Biochemical Leak Research Articles

Primary delayed gastric emptying after pylorus-resecting pancreatoduodenectomy: A matched-pair comparison of Roux-en-Y vs. Billroth-II reconstruction

BackgroundAfter pylorus-resecting pancreatoduodenectomy (PrPD), delayed gastric emptying (DGE) might partially be attributed to biliary reflux. We investigated whether the incidence of primary DGE is reduced after Roux-en-Y instead of Billroth-II reconstruction. MethodsPatients undergoing PrPD from 2016 to 2019 at a high-volume center were identified. Excluding causes of secondary DGE, we matched patients with Roux-en-Y and Billroth-II reconstruction in a 1:2 ratio and compared primary DGE. ResultsIn 24 vs. 48 (Roux-en-Y vs. Billroth-II) patients, DGE (grade B/C) incidence (20.8 % vs. 18.8 %; P = 1.000), nasogastric tube requirement (median 2 vs. 2 days; P = 0.844) and time to solid food intake (7 vs. 7 days; P = 0.933) were comparable. Univariable logistic regression showed no association between DGE and Roux-en-Y reconstruction (OR 1.47; P = 0.524), in contrast to age (1.08; P = 0.030) and pancreatic biochemical leak (4.98; P = 0.007). ConclusionsPrimary DGE did not differ between Roux-en-Y and Billroth-II reconstruction after PrPD. Instead, age and postoperative pancreatic biochemical leak were associated with higher DGE risk.

Pancreatoduodenectomy with colon-last approach for advanced pancreatic head cancer.

Margin-negative surgery is very important in surgical oncology. Considering margin-negative pancreatectomy is known to be essential for cure of the pancreatic cancer, pancreatoduodenectomy with combined venous vascular or arterial resection can be a potential option for margin-negative resection, especially, in era of neoadjuvant treatment with potent systemic chemotherapy. To the contrary, special attention was not paid on combined colonic resection during PD. In this article, safe surgical technique for PD with combined colonic resection is introduced, under the name of PD with "colon-last" approach. At Severance Hospital (Yonsei University College of Medicine, Seoul, Republic of Korea), between 2014 and 2021, a total of six patients underwent PD with "colon-last" approach. The surgical technique and surgical outcome are reviewed. All patients recovered without major complications (Clavien-Dindo classification grade ≥ III) after surgery, and most of them recovered after conservative treatment with postoperative pancreatic fistula biochemical leak. None of the patients were readmitted. Only the first and second cases represent cancer-related mortality, and the other patients are still alive and are being followed up. It is hoped that the present technique, PD with colon-last approach, could be helpful enhance the procedural safety in treating advanced cancer requiring PD with combined colon resection. However, its technical safety and oncologic role should be validated by many pancreatic surgeons' collaborative studies in the near future.

Evaluation of Patients with Postoperative Pancreatic Fistula After Isolated Splenectomy: A Retrospective Study

Objective: Postoperative pancreatic fistula (POPF) is a potentially life-threatening complication. This complication occurs not only after pancreatic surgery but may also arise after other abdominal procedures. In this study, we aimed to determine the incidence and risk factors of POPF in patients undergoing isolated splenectomy. Methods: Patients who underwent isolated splenectomy were identified. POPF was defined according to the 2016 update of International Study Group of Pancreatic Fistula classification and graded as biochemical leak (BL), grade B fistula, and grade C fistula. Characteristics and perioperative variables were compared between patients who had pancreatic fistula and those who have not. Results: The study cohort consisted of 59 patients with median age 38.9 years, and 50.8% male. The indication was trauma in 18 (30.5%) patients. Twenty (33.9%) patients were operated upon emergently. Thirty-seven (62.7%) splenectomies were performed open. Out of all patients, 14 (23.7%) developed any sort of pancreatic fistula. BL occurred in 11 (18.6%) patients and 3 (5.1%) patients developed a grade B fistula. Comparison of patients with and without BL/POPF demonstrated no significant differences in demographics, surgical indication, operative method, surgical approach, or postoperative outcome. Conclusions: Despite higher incidence of pancreatic leak, the rate of clinically relevant fistula is relatively low. In this study, we did not identify any factors associated with BL/POPF. Thus, further studies are needed on pancreatic fistula after splenectomy.

