist in seven departments of the Second Affiliated Hospital of Dalian Medical University from May 2020 to April 2022. We designed the oral nutrition intervention program which mainly standardized the type and amount of foods contained in the medium-chain triglyceride (MCT) diet. The influencing factors of curative efficacy were analyzed. Finally, binary logistic regression analysis was conducted to observe the relationship between curative efficacy and potentially predictive variables, including post-operative albumin, post-operative hemoglobin, surgical procedure, and drainage volume at consultation. Results Sixty-three patients with post-operative CL were included in this analysis. Of this number, 58 patients were cured successfully without other treatments. Three patients had a significantly prolonged recovery period, and the remaining two cases were treated by reoperation therapy. The leakage volume at the initiation of enteral intervention had no statistically significant difference in seven surgical departments and surgical sites (left, right, median, and bilateral). The length of stay (LOS) of patients with CL after the intervention was not significantly increased in cardiac, hepatobiliary, gastrointestinal, and urological surgeries. Patients with CL had longer LOS than those without CL in gynecology (P=0.044) and thyroid surgery departments (P=0.008). Each unit increase in post-operative hemoglobin would increase the probability of an effective outcome by 8%, which was statistically significant (P = 0.037). Conclusion In treating patients with post-operative CL, we recommend the MCT diet and EN as the first option, rather than fasting, parenteral nutrition (PN), or octreotide.
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Affiliation(s)
- Ke Wang
- Department of Clinical Nutrition, Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Jiaming Xiao
- Department of Nutrition and Food Hygiene, School of Public Health, Dalian Medical University, Dalian, Liaoning, China
| | - Li Li
- Department of Clinical Nutrition, Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Xu Li
- Department of Clinical Nutrition, Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Yilun Yang
- Department of Clinical Nutrition, Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Zhiyu Liu
- Department of Urological Surgery, Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Jing Jiang
- Department of Nursing, Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
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Augustinus S, Latenstein AE, Bonsing BA, Busch OR, Groot Koerkamp B, de Hingh IH, de Meijer VE, Molenaar IQ, van Santvoort HC, de Vos-Geelen J, van Eijck CH, Besselink MG. Chyle Leak After Pancreatoduodenectomy: Clinical Impact and Risk Factors in a Nationwide Analysis. Ann Surg 2023; 277:e1299-e1305. [PMID: 35786606 PMCID: PMC10174101 DOI: 10.1097/sla.0000000000005449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to assess the clinical impact and risk factors of chyle leak (CL). BACKGROUND In 2017, the International Study Group for Pancreatic Surgery (ISGPS) published the consensus definition of CL. Multicenter series validating this definition are lacking and previous studies investigating risk factors have used different definitions and showed heterogeneous results. METHODS This observational cohort study included all consecutive patients after pancreatoduodenectomy in all 19 centers in the mandatory nationwide Dutch Pancreatic Cancer Audit (2017-2019). The primary endpoint was CL (ISGPS grade B/C). Multivariable logistic regression analyses were performed. RESULTS Overall, 2159 patients after pancreatoduodenectomy were included. The rate of CL was 7.0% (n=152), including 6.9% (n=150) grade B and 0.1% (n=2) grade C. CL was independently associated with a prolonged hospital stay [odds ratio (OR)=2.84, 95% confidence interval (CI): 1.85-4.36, P <0.001] but not with mortality (OR=0.3, 95% CI: 0.0-2.3, P =0.244). In multivariable analyses, independent predictors for CL were vascular resection (OR=2.1, 95% CI: 1.4-3.2, P <0.001) and open surgery (OR=3.5, 95% CI: 1.7-7.2, P =0.001). The number of resected lymph nodes and aortocaval lymph node sampling were not identified as predictors in multivariable analysis. CONCLUSIONS In this nationwide analysis, the rate of ISGPS grade B/C CL after pancreatoduodenectomy was 7.0%. Although CL is associated with a prolonged hospital stay, the clinical impact is relatively minor in the vast majority (>98%) of patients. Vascular resection and open surgery are predictors of CL.
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Affiliation(s)
- Simone Augustinus
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Anouk E.J. Latenstein
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bert A. Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Olivier R. Busch
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | - Vincent E. de Meijer
- Department of Surgery, University Medical Center Groningen and University of Groningen, Groningen, The Netherlands
| | - I. Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Hjalmar C. van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht & St Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, GROW—School for Oncology and Developmental Biology, Maastricht UMC+, Maastricht, The Netherlands
| | - Casper H. van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Marc G. Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
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Risk factors of chylous ascites and its relationship with long-term prognosis in laparoscopic D3 lymphadenectomy for right colon cancer. Langenbecks Arch Surg 2022; 407:2453-2462. [PMID: 35589848 DOI: 10.1007/s00423-022-02527-3] [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: 03/01/2022] [Accepted: 04/21/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Chylous ascites (CA) after laparoscopic D3 lymphadenectomy for right colon cancer is not rare. However, the risk factors for CA have not been fully explored. Few studies have investigated the effect of CA on long-term prognosis. METHODS The clinical data of patients with right colon cancer who underwent laparoscopic D3 lymphadenectomy in five centers from January 2013 to December 2018 were retrospectively collected. Univariate and multivariate analyses were performed to determine the clinicopathological factors associated with CA. Then, the long-term prognosis of patients with and without CA was compared by propensity score matching and Kaplan-Meier survival analysis. RESULTS The incidence of CA was 4.4% (48/1090). Pathological T stage (p = 0.025), dissection along the left side of the superior mesenteric artery (p < 0.001) and the number of retrieved lymph nodes (p < 0.001) were independent risk factors for CA. After propensity score matching, 48 patients in the CA group and 353 patients in the non-CA group were enrolled. Kaplan-Meier survival analysis indicated that CA was not associated with overall survival (p = 0.454) and disease-free survival (p = 0.163). In patients with stage III right colon cancer, there were no significant differences in overall survival (p = 0.501) and disease-free survival (p = 0.254). CONCLUSIONS Pathological T stage, number of retrieved lymph nodes, and left side dissection along the superior mesenteric artery were independent risk factors for CA after laparoscopic D3 lymphadenectomy. CA does not impair the oncological outcomes of patients.
