Biochemical Leak Research Articles

Drain fluid amylase in defining clinically relevant postoperative pancreatic fistula following pancreaticoduodenectomy: day 5 is better than day 3

Background: Postoperative pancreatic fistula (POPF) remains the most serious complication of Pancreaticoduodenectomy. ISGPF defined POPF in 2005 based on drain fluid amylase on or after day 3 and graded the severity. But as Grade A fistulas are not clinically relevant, most of the clinicians do not consider them as POPF. Hence exact incidence of POPF is not known. Our aim is to see weather drain fluid amylase on or after day 5 can define clinically relevant POPF better than day 3.Methods: Prospective study included all patients who underwent Pancreaticoduodenectomy during the period January 2013 to November 2016. Serum and Drain fluid amylase were analyzed on Day 3. Those who met criteria of POPF underwent repeat amylase on Day 5. These patients were divided into 2 groups. Group A includes patients whose Day 5 amylase normalized and Group B where elevated Amylase persisted. Outcomes were compared in 2 Groups in terms of clinically relevant POPF (CRF), DGE, Haemorrhage (PPH), hospital stay and 30 Days mortality. Results were analysed and p value <0.05 was considered significant.Results: On 110 patients, 44 (40%) met ISGPF criteria of POPF. Of 44, 36 (82%) had normalized Amylase on Day 5 (Group A). Only 8 (18%) had persistent elevated amylase (Group B). None in Group A had CRF, whereas in Group B, 6(75%) had CRF and 2(25%) had only biochemical leak (p<0.0001). DGE was significantly higher in Group B (87.5% vs. 33.3%; p=0.013). PPH was seen in only 1 patient (Group A). Duration of hospital stay and 30day mortality were similar.Conclusions: Drain fluid amylase levels on or after Day 5 defines clinically relevant POPF better than levels on or after day 3.

Totally laparoscopic stapled distal pancreatectomy

To evaluate the outcomes of totally laparoscopic distal pancreatectomy (LDP). A prospective database of patients treated within a single institution was studied retrospectively. Between March 2003 and January 2010, 15 patients underwent pancreatic transection with the use of a stapler, followed by sealing of the pancreatic stump with fibrin-coated collagen fleece (TachoComb) in LDP. LDP was completed successfully in all 15 patients. The median operating time and blood loss were 168 min (range 105-213 min) and 36 ml (range 12-89 ml), respectively. The median drain amylase level peaked at 969 IU/l (93-3077 IU/l) on postoperative day (POD) 1, and then dropped to 165 IU/l (30-846 IU/l) on POD 3. The median hospital stay was 7 days (range 4-15 days). Biochemical pancreatic leaks developed in three patients (20 %), but there was no clinical pancreatic fistula or postoperative hemorrhage. Our study shows that the combined use of a stapler and TachoComb decreased the incidence of pancreatic fistulas after LDP. This procedure offers more efficient and consistent results than those achieved by closing the pancreatic stump by stapling alone.

PANCREATODUODENECTOMY: ROLE OF DRAIN FLUID ANALYSIS IN THE MANAGEMENT OF PANCREATIC FISTULA

Pancreatic fistula remains an important cause of death following pancreatoduodenectomy. There is still uncertainty regarding the use of drains following pancreatoduodenectomy with recent reports suggesting that it might be harmful with increased complications. We evaluated the use of drain fluid analysis in the management of patients following pancreatoduodenectomy. A prospective study was conducted on all patients undergoing pancreatoduodenectomy at two hospitals between April 2004 and August 2006. Drain fluid analysis was carried out from day 3 to day 5. These data were collected with the clinical pictures of the patients and with subsequent radiological assessment. Fifty consecutive patients underwent modified extended pancreatoduodenectomy for a periampullary tumour. In patients with no clinical evidence of a fistula, the mean postoperative drain fluid amylase levels were as follows: on postoperative day 3 it was 262 U/mL (standard error of mean 69), on postoperative day 4 it was 112 U/mL (standard error of mean 47) and on postoperative day 5 it was 125 U/mL (standard error of mean 64). Only three (6/6, 50%) of these patients had clinical features suggestive of a leak and were found to have a pancreatic fistula on subsequent imaging. There was no correlation between the total or mean volumes of drainage and development of a pancreatic fistula. The drain fluid analysis did not provide additional information that was not already evident from the clinical picture of the patient. Drain fluid analysis had no effect on patients with a biochemical leak only. Patients who had a significant disruption of their pancreatic anastamosis did not need biochemical analysis as the character, that is, turbidity of the drain fluid was an equally reliable indicator of the underlying pathology.

Does Prior Adjuvant Chemoradiotherapy Lead to a Safer Pancreatoduodenectomy?