Open distal pancreatectomy stump closure by linear stapling versus continuous suturing: a retrospective–prospective comparative study

BackgroundDistal pancreatectomy (DP), performed for removing pancreatic lesions located to the left of the superior mesenteric vein, accounts for ~25% of all pancreatic resections. Most recently reported overall mortality rate of DP is less than 3%. However, albeit technically simpler to perform than pancreaticoduodenectomy, morbidity rate of DP remains substantial. Postoperative pancreatic fistulas (POPFs), which may result in numerous clinically significant and potentially life-threatening complications such as intraabdominal abscess, hemorrhage, and surgical site infection, is the leading cause of morbidity after DP, with an incidence of ~30–60%. Risk factors associated with POPFs after DP include decreased serum albumin levels, concurrent splenectomy, increased body weight, increased duration of surgery, higher American Society of Anesthesiologists score, and impaired renal function. Furthermore, POPFs often translate to significant increases in hospitalization costs.ObjectiveTo compare the technique of DP stump closure in two groups of patients; a group underwent stump closure with linear stapling technique and the other group underwent stump closure with continuous suturing technique.Patients and methodsThis was a retrospective–prospective clinical trial that was conducted at General Surgery Department, Ain Shams University Hospitals on 30 patients who were admitted to specialized hepatobiliary units in Cairo, Egypt for open DP. Between January 2020 and June 2022 with postoperative follow-up period of 2 months. In our study, there were 30 patients (15 in the continuous suturing technique group and 15 in the linear stapling technique group) with a mean age of 45.37±10.662 years. Groups were similar in demographic and clinical characteristics (P>0.05).ResultsIn our study, 13.33% patients in continuous suturing technique group developed clinically relevant POPF (grade B and grade C POPF), whereas 33.33% patients in stapling technique group develop POPF (P=1.00).The amount of the blood loss which was found to be statistically significant as thePvalue was found less than 0.05 and thettest was found to be −2.396 which mean that the amount of the blood lost was more in the stapler group.There was no statistically significant difference in the rate of clinically relevant POPF (grade B and grade C POPF) with suture closure compared with stapler closure (13.33 vs. 33.33%).There was no statistically significant difference in the risk of intraabdominal abscess.There were three (20%) patients with a biochemical leak in continuous suturing technique group. In stapling technique group, three (20%) patients developed biochemical leaks. There was no significant in difference between groups in terms of biochemical leak.In our study, mortality rates did not differ between stapler and suture closure techniques.ConclusionOur study showed no significant difference between suture and stapler closure of DP stump with respect to POPF or intraabdominal collection after DP.The amount of the blood lost was more in the stapler group.

Is 3 weeks a proper time point for the diagnosis of grade B POPF after pancreaticoduodenectomy?

Background: In 2016, the International Study Group of Pancreatic Fistula (ISGPF) improved the definition of postoperative pancreatic fistula (POPF) which defines one of diagnostic criteria for progression of biochemical leak (BL) to grade B fistula as drain for more than 3 weeks. However, we found patients with BL after pancreaticoduodenectomy (PD) or laparoscopic pancreatoduodenectomy (LPD) in our medical center usually progressed to grade B fistula within 3 weeks, which is inconsistent with diagnostic criteria (more than 3 weeks) described in the guidelines. The objective of this study was to investigate the time point at which patients with BL progressed to grade B fistula after PD or LPD. Methods: We selected patients from June 2013 to October 2022 as the research subjects. We used a receiver operating characteristic (ROC) curve to calculate the cutoff value of the time point when BL progressed to grade B fistula. Results: The cutoff value of the time point at which BL progresses to grade B fistula was postoperative day (POD) 9.5. The sensitivity and specificity were 63.6% and 81.4%, respectively. Conclusion: The cutoff value of time point of BL progression to grade B fistula was 9.5, which indicated that we do not need to define grade B fistula as drain for more than 3 weeks. We considered that a too-late time point might delay the timely diagnosis and treatment of grade B fistula and further optimization of the definition of grade B fistula was necessary.

Postoperative infectious complications worsen oncologic outcomes following pancreaticoduodenectomy for pancreatic ductal adenocarcinoma.