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Relationship between Nutritional Treatment Compliance and Nutritional Status Improvements in Patients with Gastrointestinal Impairment taking an Oral-Peptide Based Supplement. Nutrition 2022; 102:111734. [DOI: 10.1016/j.nut.2022.111734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/02/2022] [Accepted: 05/04/2022] [Indexed: 11/21/2022]
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Muzzolini M, Araujo RLC, Kingham TP, Peschaud F, Paye F, Lupinacci RM. Incidence and risk factors for Chyle leak after pancreatic surgery for cancer: A comprehensive systematic review. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:707-717. [PMID: 34887165 PMCID: PMC8995357 DOI: 10.1016/j.ejso.2021.11.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/25/2021] [Accepted: 11/29/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Chyle leak (CL) is a clinically relevant complication after pancreatectomy. Its incidence and the associated risk factors are ill defined, and various treatments options have been described. There is no consensus, however, regarding optimal management. The present study aims to systematically review the literature on CL after pancreatectomy. METHODS A systematic review from PubMed, Scopus and Embase database was performed. Studies using a clear definition for CL and published from January 2000 to January 2021 were included. The PRISMA guidelines were followed during all stages of this systematic review. The MINORS score was used to assess methodological quality. RESULTS Literature search found 361 reports, 99 of which were duplicates. The titles and abstracts of 262 articles were finally screened. The references from the remaining 181 articles were manually assessed. After the exclusions, 43 articles were thoroughly assessed. A total of 23 articles were ultimately included for this review. The number of patients varied from 54 to 3532. Incidence of post pancreatectomy CL varied from 1.3% to 22.1%. Main risk factors were the extent of the surgery and early oral or enteral feeding. CL dried up spontaneously or after conservative management within 14 days in 53% to 100% of the cases. CONCLUSIONS The extent of surgery is the most common predictor of risk of CL. Conservative treatment has been shown to be effective in most cases and can be considered the treatment of choice. We propose a management algorithm based on the current available evidence.
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Affiliation(s)
- Milena Muzzolini
- AP-HP, Department of Digestive and Oncologic Surgery, Ambroise Paré Hospital, 9 Avenue Charles de Gaulle, 92104, Boulogne-Billancourt, France
| | - Raphael L C Araujo
- Department of Surgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - T Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Frédérique Peschaud
- AP-HP, Department of Digestive and Oncologic Surgery, Ambroise Paré Hospital, 9 Avenue Charles de Gaulle, 92104, Boulogne-Billancourt, France; Versailles St-Quentin-en-Yvelines/Paris Saclay University, UFR des Sciences de la Santé Simone Veil, 78180, Montigny-le-Bretonneux, France
| | - François Paye
- Department of Surgery, Saint Antoine Hospital, 184 Rue du Faubourg Saint Antoine, 75012, Paris, France; Sorbonne Université, 75013, 91-105, Bd de l'Hôpital, Paris, France
| | - Renato M Lupinacci
- AP-HP, Department of Digestive and Oncologic Surgery, Ambroise Paré Hospital, 9 Avenue Charles de Gaulle, 92104, Boulogne-Billancourt, France; Versailles St-Quentin-en-Yvelines/Paris Saclay University, UFR des Sciences de la Santé Simone Veil, 78180, Montigny-le-Bretonneux, France.
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Russell TB, Aroori S. Procedure‐specific morbidity of pancreatoduodenectomy: a systematic review of incidence and risk factors. ANZ J Surg 2022; 92:1347-1355. [DOI: 10.1111/ans.17473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/04/2022] [Accepted: 01/04/2022] [Indexed: 12/16/2022]
Affiliation(s)
- Thomas B Russell
- Department of HPB Surgery University Hospitals Plymouth NHS Trust Plymouth UK
| | - Somaiah Aroori
- Department of HPB Surgery University Hospitals Plymouth NHS Trust Plymouth UK
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Muscaritoli M, Pradelli L. Medium-Chain Triglyceride (MCT) Content of Adult Enteral Tube Feeding Formulas and Clinical Outcomes. A Systematic Review. Front Nutr 2021; 8:697529. [PMID: 34409063 PMCID: PMC8364971 DOI: 10.3389/fnut.2021.697529] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/06/2021] [Indexed: 01/03/2023] Open
Abstract
Available data on the effect of lipid composition of enteral formulas on clinical outcomes are controversial. The present systematic review was performed in order to verify whether the presence of specific lipidic substrates, namely medium-chain triglycerides (MCT), in enteral tube feeding formulas is associated to measurable clinical benefits in patients receiving enteral nutrition in different clinical settings, including home enteral nutrition (HEN). The results of this systematic review highlight a lack of robust evidence supporting the use of specific types of lipids in standard or disease-specific formulas. Evidence exists, however, that MCT-containing formulas are safe and well-tolerated. Further, well-designed, adequately powered, randomized controlled trials would be needed in order to assess the superiority of MCT- containing enteral formulas over other standard or disease-specific commercially available enteral products.
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Affiliation(s)
- Maurizio Muscaritoli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
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Varghese C, Wells CI, Lee S, Pathak S, Siriwardena AK, Pandanaboyana S. Systematic review of the incidence and risk factors for chyle leak after pancreatic surgery. Surgery 2021; 171:490-497. [PMID: 34417025 DOI: 10.1016/j.surg.2021.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/28/2021] [Accepted: 07/15/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND The incidence of and risk factors for chyle leak, as defined by the 2017 International Study Group on Pancreatic Surgery, remain unknown. METHODS MEDLINE, EMBASE, and Scopus were systematically searched for studies of patients undergoing pancreatectomy that reported chyle leak according to the 2017 International Study Group on Pancreatic Surgery definition. The primary outcomes were the incidence of overall and clinically relevant chyle leak. A random-effects pairwise meta-analysis was used to calculate the incidence of chyle leak. RESULTS Thirty-five studies including 7,083 patients were included in the meta-analysis. The weighted incidence of overall chyle leak was 6.8% (95% confidence interval 5.6-8.2), and clinically relevant chyle leak was 5.5% (95% confidence interval 3.8-7.7). Pancreaticoduodenectomy, total pancreatectomy, and distal pancreatectomy were associated with a CL incidence of 7.3%, 4.3%, and 5.8%, respectively. Fourteen individual risk factors for chyle leak were identified from included studies. Younger age, low prognostic nutritional index, para-aortic node manipulation, lymphatic involvement, and post-pancreatectomy pancreatitis were significantly associated with chyle leak, all from individual studies. CONCLUSION The incidence of overall chyle leak and clinically relevant chyle leak after pancreatic surgery, as defined by the 2017 International Study Group on Pancreatic Surgery, is 6.8% and 5.5%, respectively. Several risk factors for chyle leak were identified in the present review; however, larger high-quality studies are needed to more accurately define these risks.