The article by Cheng et al. is another attempt to compare the effects of preoperative versus postoperative adjuvant chemoradiotherapy (CRT) for presumably localized pancreatic adenocarcinoma by retrospective analysis of two nonrandomized treatment cohorts. Because the only significant differences in morbidity within the preoperative and postoperative cohorts in this study were in pancreatic leak and intra-abdominal abscess formation (favoring the preoperative CRT cohort), the primary focus of this study was the relative incidence of postoperative pancreatic leaks. The authors aver that preoperative CRT reduces the incidence of both pancreatic leaks and leak-associated morbidity and mortality, and they even go so far as to recommend preoperative CRT in those with ampullary cancer to decrease postoperative leaks. Is this information new, true, or relevant? Ishikawa et al. were the first to examine the question. They described two retrospective nonrandomized cohorts: one treated with preoperative radiotherapy (RT) and the other not. Patients with fistulas were defined as those with amylase levels >2000 U/L in their drains for >1 week. Furthermore, a fistula was defined as major if either bile was seen in the drain fluid or the fistulogram showed entry of dye into the jejunum (all patients had pancreatojejunostomy over external pancreatic stents). Minor fistulas were those without either of these findings but with the defined drain amylase levels. One of 22 patients with preoperative RT developed a major fistula, and 1 of 54 patients without preoperative RT had a major fistula; 3 of 54 had minor fistulas that became major, and 6 had minor fistulas. Because the two immediate major fistulas were attributed to premature withdrawal or occlusion of pancreatic stents, these cases were excluded. The 9 of 53 patients with minor or minor changing to major fistulas without RT were compared with the 0 of 21 patients without fistulas in the post-RT cohort: differences were significant (P = .05). Statistical significance here, however, required that the two major leaks be omitted. Clearly, those receiving preoperative RT seemed to do no worse than those without it. Lowy et al. examined pancreatic leak in patients with and without preoperative CRT in a randomized study of perioperative octreotide. Their definition of fistula was either biochemical (defined as increased drain amylase at postoperative day 3) or clinical (requiring reoperation or drainage). Whereas none of the 46 patients with protocol-based preoperative CRT for pancreatic cancer developed clinical pancreatic fistulas, there were enough with biochemical leaks that no difference was shown between those treated with preoperative CRT and those who had surgery first. Again, preoperative CRT seemed not to be a deterrent to safe recovery from pancreatoduodenectomy, but leaks were no less frequent than in those treated without preoperative therapy. Cheng et al. defined a leak as any drainage fluid at any time after surgery with a value three times that of serum amylase. Multivariate analysis showed that preoperative CRT produced a statistically significant decrease in pancreatic leaks (10.1% vs. 43.3%; P < .001). For those with pancreatic head cancer, 3 (4.8%) of 62 of those with preoperative CRT had a fistula, Received October 19, 2005; accepted October 26, 2005; published online January 1, 2006. Address correspondence and reprint requests to: John Hoffman, MD; E-mail: jp_hoffman@fccc.edu

Laparoscopic distal pancreatectomy combined with preservation of the spleen for cystic neoplasms of the pancreas.

The precise role of laparoscopy in the resection of cystic neoplasms of the pancreas (CyNP) remains unknown. In addition, the question of spleen-preserving distal pancreatectomy is controversial. This report evaluates the feasibility and outcome of laparoscopic spleen-preserving distal pancreatectomy (LapSPDP) in 19 patients (17 women and 2 men) with CyNP. A prospective comparison was made between 11 consecutive patients (group I) with splenic vessel preservation (SVP) and 8 patients (group II) without SVP (Warshaw technique). This study used color-Doppler ultrasound (CDUS) as a tool to identify patients at high risk for postoperative splenic complications. The mean tumor size was, in both groups, 5 cm. In group I, with an intent-to-treat basis of SVP, only in 54.5% of patients the spleen was preserved with an intact splenic artery and vein; in the remainder, conversion to the Warshaw technique was required for intraoperative bleeding. Evaluation of intraoperative factors showed that the mean operative time was significantly shorter (165 vs. 222 minutes) and the mean blood loss significantly lower (225 vs. 495 mL) in the group of LapSPDP with the Warshaw technique. No patients required blood transfusion in both groups. The overall conversion rate was 0%. The overall rate of pancreatic fistula was 15% and it was classified as biochemical leak (no clinical symptomatology). Overall splenic complications were observed in 16.6% of patients but occurred only in three patients undergoing LapSPDP with the Warshaw technique; CDUS showed in 2 patients a focal splenic infarct; the third patient had an initial hospital stay of 5 days, was readmitted 2 days later for a massive splenic necrosis, and splenectomy was performed. The overall hospital stay was 5.7 days. At mean follow up of 22 months (range 6-42), there have been no local recurrences.