Pancreaticoduodenectomy (PD) remains the only curative option for patients with pancreatic adenocarcinoma (PDAC). Infectious complications (IC) can negatively impact patient outcomes and delay adjuvant therapy in most patients. This study aims to determine IC effect on overall survival (OS) following PD for PDAC. Patients who underwent PD for PDAC between 2010 and 2020 were identified from a single institutional database. Patients were categorized into two groups based on whether they experienced IC or not. The relationship between postoperative IC and OS was investigated using Kaplan-Meier and Cox-regression multivariate analysis. Among 655 patients who underwent PD for PDAC, 197 (30%) experienced a postoperative IC. Superficial wound infection was the most common type of infectious complication (n = 125, 63.4%). Patients with IC had significantly more minor complications (Clavien-Dindo [CD] < 3; [59.4% vs. 40.2%, p < 0.001]), major complications (CD ≥ 3; [37.6% vs. 18.8%, p < 0.001]), prolonged LOS (47.2% vs 20.3%, p < 0.001), biochemical leak (6.1% vs. 2.8%, p = 0.046), postoperative bleeding (4.1% vs. 1.3%, p = 0.026) and reoperation (9.6% vs. 2.2%, p < 0.001). Time to adjuvant chemotherapy was delayed in patients with IC versus those without (10 vs. 8 weeks, p < 0.001). Median OS for patients who experienced no complication, noninfectious complication, and infectious complication was 33.3 months, 29.06 months, and 27.58 months respectively (p = 0.023). On multivariate analysis, postoperative IC were an independent predictor of worse OS (HR 1.32, p = 0.049). IC following PD for PDAC independently predict worse oncologic outcomes. Thus, efforts to prevent and manage IC should be a priority in the care of patients undergoing PD for PDAC.

Postoperative Hyperamylasemia (POH) is an Early Predictor of Pancreatic Fistula Occurrence and Severity after Distal Pancreatectomy: Results from a European Multicentric Study.

The aim of this international multicentric study is to characterize postoperative hyperamylasemia (POH) after distal pancreatectomy (DP), with particular focus on its relationship with postoperative pancreatic fistula (POPF) occurrence and severity. The clinical relevance of POH after DP and its relationship with the occurrence and severity of POPF have not been explored yet. All patients undergoing DP for any indication between 2015 and 2021 at three European referral Centers for pancreatic surgery were retrospectively analyzed. Drain fluid amylase (DFA), C-reactive protein (C-RP), and serum amylase were examined from postoperative-day (POD) 1 to 3. Biochemical leak (BL), POPF, POH, and post-pancreatectomy hemorrhage (PPH) were defined and graded according to ISGPS definitions. In total 1192 patients were included. Overall rates of POH and POPF were 18% (n= 210) and 29% (n= 344), respectively. The presence of DFA ≥2000 U/L on POD 1 (OR=2.11, 95% CI 1.68-2.86), C-RP ≥200 mg/L on POD 3 (OR=2.19, 95% CI 1.68-2.86), and POH (OR=1.58, 95% CI 1.14-2.19) were all independent early predictors of POPF (all P< 0.01). The presence of POH almost doubled the rate of POPF (43% vs. 26%, P<0.001), and higher POPF severity presented also higher POH rates (no POPF= 12%; BL= 19%; B POPF= 24%; C POPF= 52%). Among patients developing POPF, patients with POH had higher rates of PPH (22% vs 9%, P= 0.001), sepsis (24% vs 13%; P=0.011), re-operation (21% vs 8%; P< 0.01), and mortality (3% vs 0.3%; P= 0.025). The occurrence of POH is an early predictor of POPF and its severity after DP. The diagnosis of POH might define patients at higher risk for a complicated course, targeting them for prevention / mitigation strategies against pancreas specific complications.

Distal pancreatectomy.