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Affiliation(s)
- Chris Varghese
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, New Zealand. https://twitter.com/chrisvarghese98
| | - Cameron Iain Wells
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, New Zealand. https://twitter.com/drcamwells
| | - Shiela Lee
- HPB and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Samir Pathak
- Department of Oncology and Surgery, St James Hospital, Leeds, UK. https://twitter.com/Drsampathak
| | - Ajith K Siriwardena
- Department of Hepatobiliary Surgery, Manchester Royal Infirmary, Manchester, UK
| | - Sanjay Pandanaboyana
- HPB and Transplant Unit, Freeman Hospital, Newcastle Upon Tyne, UK; Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK.
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12
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Nguyen TK, Luong TH, Nguyen NC, Nguyen HH, Le VK, Trinh HS, Do HD, Le VD, Nguyen NH. Hepatic lymphorrhea following pancreaticoduodenectomy: Preliminary diagnosis and treatment experience from case series of four patients. Ann Med Surg (Lond) 2021; 68:102648. [PMID: 34386232 PMCID: PMC8346360 DOI: 10.1016/j.amsu.2021.102648] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction Hepatic lymphorrhea (HL) is an uncommon but potentially life-threatening type of postoperative lymphatic leakage, especially following pancreaticoduodenectomy. Case presentation We herein report a case series of four patients with HL following pancreaticoduodenectomy that presented to the department with a severe clinical picture with the discovery in imaging and intraperitoneal fluid's tests. All our patients presented with a condition of Hepatic lymphorrhea secondary to pancreaticoduodenectomy, which were treated successfully with percutaneous hepatic lymphangiography (HLG). Discussion Hepatic lymphorrhea is an uncommon but potentially life-threatening complication following pancreaticoduodenectomy. Periportal lymphatic vessels, which was often isolated and dissected especially with extended lymphadenectomy, is potentially damaged and caused resistant chylous leakage. Newly techniques are updated and applied in diagnosis and treatment for this difficult-to-treat complication, one of them is percutaneous Hepatic Lymphangiography (HLG). Conclusion HLG with percutaneous access could be effective to identify and terminate the chylous fistula from periportal lymphatic vessels after pancreaticoduodenectomy.
Hepatic lymphorrhea is a rare, life-threatening complication of pancreaticoduodenectomy. Periportal lymphatic vessels was a potential location of lymphatic fistula and leakage. This complication can be diagnosed with imaging and intraperitoneal fluid's tests. Hepatic lymphangiography is a minor-invasive therapy to close the lymphatic fistula.
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Affiliation(s)
- Thanh Khiem Nguyen
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Bach Mai Hospital, Hanoi, Viet Nam
| | - Tuan Hiep Luong
- Department of Surgery, Hanoi Medical University, Hanoi, Viet Nam
| | - Ngoc Cuong Nguyen
- Department of Diagnostic and Interventional Radiology, Hospital of Hanoi Medical University, Hanoi, Viet Nam
| | - Ham Hoi Nguyen
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Bach Mai Hospital, Hanoi, Viet Nam
| | - Van Khang Le
- Department of Diagnostic and Interventional Radiology, Bach Mai Hospital, Hanoi, Viet Nam
| | - Hong Son Trinh
- Department of Oncology, Viet Duc University Hospital, Hanoi, Viet Nam
| | - Hai Dang Do
- Department of Surgery, Hanoi Medical University, Hanoi, Viet Nam
| | - Van Duy Le
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Bach Mai Hospital, Hanoi, Viet Nam
| | - Ngoc Hung Nguyen
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Bach Mai Hospital, Hanoi, Viet Nam
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13
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Sakamoto T, Okui N, Suzuki F, Hamura R, Shirai Y, Haruki K, Furukawa K, Ikegami T. Daily Triglyceride Output Volume as an Early Predictor for Chyle Leak Following Pancreaticoduodenectomy. In Vivo 2021; 35:1271-1276. [PMID: 33622930 DOI: 10.21873/invivo.12378] [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: 01/13/2021] [Revised: 01/30/2021] [Accepted: 02/01/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Useful prophylaxes of chyle leak (CL) after pancreatic surgery have not been established. The aim of the study was to identify an early clinical predictor for CL. PATIENTS AND METHODS Fifty-five patients who underwent subtotal stomach preserved pancreaticoduodenectomy (SSPPD) were included. Clinical factors associated with postoperative CL were evaluated. RESULTS Eleven patients (20%) developed a CL after SSPPD. Shorter operative time, absent pancreatic fistula, and triglyceride output volume at postoperative day (POD) two were independent risk factors for CL. The receiver operating characteristics curve of the daily triglyceride output volume at POD two indicated a cut-off point of 177 mg (AUC=0.782; p=0.004; 95% CI=0.639-0.925). CL was significantly associated with prolonged postoperative hospital stay in patients who did not develop a pancreatic fistula (p=0.003). CONCLUSION Daily triglyceride output volume of >177 mg at POD two may be a predictor of CL following pancreaticoduodenectomy.
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Affiliation(s)
- Taro Sakamoto
- Division of Digestive Surgery, Saku Central Hospital Advanced Care Center, Saku, Japan;
| | - Norimitsu Okui
- Division of Digestive Surgery, Saku Central Hospital Advanced Care Center, Saku, Japan
| | - Fumitake Suzuki
- Division of Digestive Surgery, Saku Central Hospital Advanced Care Center, Saku, Japan
| | - Ryoga Hamura
- Division of Digestive Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshihiro Shirai
- Division of Digestive Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Koichiro Haruki
- Division of Digestive Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Kenei Furukawa
- Division of Digestive Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Toru Ikegami
- Division of Digestive Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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De Luis Román D, Domínguez Medina E, Molina Baena B, Matía-Martín P. Oligomeric Formulas in Surgery: A Delphi and Consensus Study. Nutrients 2021; 13:nu13061922. [PMID: 34205024 PMCID: PMC8227417 DOI: 10.3390/nu13061922] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 05/28/2021] [Accepted: 05/29/2021] [Indexed: 01/04/2023] Open
Abstract
Nutritional management of patients with intestinal failure often includes the use of oligomeric formulas. Implementing the use of oligomeric formulas in surgical patients with maldigestion or malabsorption could be a nutritional strategy to be included in clinical protocols. We aim to generate knowledge from a survey focused on the effectiveness of nutritional therapy with oligomeric formulas with Delphi methodology. Each statement that reached an agreement consensus among participants was defined as a median consensus score ≥7 and as an interquartile range ≤3. The use of oligomeric formulas in surgical patients, starting enteral nutrition in the post-operative phase in short bowel syndrome and in nonspecific diarrhea after surgical procedures, could improve nutritional therapy implementation. Stakeholders agreed that early jejunal enteral nutrition with oligomeric formula is more effective compared to intravenous fluid therapy and it is useful in patients undergoing upper gastro-intestinal tract major surgery when malabsorption or maldigestion is suspected. Finally, oligomeric formulas may be useful when a feeding tube is placed distally to the duodenum. This study shows a practical approach to the use of oligomeric formulas in surgical patients with intestinal disorders and malabsorption, and it helps clinicians in the decision-making process.