Distal pancreatectomy is astandard surgical procedure for selected benign, premalignant, and malignant lesions localized in the pancreatic body or tail. Surgical resection remains the only curative option for patients diagnosed with adenocarcinoma of the pancreas. Perioperative and postoperative clinical courses were retrospectively assessed in patients, who underwent distal pancreatectomy during the 2011‒2021 period. During the 2011‒2021 period, atotal of 112 distal pancreatectomies were performed. 67 patients (59.8%) underwent laparoscopic distal pancreatectomy, and 45 patients (40.2%) open laparotomy. The conversion was necessary for 13 patients (11.6%). Distal pancreatectomies performed laparoscopically were associated more often with biochemical leak and the development of grade Bfistula, on the other hand grade Cfistula developed only in patients operated by open laparotomy (LPT). The mean operating time was slightly longer in the laparoscopic group (227.1 min vs 214.6 min). The mean estimated blood loss was significantly higher in the LPT group (540.4 ml vs 191.9 ml). The mean hospitalization time was slightly longer in the LPT group (11.8 days vs 9.3 days). The rates of early reoperations were comparable between both groups (6 vs 5). Laparoscopic techniques are preferred in centers around the world to bring patients benefits by using aminimally invasive approach. These techniques are also preferred in our center, in nearly 60% of all distal pancreatectomies performed during 10 years, but on the other hand, there is amuch more careful approach chosen in cases of malignant disease to achieve adequate radicality (Tab.4, Ref. 20).

Outcomes of Pancreatic Fistula After Pancreaticoduodenectomy

Background: The occurrence of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) is a major contributor to morbidity and mortality. Hence, it is imperative to decrease the occurrence of clinically significant POPF to enhance the overall morbidity outcomes associated with PD. This study seeks to assess the outcomes of pancreatic fistula following PD. Methods: This study was a combined prospective and retrospective analysis of patients who underwent PD at Al-Thawra Modern General Hospital between January 2016 and April 2021. A total of 42 patients were included in the analysis. Results: Among the 42 patients who underwent PD, 40% were male and 60% were female. The age distribution showed that 5% of patients were under 20, 14% were between 20 and 40, and 81% were above 40. The primary indications for PD were malignant periampullary tumors in 83.3% of patients, solid pseudopapillary tumors of the pancreas in 7.1% of patients, chronic pancreatitis in 4.76% of patients, duodenal adenocarcinoma in 2.38% of patients, and trauma in 2.38% of patients. Among the patients, 30 (71.43%) had a successful recovery without evidence of pancreatic fistula (PF), whereas 12 (28.57%) developed POPF. Among the 12 patients with POPF, 3 (7.14%) had a biochemical leak, 5 (11.9%) had a grade B fistula, and 4 (9.53%) had a grade C fistula according to the revised ISGPS definition. Of the patients with POPF, those with a biochemical leak did not experience significant morbidity and were managed conservatively. Patients with grade B fistula (5 patients) had an extended hospital stay of approximately 2-3 weeks and received percutaneous drainage as an intervention. One patient (8.33%) with grade C fistula required reoperation because of bleeding, and 3 patients (25%) developed septic shock and subsequently died, resulting in an overall mortality rate of 25% among patients with POPF. Conclusion: POPF following PD remains a serious complication of substantial morbidity and mortality. Further improvements in the prevention, early detection, and management of POPF are necessary to reduce postoperative morbidity and mortality. Using the ISGPS definition and grading of PF aids in the clinical assessment and management of PF.

Effect of main pancreatic duct suture ligation on the prevention of clinically relevant pancreatic fistula after distal pancreatectomy: analysis of 82 consecutive patients.

This study aimed to examine the factors linked to the development of clinically significant pancreatic fistulas following distal pancreatectomy (DP) and to assess the efficacy of suture ligation of the main pancreatic duct. A single-center retrospective study was performed on the medical records of 82 patients who underwent DP in our institution between January 2011 and December 2019. There were 28 males (34.1%) and 54 females (65.9%). The patients' age ranged from 18 to 86 years (median: 55.5 years). Indications for DP included primary pancreatic disease (n=63, 76.8%) and non-pancreatic disease (n=19, 23.2%). Postoperative mortality and morbidity rates were 3.7% and 48%, respectively. Pancreatic parenchymal closure was accomplished by a hand-sewn technique or mechanical stapling in 89 and 13 patients, respectively. Identification of the pancreatic duct and suture ligation was performed in 46 patients (56.1%). Pancreatic fistula was developed in 20 patients (24.4%); 12 fistulas were classified as Grade B, and 8 as Grade C. Biochemical leaks (Grade A) were identified in 8 patients (9.8%). Multivariate analysis indicated that failure to ligate the main pancreatic duct was the only variable associated with an increased risk for pancreatic leak (p=0.031; odds ratio=0.233; 95% confidence interval, 0.062-0.879). Pancreatic leak remains a common complication after DP. The incidence of leaks is reduced significantly when the main pancreatic duct is identified and directly ligated during DP.