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Affiliation(s)
- Daniel De Luis Román
- Center of Investigation Endocrinology and Nutrition, Hospital Clínico Universitario de Valladolid, Medicine School University, 47002 Valladolid, Spain;
| | - Eduardo Domínguez Medina
- Center for Research in Molecular Medicine and Chronic Diseases (CiMUS), 15782 Santiago de Compostela, Spain;
| | | | - Pilar Matía-Martín
- Endocrinology and Nutrition Unit, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
- Correspondence: ; Tel.: +34-639851411
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15
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Successful minimal invasive treatment of chylous ascites following pancreaticoduodenectomy: A case report and review of literature. Ann Med Surg (Lond) 2021; 66:102451. [PMID: 34141422 PMCID: PMC8188255 DOI: 10.1016/j.amsu.2021.102451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/18/2021] [Accepted: 05/23/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction Chylous ascites is an uncommon but potentially life-threatening type of postoperative lymphatic leakage, especially following pancreaticoduodenectomy. Case presentation A 59-year-old man underwent pancreaticoduodenectomy (PD) with extended lymphadenectomy and segmental Superior Mesenteric Vein (SMV) resection for SMV-involved pancreatic ductal adenocarcinoma (PDAC). After 20th postoperative day, patient had a drain output with a milky appearance, and with a triglyceride level was 1.6 mmol/L, and the daily output volume was up to 1500 mL per day. She has been performed Conventional Lymphangiography (CLAG) to identify the broken lymphatic vessels as well as close the leakage. Following two consecutive lymphangiography, the source of chylous leakage was identified from hilar lymphatic system, and injection of Aetoxisclerol 2% into lymphatic vessels to close the leakage was performed. Partial parenteral nutrition with limited fat components or medium-chain triglyceride (MCT) was administered, and the amount of ascites decreased particularly. The drain was removed in 20th day after the second CLAG. He had no symptoms of abdominal distention after drain removal and had been discharged after 37 postoperative days (PODs). Discussion Chylous ascites is an uncommon but potentially life-threatening complication following pancreaticoduodenectomy. Portal lymphatic plexus, which was often isolated and dissected especially with extended lymphadenectomy, is potentially damaged and caused resistant chylous leakage. Newly techniques are updated and applied in diagnosis and treatment for this difficult-to-treat complication, one of them is percutaneous transhepatic Conventional Lymphangiography (CLAG). Conclusion CLAG with percutaneous transhepatic access could be effective to identify and terminate the chylous fistula from portal lymphatic plexus after pancreaticoduodenectomy.
Chylous ascites is a potentially life-threatening type of lymphatic leakage, following pancreaticoduodenectomy. Portal lymphatic plexus was a potential location of lymphatic fistula due to the regularity of isolation and dissection in pancreaticoduodenectomy with extended lymphadenectomy. Conventional Lymphangiography (CLAG) is an invasion to identify the broken lymphatic vessels and close the leakage. Percutaneous transhepatic CLAG is a technique to puncture the portal lymphatic vessels, which could not be approached with other methods.
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16
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Postoperative chyle leak after pancreatic surgery - Is treatment effective? J Visc Surg 2021; 159:194-200. [PMID: 34023249 DOI: 10.1016/j.jviscsurg.2021.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
PURPOSE With increasing soft tissue clearance in pancreatic cancer surgery, postoperative chyle leak (CL) has become a more commonly observed complication. Recently, a new consensus definition was established by the International study group of pancreatic surgery (ISGPS). The aim of the present analysis was to evaluate risk factors and treatment options of patients with CL after pancreatic surgery. METHODS Two hundred and twenty-eight patients with serous or chylous drainage after pancreatic surgery were included in this analysis of a prospectively collected database between 01/2014 and 12/2016. Risk factors for CL and treatment options were compared. A subgroup analysis on those patients, who had drain removal despite of persistent CL with respect to the need of subsequent percutaneous drainage or reoperation within three months postoperatively, was performed. RESULTS Sixty patients with CL were identified. Of those, 41 patients were treated with medium-chain triglyceride-diet, with a median duration of therapy of 12 days. In patients with CL, the type of treatment had no effect on time to drain removal (P=0.29) and morbidity (P=0.15). Furthermore, morbidity was not increased in patients who had their drains removed despite persistent CL (P=0.84). None of the latter patients had percutaneous drainage or reoperation for CL after removal of the surgical drains. CONCLUSIONS Dietary treatment may not be very effective in treating CL. Further research is warranted to explore the effect and necessity of CL treatment.
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Russell T, Tanase A, Bowles M, Briggs C, Kanwar A, Stell D, Aroori S. Chyle leak following pancreatico-duodenectomy: a tertiary hepatopancreaticobiliary unit's experience and a proposed management algorithm. ANZ J Surg 2021; 91:355-360. [PMID: 33459512 DOI: 10.1111/ans.16535] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Chyle leak (CL) is an uncommon complication of pancreatico-duodenectomy (PD). Its incidence, risk factors, and effect on prognosis are not well described and optimum management remains debated. This study aims to calculate incidence of CL following PD and identify risk factors. Following a literature review, we have proposed a management algorithm. METHODS This is a retrospective review of all patients who underwent PD between January 2006 and April 2020 at a tertiary hepatopancreaticobiliary unit in the UK. The following data were obtained: age, gender, American Society of Anesthesiologists grade, body mass index, co-morbidities, duration of surgery, tumour histology, length of stay and mortality. RESULTS A total of 560 patients were included. Seventeen developed CL (3.04%). Median age was 64 years (range 50-81). Sixteen (94.1%) patients still had their surgical drain in at the time of CL diagnosis. One (5.9%) did not and had free intra-abdominal fluid on computed tomography; a diagnosis was made after an ultrasound-guided drain had been inserted. CL patients were more likely to have higher body mass index (mean 30.5 kg/m2 (range 17-43) versus 26.7 kg/m2 (22-38)) (P = 0.02) and longer duration of operation (mean 6.2 h (range 4.3-9.0) versus 5.6 (3.0-11.0)) (P = 0.03). All cases of CL resolved without operative intervention. CL did not affect length of stay (median 10 days (range 4-41) versus 11 (4-34)). CONCLUSIONS In our series, 3.04% of patients who underwent PD developed CL. No patients required a return to theatre, and none had CL recurrence.
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Affiliation(s)
- Thomas Russell
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Andrei Tanase
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Matthew Bowles
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Christopher Briggs
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Aditya Kanwar
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - David Stell
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Somaiah Aroori
- Department of HPB Surgery, University Hospitals Plymouth NHS Trust, Plymouth, UK
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18
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Shyr BU, Shyr BS, Chen SC, Shyr YM, Wang SE. Chyle leakage after robotic and open pancreaticoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:273-279. [PMID: 31971351 DOI: 10.1002/jhbp.716] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 01/04/2020] [Accepted: 01/10/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Chyle leakage is a well-known but poorly characterized complication after pancreaticoduodenectomy (PD). No study examined the chyle leakage after robotic PD (RPD). METHODS Data regarding chyle leakage were prospectively collected and analyzed from patients undergoing RPD or open PD (OPD). RESULTS The study included 118 RPD and 165 OPD. Overall chyle leakage rate was 12.0%, with 13.6% for RPD and 10.9% for OPD. Chyle leakage was eventually resolved in all patients through conservative treatment. The drainage volumes were significantly higher in chyle leakage group from postoperative days (PODs) 1-7, with a median of 240 mL on POD 1 and POD 7, as compared to 160 mL on POD 1 and 70 mL on POD 7 for those without chyle leakage. The number of lymph nodes involved and resected and pancreatic head adenocarcinoma affected the risk of developing chyle leakage, whereas the surgical approach used (RPD or OPD) did not. CONCLUSIONS Chyle leakage after PD is not rare, and it can eventually be resolved through conservative treatment. The extent and radicality of the surgery probably have a significant effect on the risk of developing chyle leakage, but the surgical approach used does not.
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Affiliation(s)
- Bor-Uei Shyr
- Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - Bor-Shiuan Shyr
- Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - Shih-Chin Chen
- Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - Yi-Ming Shyr
- Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - Shin-E Wang
- Department of Surgery, Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
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19
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Chen Z, Zhang Z, Lin B, Feng W, Meng F, Shi X. Relationship Between Early Oral Intake Post Pancreaticoduodenectomy and Chyle Leakage: A Retrospective Cohort Study. J INVEST SURG 2019; 34:575-582. [PMID: 31533484 DOI: 10.1080/08941939.2019.1663378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Early oral intake is strongly recommended according to the enhanced recovery after surgery (ERAS) guidelines because it can reduce complications and improve recovery. However, early oral intake has been indicated to be associated with chyle leakage (CL) after pancreatic surgery, which may lead to worsening of existing malnutrition and impeded recovery. This study investigated the relationship between early oral intake and CL and identified risk factors for CL to reduce its occurrence and promote recovery after pancreaticoduodenectomy. MATERIALS AND METHODS All patients who underwent pancreaticoduodenectomy between June 2014 and June 2018 were identified retrospectively. Patients were divided into the early-oral-intake and control groups according to whether they had early oral intake according to ERAS protocols. CL and other clinicopathological characteristics were recorded. Univariable and multivariable analyses assessed CL risk factors. RESULTS Early oral intake improved recovery, leading to a shorter postoperative hospital stay for the early-oral-intake group in comparison to that of the control group [13.6 (range, 12-68) vs. 17.8 (range, 14-83) days; p = 0.047] without increasing the incidence of CL and other complications. CL was diagnosed significantly earlier in the early-oral-intake group than in the control group [4.6 (range 3-5) vs. 6.7 (range 3-9) days; p = 0.001]. Early oral intake did not increase the grade severity (p = 0.845) or the costs (p = 0.241) or prolong postoperative hospital stays (p = 0.611). A primary diagnosis of malignancy, para-aortic lymph node dissection, lymphatic invasion, lymph node metastases, the number of harvested nodes, and the number of positive nodes were significantly associated with CL (p < 0.05), whereas early oral intake was not (p = 0.525). Multivariate analyses demonstrated that para-aortic lymph node dissection (p = 0.039) and the number of harvested nodes (p = 0.001) were independent risk variables. CONCLUSION This study provides significant evidence that early oral intake after pancreaticoduodenectomy is not associated with CL. The identification of the independent risk factors for CL can help prevent it.
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Affiliation(s)
- Zheng Chen
- Department of General Surgery, The Affiliated Suqian Hospital of Xuzhou Medical University, Suqian, China.,Suqian People's Hospital of Nanjing Drum Tower Hospital Group, Suqian, China
| | - Zhen Zhang
- Suqian People's Hospital of Nanjing Drum Tower Hospital Group, Suqian, China.,Department of Anesthesiology, The Affiliated Suqian Hospital of Xuzhou Medical University, Suqian, China
| | - Bin Lin
- Department of General Surgery, The Affiliated Suqian Hospital of Xuzhou Medical University, Suqian, China.,Suqian People's Hospital of Nanjing Drum Tower Hospital Group, Suqian, China
| | - Wei Feng
- Department of General Surgery, The Affiliated Suqian Hospital of Xuzhou Medical University, Suqian, China.,Suqian People's Hospital of Nanjing Drum Tower Hospital Group, Suqian, China
| | - Fanlai Meng
- Suqian People's Hospital of Nanjing Drum Tower Hospital Group, Suqian, China.,Department of Pathology, The Affiliated Suqian Hospital of Xuzhou Medical University, Suqian, China
| | - Xin Shi
- Department of General Surgery, The Affiliated Suqian Hospital of Xuzhou Medical University, Suqian, China.,Suqian People's Hospital of Nanjing Drum Tower Hospital Group, Suqian, China
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20
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Limketkai BN, Shah ND, Sheikh GN, Allen K. Classifying Enteral Nutrition: Tailored for Clinical Practice. Curr Gastroenterol Rep 2019; 21:47. [PMID: 31368086 DOI: 10.1007/s11894-019-0708-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW To discuss the different forms of enteral nutrition, while outlining available evidence for its use in specific conditions and how enteral nutrition composition may or may not influence relevant outcomes. RECENT FINDINGS Enteral nutrition formulas were originally conceived as a liquid form of nutrition for individuals who otherwise could not consume adequate calories through solid food. Over time, the emergence of specialty formulas marketed to benefit specific diseases or conditions has led to a broad range of potentially confusing options. While most options have theoretical benefit for their marketed conditions, the evidence demonstrating practical benefit is not consistent. Overall, the certainty of evidence for specialty formulas remains low or very low. In most instances, one could begin with standard polymeric formula, except in cases where disease-specific formulas are recommended. Much research is nonetheless still needed to clarify whether some disease-specific formulas are truly beneficial or merely theoretical features.