Serum amylase on postoperative day one is a strong predictor of pancreatic fistula after pancreaticoduodenectomy: a retrospective cohort.

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. 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. 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). 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.

WTP3.9 Procedure-specific morbidity of pancreatoduodenectomy: a systematic review of incidence and risk factors

Abstract Aims Pancreatoduodenectomy (PD) remains the only curative-intent treatment option for patients with a cancer affecting the head of the pancreas. It is high-risk and overall morbidity is around 40%. Due to the necessary resection and subsequent anastomoses required, multiple procedure-specific complications are possible. An in-depth understanding of the recent evidence on these will guide the consenting process and allow surgeons to evaluate their own performance. We aimed to consolidate the recent literature on pre-selected PD complications (postoperative pancreatic fistula (POPF), bile leak (BL), gastro-jejunal leak, post-pancreatectomy haemorrhage (PPH), cholangitis, and chyle leak (CL)). Methods A search of the PubMed database was carried out on 1st July 2021. Articles from July 2011 through to July 2021 were included. The initial search returned 297 results. After screening, 226 articles were excluded. The remaining 71 were assessed for eligibility and a further 34 were excluded. 37 were included in the final synthesis (two meta-analyses and 35 single/multicentre studies). Results Due to recently updated diagnostic criteria, differing definitions among authors and subclinical cases, true incidence rates are difficult to appreciate. The following were obtained: POPF (excluding biochemical leak): 10.0-25.9%, BL: 3.0-7.9%, gastro-jejunal leak: 0.4-1.2%, PPH: 7.3-13.6%, cholangitis: 0.1-21.1% and CL: 2.6-19.0%. Numerous risk factors, both modifiable and non-modifiable, were identified for each. Conclusions Most of the recent evidence on the studied complications comes from single institution studies of retrospective design. Robust case-control studies are required so predictive models can estimate the likelihood of specific complications in individual patients.

End-to-end invaginated pancreaticojejunostomy during minimally invasive pancreatoduodenectomy: technical description and single center experience.

Remarkable progress has been made in pancreatic surgery over the last decades with the introduction of minimally invasive techniques. Minimally invasive pancreatoduodenectomy (MIPD) remains one of the most challenging operations in abdominal surgery and it is performed in a few centers worldwide. The treatment of the pancreatic stump is a crucial step of this operation; however, the best strategy to perform pancreatic anastomosis is still debated. In this article, we describe the technical details of our original technique of modified minimally invasive end-to-end invaginated pancreaticojejunostomy (EIPJ) using video footage. In the current study, we retrospectively analyzed a pilot series of 67 consecutive cases of minimally invasive (7 robotic/60 fully laparoscopic) MIPD operated on at the General Surgery Department of the Panico Hospital, Tricase (Italy) between March 2017 and October 2022.The reconstruction phase involved an EIPJ, tailored using an intra-ductal anastomotic plastic stent. The aim of this study was to describe the technique and evaluate the short-term outcomes of patients undergoing MIPD with EIPJ. The mean operative time to perform the EIPJ was 21.57 ± 3.32min. Seven patients (10.5%) developed biochemical leaks and 13 (19.4%) developed clinically relevant pancreatic fistulas (grade B or C according to the definition of the International Study Group on Pancreatic Surgery). The early results confirm that this anastomosis is safe, easy to perform, and effective in the hands of hepatobiliopancreatic (HBP) surgeons with experience in minimally invasive surgery.

Routes of nutrition for pancreatic fistula after pancreatoduodenectomy: a prospective snapshot study identifies the need for therapy standardization.