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Affiliation(s)
- Berkeley N Limketkai
- Vatche and Tamar Manoukian Division of Digestive Diseases, UCLA School of Medicine, 100 Medical Center Drive, Suite 345, Los Angeles, CA, 90095, USA.
| | - Neha D Shah
- Comprehensive Cancer Center, Stanford Health Care, Palo Alto, CA, USA
| | - Ghias N Sheikh
- Department of Medicine, University of Oklahoma College of Medicine, Oklahoma City, OK, USA
| | - Karen Allen
- Section of Pulmonary, Critical Care & Sleep Medicine, Veterans Affairs Hospital and University of Oklahoma College of Medicine, Oklahoma City, OK, USA
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Singh H, Pandit N, Krishnamurthy G, Gupta R, Verma GR, Singh R. Management of chylous ascites following pancreaticobiliary surgery. JGH OPEN 2019; 3:425-428. [PMID: 31633049 PMCID: PMC6788374 DOI: 10.1002/jgh3.12179] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 03/02/2019] [Accepted: 03/09/2019] [Indexed: 02/06/2023]
Abstract
Background Chyle leak is an uncommon form of ascites occurring due to the accumulation of lipid‐rich lymph into the peritoneal cavity. Traumatic injury to the lymphatic system due to pancreaticobiliary surgery can lead to this phenomenon. Method We retrospectively evaluated the data of 159 patients of pancreticobiliary surgery from January 2012 to December 2016. Five patients (5/137, 3.6%) sustained a chylous leak following pancreaticoduodenectomy and one patient (1/22, 4.5%) sustained a chylous leak following Roux‐en‐Y hepaticojejunostomy for postcholecystectomy biliary stricture. Results Average daily output was 441 mL (range: 150–800 mL/day), and total duration of output was 16.5 days (range: 4–35 days). Mean hospital stay increased to 19.1 days (range: 10–40 days). All the patients were successfully managed conservatively with a combination of customized enteral feeds, supplemental parenteral nutrition, and octreotide. One patient required additional percutaneous drainage. Conclusion Chyle leak can be successfully treated with conservative management but at the cost of increased hospital stay.
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Affiliation(s)
- Harjeet Singh
- Department of General Surgery Post Graduate Institute of Medical Education and Research (PGIMER) Chandigarh India
| | - Narendra Pandit
- Department of General Surgery Post Graduate Institute of Medical Education and Research (PGIMER) Chandigarh India
| | - Gautham Krishnamurthy
- Department of General Surgery Post Graduate Institute of Medical Education and Research (PGIMER) Chandigarh India
| | - Rajesh Gupta
- Department of General Surgery Post Graduate Institute of Medical Education and Research (PGIMER) Chandigarh India
| | - Ganga R Verma
- Department of General Surgery Post Graduate Institute of Medical Education and Research (PGIMER) Chandigarh India
| | - Rajinder Singh
- Department of General Surgery Post Graduate Institute of Medical Education and Research (PGIMER) Chandigarh India
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Paiella S, De Pastena M, Casciani F, Pan TL, Bogoni S, Andrianello S, Marchegiani G, Malleo G, Bassi C, Salvia R. Chyle leak after pancreatic surgery: validation of the International Study Group of Pancreatic Surgery classification. Surgery 2018; 164:450-454. [PMID: 29958728 DOI: 10.1016/j.surg.2018.05.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 04/08/2018] [Accepted: 05/08/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chyle leak is an uncommon complication after pancreatic surgery. The chyle leak incidence, definition, diagnosis, and treatment had been reported heterogeneously so far. Recently a consensus definition and grading system was published by the International Study Group for Pancreatic Surgery. This study aims to evaluate the differences in the clinical and economic burden of chyle leak applying the new definition. METHODS All data from patients who underwent pancreatic surgery for any disease from January 2014 to December 2016 were retrieved from the institutional prospective database. The 2017 International Study Group for Pancreatic Surgery definition and classification were applied. The classification was validated analyzing the differences in major complications, length of stay, and hospitalization costs. RESULTS A total of 945 patients was the final population. A chyle leak was reported in 43 patients (4.5%). Grade A chyle leak occurred in 10 patients (23.3%), Grade B chyle leak in 31 patients (72.1%), and Grade C chyle leak in 2 patients (4.6%). Chyle leak occurred as unique postoperative complication in 29 cases (67.4%). The economic analysis showed that the average costs of the 3 grades were 2,806, 7,150 and 15,684 euros respectively (P < .001). Furthermore, the length of stay, the rates of septic events, and major complications were significantly different among the 3 grades (P = .008, P = .004, and P < .001, respectively). Of note, we did not find any intraoperative factor associated with chyle leak. CONCLUSION The present study confirms the validity of the International Study Group for Pancreatic Surgery classification of chyle leak. The 3 grades of chyle leak proposed identify reliably clinical and economical differences among the chyle leak cases.