The aim of this study is to describe the current utilization of artificial nutrition [enteral (EN) or total parenteral (TPN)] for pancreatic fistula (POPF) after pancreatoduodenectomy (PD). Prospective data of 311 patients who consecutively underwent PD at a tertiary referral center for pancreatic surgery were collected. Data included the use of EN or TPN specifically for POPF treatment, including timing, outcomes, and adverse events related to their administration. POPF occurred in 66 (21%) patients and 52 (79%) of them were treated with artificial nutrition, for a median of 36days. Forty (76%) patients were treated with a combination of TPN and EN. The median day of artificial nutrition start was postoperative day 7, with a median drain output of 180cc/24h. In 33 (63%) patients, artificial nutrition was started while only a biochemical leak was ongoing. Fungal infections and catheter-related bloodstream infection occurred in 13 (28%) and 15 (33%) TPN patients, respectively; among EN patients, 19 (41%) experienced diarrhea not responsive to pancreatic enzymes and 9 (20%) needed multiple endoscopic naso-jejunal tube positioning. The majority of the patients developing POPF after PD were treated with a combination of TPN and EN, with a clinically relevant rate of adverse events related to their administration. Standardization of nutrition routes in patients developing POPF is urgently needed.

Preliminary experience with a new robotic technique to facilitate distal pancreatectomy with spleen preservation: left lateral approach in right lateral decubitus position.

Spleen-preserving distal pancreatectomy (SP-DP), for patients with benign or small low-grade malignant tumors of the body or tail of the pancreas, is the ideal procedure although it is technically demanding. The robotic da Vinci system has been introduced to overcome these technical challenges and reduce operative risks. We report our experience of a new variation in surgical technique: the left lateral approach robotic spleen-preserving distal pancreatectomy (RSP-DP) in right lateral decubitus position. We performed this new variant of SP-DP, in five patients, using the da Vinci Xi system. Technical and clinical feasibility are described. The mean age and body mass index were 53.4years and 31.4kg/m2, respectively. The mean total operative time was 323min. The estimated mean blood loss was 240ml. In all patients, the spleen could be preserved. In four patients, the splenic vessels were also preserved. One patient required a Warshaw technique due to significant fibrosis attached to the splenic vein. The postoperative period of all patients was uneventful except the presence of biochemical leak (BL) in two patients that only required maintenance of the drainage at home. The mean length of hospital stay was 6days after surgery. The left lateral approach robotic SP-DP in right lateral decubitus position is a feasible and safe procedure for distal benign or small low-grade malignant tumors of the left pancreas. The right lateral decubitus position associated to robotic surgery can facilitate this complex procedure, especially when splenic vessels preservation is indicated, with a lower risk of conversion and shortening of the learning curve.

Retrospective Analysis of the Effect of Hand-sewn and Stapler Closure of Pancreatic Stump After Distal Pancreatectomy on the Development of Postoperative Pancreatic Fistula

Aim: Hand-sewn (HS) and stapled closure (ST) of pancreatic stump following distal pancreatectomy are two frequently used techniques. Rates of postoperative pancreatic fistula (POPF) might be associated with stump closure techniques. This study was carried out to determine rates of POPF after distal pancreatectomy and evaluate impact of two closure methods on development of POPF. &#x0D; Material and Methods: All patients who underwent elective open or laparoscopic distal pancreatectomy for malignant and benign pancreatic pathologies between 2011 and 2021 were retrospectively evaluated. Patients were grouped as Groups HS and ST. POPF was diagnosed and graded according to International Study Group of Pancreatic Fistula guidelines. Rates of biochemical leak and grades of POPF were primary outcome. &#x0D; Results: There were 44 patients (28 in Group HS and 16 in Group ST) with a mean age of 51.8±15.1 years. Groups were similar in demographic and clinical characteristics (p&gt;0.05). There were 15 patients (53.6%) with a biochemical leak in Group HS. In Group ST, six patients (37.5%) developed biochemical leaks. There was no significant in difference between groups in terms of biochemical leak (p=0.305). No patient in Group ST developed a pancreatic fistula. There was only one case with Grade B POPF in Group HS. We did not detect a significant difference in terms of POPF between groups (p=0.999). &#x0D; Conclusion: Both techniques had no significant impact on biochemical leak and POPF rates in patients who underwent distal pancreatectomy. Both pancreatic stump closure approaches are equally safe and can be used with similar clinical efficacy.

From Biochemical Leak to Pancreatic Fistula after Pancreaticoduodenectomy: The Role of Minimally Invasive Surgery

From Biochemical Leak to Pancreatic Fistula after Pancreaticoduodenectomy: The Role of Minimally Invasive Surgery

Primary non-functional pancreatic paraganglioma: A case report and review of the literature.

Primary pancreatic paragangliomas are rare. They are mainly non-functional tumours that lack typical clinical manifestations. Definite diagnosis relies on histopathology and immunohistochemistry, and the main treatment is surgery. We report here a case of primary, non-functional, pancreatic paraganglioma in a 49-year-old woman. The tumour was approximately 5.0 × 3.2 ×4.7 cm in size and located in the pancreatic neck and body. We undertook 3D laparoscopic complete resection of the tumour. The patient developed a pancreatic fistula (biochemical leak) post-surgery, but she recovered and was discharged from hospital 11 days after surgery. We describe this case study and briefly summarize previous related reports.

Early postoperative risk stratification in patients with pancreatic fistula after pancreaticoduodenectomy

BackgroundEarly stratification of postoperative pancreatic fistula according to severity and/or need for invasive intervention may improve outcomes after pancreaticoduodenectomy. This study aimed to identify the early postoperative variables that may predict postoperative pancreatic fistula severity. MethodsAll patients diagnosed with biochemical leak and clinically relevant-postoperative pancreatic fistula based on drain fluid amylase >300 U/L on the fifth postoperative day after pancreaticoduodenectomy were identified from a consecutive cohort from Birmingham, UK. Demographics, intraoperative parameters, and postoperative laboratory results on postoperative days 1 through 7 were retrospectively extracted. Independent predictors of clinically relevant-postoperative pancreatic fistula were identified using multivariable binary logistic regression and converted into a risk score, which was applied to an external cohort from Verona, Italy. ResultsThe Birmingham cohort had 187 patients diagnosed with postoperative pancreatic fistula (biochemical leak: 99, clinically relevant: 88). In clinically relevant-postoperative pancreatic fistula patients, the leak became clinically relevant at a median of 9 days (interquartile range: 6–13) after pancreaticoduodenectomy. Male sex (P = .002), drain fluid amylase-postoperative day 3 (P < .001), c-reactive protein postoperative day 3 (P < .001), and albumin-postoperative day 3 (P = .028) were found to be significant predictors of clinically relevant-postoperative pancreatic fistula on multivariable analysis. The multivariable model was converted into a risk score with an area under the receiver operating characteristic curve of 0.78 (standard error: 0.038). This score significantly predicted the need for invasive intervention (postoperative pancreatic fistula grades B3 and C) in the Verona cohort (n = 121; area under the receiver operating characteristic curve: 0.68; standard error = 0.06; P = .006) but did not predict clinically relevant-postoperative pancreatic fistula when grades B1 and B2 were included (area under the receiver operating characteristic curve 0.52; standard error = 0.07; P = .802). ConclusionWe developed a novel risk score based on early postoperative laboratory values that can accurately predict higher grades of clinically relevant-postoperative pancreatic fistula requiring invasive intervention. Early identification of severe postoperative pancreatic fistula may allow earlier intervention.

Association Between High Body Fat Percentage and Outcomes after Pancreaticoduodenectomy: Analysis of the NSQIP Database

INTRODUCTION: The relationship between high body fat (BF) and outcomes in pancreatic operation has not been studied in the literature. Therefore, the purpose of the study was to identify the association between BF and outcomes after pancreaticoduodenectomy (PD). METHODS: A retrospective analysis of the 2019 NSQIP database was performed. Patients were categorized into obese and nonobese groups based on BF percentage. We matched the 2 groups based on propensity score matching in a 1:1 ratio. The primary outcomes measure was mortality. Secondary outcomes measure was complication, including pancreatic fistula. RESULTS: After propensity score matching in a 1:1 ratio, there were 670 patients in the obese group and 670 patients in the nonobese group. Obese patients were more likely to have superficial surgical site infection (7% vs 4.4%; p = 0.04), and pulmonary embolism (3.4% vs 0.2%; p = 0.02), organ space surgical site infection (20.1% vs 13.9%; p = 0.002); rate of biochemical leak (9.5% vs 5%; p = 0.001) and grade B/C postoperative pancreatic fistula (16.2% vs 10.4%; p = 0.001). There was no difference in mortality between the 2 groups (2.1% vs1.1%; p = 0.1; Table).TableCONCLUSION: Percent BF may help surgeons improve risk stratification, project patient-reported functional outcomes, and better educate obese patients regarding postoperative expectations before undergoing pancreatic resection.