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Affiliation(s)
- Salvatore Paiella
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Verona, Italy.
| | - Matteo De Pastena
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Verona, Italy
| | - Fabio Casciani
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Verona, Italy
| | - Teresa Lucia Pan
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Verona, Italy
| | - Selene Bogoni
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Verona, Italy
| | - Stefano Andrianello
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Verona, Italy
| | - Giovanni Marchegiani
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Verona, Italy
| | - Giuseppe Malleo
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Verona, Italy
| | - Claudio Bassi
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Verona, Italy
| | - Roberto Salvia
- General and Pancreatic Surgery Unit, Pancreas Institute, University of Verona, Policlinico GB Rossi, Verona, Italy
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The TRIANGLE operation - radical surgery after neoadjuvant treatment for advanced pancreatic cancer: a single arm observational study. HPB (Oxford) 2017; 19:1001-1007. [PMID: 28838632 DOI: 10.1016/j.hpb.2017.07.007] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 07/21/2017] [Accepted: 07/29/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Neoadjuvant therapy is an important strategy for locally advanced pancreatic cancer (PDAC) as resection rates increase with modern chemotherapy regimens even in patients with arterial tumor encasement. The aim of this study is the description of technique and initial outcomes of a new type of radical and arterial-sparing resection after neoadjuvant treatment for locally advanced PDAC. METHODS The surgical technique and perioperative results of a new type of operation are described, comprising radical tumor removal by sharp dissection along the celiac axis and the superior mesenteric artery with complete dissection of all soft tissue between both - arteries and superior mesenteric/portal vein (TRIANGLE operation). RESULTS 15 patients underwent artery-preserving tumor removal without mortality, 7/15 patients showed postoperative complications and an R0 resection was achieved in 6/15 patients. Functional outcome was good in 11/15 patients despite the extended approach of dissection. CONCLUSION After neoadjuvant therapy for locally advanced PDAC, surgical exploration should be attempted in patients with stable disease or remission to clarify true vascular infiltration. In case of absent viable tumor, the described technique allows to perform radical surgery without arterial resection in this subgroup of patients.
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Implementation and Evaluation of a Clinical Pathway for Pancreaticoduodenectomy Procedures: a Prospective Cohort Study. J Gastrointest Surg 2017; 21:1428-1441. [PMID: 28589299 DOI: 10.1007/s11605-017-3459-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 05/16/2017] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Medical and nursing protocols in perioperative care for pancreaticoduodenectomy are mainly mono-disciplinary, limiting their integration and transparency in a continuous health care system. The aims of this study were to evaluate adherence to a multidisciplinary clinical pathway for all pancreaticoduodenectomy patients during their entire hospital stay and to determine if the use of this clinical pathway is associated with beneficial effects on clinical end points. MATERIALS AND METHODS A prospective cohort study was conducted in 95 pancreaticoduodenectomy patients treated according to a clinical pathway, including a variance report, compared to a historical control group (n = 52) with a traditional treatment regime. RESULTS Process evaluation of the clinical pathway group revealed that protocol adherence throughout all units was above 80%. Major complications according to Clavien-Dindo classification grade ≥3 decreased from 27 to 13%; p = 0.02. Hospital length of stay was significantly shorter in the clinical pathway group, median 10 days [IQR 8-15], compared with the control group, median 13 days [IQR 10-18]; p = 0.02. CONCLUSION The use of a clinical pathway in pancreaticoduodenectomy patients was associated with high protocol adherence, improved outcome and shorter hospital length of stay. Variance report analysis and protocol adherence with a Prepare-Act-Reflect Cycle are essential in surveillance of outcome.
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Besselink MG, van Rijssen LB, Bassi C, Dervenis C, Montorsi M, Adham M, Asbun HJ, Bockhorn M, Strobel O, Büchler MW, Busch OR, Charnley RM, Conlon KC, Fernández-Cruz L, Fingerhut A, Friess H, Izbicki JR, Lillemoe KD, Neoptolemos JP, Sarr MG, Shrikhande SV, Sitarz R, Vollmer CM, Yeo CJ, Hartwig W, Wolfgang CL, Gouma DJ. Definition and classification of chyle leak after pancreatic operation: A consensus statement by the International Study Group on Pancreatic Surgery. Surgery 2017; 161:365-372. [PMID: 27692778 DOI: 10.1016/j.surg.2016.06.058] [Citation(s) in RCA: 244] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 06/22/2016] [Accepted: 06/22/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Recent literature suggests that chyle leak may complicate up to 10% of pancreatic resections. Treatment depends on its severity, which may include chylous ascites. No international consensus definition or grading system of chyle leak currently is available. METHODS The International Study Group on Pancreatic Surgery, an international panel of pancreatic surgeons working in well-known, high-volume centers, reviewed the literature and worked together to establish a consensus on the definition and classification of chyle leak after pancreatic operation. RESULTS Chyle leak was defined as output of milky-colored fluid from a drain, drain site, or wound on or after postoperative day 3, with a triglyceride content ≥110 mg/dL (≥1.2 mmol/L). Three different grades of severity were defined according to the management needed: grade A, no specific intervention other than oral dietary restrictions; grade B, prolongation of hospital stay, nasoenteral nutrition with dietary restriction, total parenteral nutrition, octreotide, maintenance of surgical drains, or placement of new percutaneous drains; and grade C, need for other more invasive in-hospital treatment, intensive care unit admission, or mortality. CONCLUSION This classification and grading system for chyle leak after pancreatic resection allows for comparison of outcomes between series. As with the other the International Study Group on Pancreatic Surgery consensus statements, this classification should facilitate communication and evaluation of different approaches to the prevention and treatment of this complication.
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Affiliation(s)
- Marc G Besselink
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - L Bengt van Rijssen
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Claudio Bassi
- Department of Surgery and Oncology, Pancreas Institute, University of Verona, Verona, Italy
| | | | - Marco Montorsi
- Department of Surgery, Humanitas Research Hospital and University, Milan, Italy
| | - Mustapha Adham
- Department of HPB Surgery, Hopital Edouard Herriot, HCL, UCBL1, Lyon, France
| | | | - Maximillian Bockhorn
- Department of General-, Visceral-, and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Oliver Strobel
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Olivier R Busch
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Richard M Charnley
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Kevin C Conlon
- Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland
| | - Laureano Fernández-Cruz
- Department of Surgery, Clinic Hospital of Barcelona, University of Barcelona, Barcelona, Spain
| | - Abe Fingerhut
- First Department of Digestive Surgery, Hippokrateon Hospital, University of Athens, Athens, Greece; Section for Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Jakob R Izbicki
- Department of General-, Visceral-, and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital and the Harvard Medical School, Boston, MA
| | - John P Neoptolemos
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Michael G Sarr
- Division of Subspecialty General Surgery, Mayo Clinic, Rochester, MN
| | | | - Robert Sitarz
- Department of Surgical Oncology, Medical University in Lublin, Poland
| | - Charles M Vollmer
- Department of Surgery, Penn Medicine, The University of Pennsylvania, Philadelphia, PA
| | - Charles J Yeo
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - Werner Hartwig
- Division of Pancreatic Surgery, Department of General, Visceral, and Transplantation Surgery, Ludwig Maximilians University, University of Munich, Germany
| | | | - Dirk J Gouma
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Strobel O, Brangs S, Hinz U, Pausch T, Hüttner FJ, Diener MK, Schneider L, Hackert T, Büchler MW. Incidence, risk factors and clinical implications of chyle leak after pancreatic surgery. Br J Surg 2016; 104:108-117. [DOI: 10.1002/bjs.10316] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 05/03/2016] [Accepted: 07/11/2016] [Indexed: 12/19/2022]
Abstract
Abstract
Background
Chyle leak is a well known but poorly characterized complication after pancreatic surgery. Available data on incidence, risk factors and clinical significance of chyle leak are highly heterogeneous.
Methods
For this cohort study all patients who underwent pancreatic surgery between January 2008 and December 2012 were identified from a prospective database. Chyle leak was defined as any drainage output with triglyceride content of 110 mg/dl or more. Risk factors for chyle leak were assessed by univariable and multivariable analyses. The clinical relevance of chyle leak was evaluated using hospital stay and resolution by 14 days for short-term outcome and overall survival for long-term outcome.
Results
Chyle leak developed in 346 (10·4 per cent) of 3324 patients. Pre-existing diabetes, resection for malignancy, distal pancreatectomy, duration of surgery 180 min or longer, and concomitant pancreatic fistula or abscess were independent risk factors for chyle leak. Both isolated chyle leak and coincidental chyle leak (with other intra-abdominal complications) were associated with prolonged hospital stay. Some 178 (87·7 per cent) of 203 isolated chyle leaks and 90 (70·3 per cent) of 128 coincidental chyle leaks resolved with conservative management within 14 days. Initial and maximum drainage volumes were associated with duration of hospital stay and success of therapy by 14 days. Impact on survival was restricted to chyle leaks that persisted at 14 days in patients with cancer undergoing palliative surgery.
Conclusion
Chyle leak is a relevant complication, with an incidence of more than 10 per cent after pancreatic surgery, and has a major impact on hospital stay. Drainage volume is associated with hospital stay and success of therapy.
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Affiliation(s)
- O Strobel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - S Brangs
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - U Hinz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - T Pausch
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - F J Hüttner
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - M K Diener
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - L Schneider
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - T Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - M W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
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Manual Lymph Drainage and Fascial Release for the Treatment of Chylous Ascites Following Radical Nephrectomy: A Case Report. REHABILITATION ONCOLOGY 2016. [DOI: 10.1097/01.reo.0000000000000023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Low fat-containing elemental formula is effective for postoperative recovery and potentially useful for preventing chyle leak during postoperative early enteral nutrition after esophagectomy. Clin Nutr 2016; 35:1423-1428. [PMID: 27071696 DOI: 10.1016/j.clnu.2016.03.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 03/08/2016] [Accepted: 03/23/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND AIMS Transthoracic esophagectomy using 3-field lymphadenectomy (TTE-3FL) for esophageal cancer is one of the most aggressive gastrointestinal surgeries. Early enteral nutrition (EN) for TTE-3FL patients is useful and valid for early recovery; however, EN using a fat-containing formula risks inducing chyle leak. In the present study, we retrospectively examined esophageal cancer patients treated byTTE-3FL and administered postoperative EN to elucidate the validity of lowering the fat levels in elemental formulas to prevent postoperative chyle leak and improve postoperative recovery. METHODS A total of 74 patients who received TTE-3FL for esophageal cancer were retrospectively examined. Patients were classified into two groups according to the type of postoperative EN: Group LF patients received a low-fat elemental formula, and Group F patients received a standard fat-containing polymeric formula. The following clinical factors were compared between the groups: EN start day, maximum EN calories administered, duration of respirator use, length of ICU stay, incidence of postoperative infectious complications, use of parenteral nutrition (PN), and incidence of postoperative chyle leak. RESULTS Patients in Group LF were started on EN significantly earlier after surgery and they consumed significantly higher maximum EN calories compared to Group F patients (P < 0.01). Duration of respirator use and length of ICU stay were also significantly shorter, and TPN was used significantly less in Group LF compared to Group F (P < 0.05). Postoperative chyle leak was observed in six patients in total (8.1%); five patients in Group F and one patient in Group LF, although there was no significant difference in frequency of chyle leak per patient between Group LF and Group F. CONCLUSIONS Early EN using low-fat elemental formula after esophagectomy with three-field lymphadenectomy was safe and valid for postoperative recovery and potentially useful in preventing chyle leak.
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Gerritsen A, Wennink RAW, Busch ORC, Borel Rinkes IHM, Kazemier G, Gouma DJ, Molenaar IQ, Besselink MGH. Feeding patients with preoperative symptoms of gastric outlet obstruction after pancreatoduodenectomy: Early oral or routine nasojejunal tube feeding? Pancreatology 2015; 15:548-553. [PMID: 26235830 DOI: 10.1016/j.pan.2015.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 07/03/2015] [Accepted: 07/05/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Early oral feeding is currently considered the optimal routine feeding strategy after pancreatoduodenectomy (PD). Some have suggested that patients with preoperative symptoms of gastric outlet obstruction (GOO) who undergo PD have such a high risk of developing delayed gastric emptying that these patients should rather receive routine postoperative tube feeding. The aim of this study was to determine whether clinical outcomes after PD in these patients differ between postoperative early oral feeding and routine tube feeding. METHODS We analyzed a consecutive multicenter cohort of patients with preoperative symptoms of GOO undergoing PD (2010-2013). Patients were categorized into two groups based on the applied postoperative feeding strategy (dependent on their center's routine strategy): early oral feeding or routine nasojejunal tube feeding. RESULTS Of 497 patients undergoing PD, 83 (17%) suffered from preoperative symptoms of GOO. 49 patients received early oral feeding and 29 patients received routine tube feeding. Time to resumption of adequate oral intake (primary outcome; 14 vs. 12 days, p = 0.61) did not differ between these two feeding strategies. Furthermore, overall complications and length of stay were similar in both groups. Of the patients receiving early oral feeding, 24 (49%) ultimately required postoperative tube feeding. In patients with an uncomplicated postoperative course, early oral feeding was associated with shorter time to adequate oral intake (8 vs. 12 days, p = 0.008) and shorter hospital stay (9 vs. 13 days, p < 0.001). CONCLUSION Also in patients with preoperative symptoms of GOO, early oral feeding can be considered the routine feeding strategy after PD.
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Affiliation(s)
- Arja Gerritsen
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Roos A W Wennink
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Olivier R C Busch
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Geert Kazemier
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Dirk J Gouma
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc G H Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
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