Clinical Pancreatic Fistula Research Articles

Learning curve of robotic pancreatoduodenectomy by a single surgeon with extensive laparoscopic pancreatoduodenectomy experience.

With the development of robotic systems, robotic pancreatoduodenectomies (RPDs) have been increasingly performed. However, the number of cases required by surgeons with extensive laparoscopic pancreatoduodenectomy (LPD) experience to overcome the learning curve of RPD remains unclear. Therefore, we aimed to analyze and explore the impact of different phases of the learning curve of RPD on perioperative outcomes. Clinical data were prospectively collected and retrospectively analyzed for 100 consecutive patients who underwent RPD performed by a single surgeon. This surgeon had previous experience with LPD, having performed 127 LPDs with low morbidity. The learning curve for RPD was analyzed using the cumulative sum (CUSUM) method based on operation time, and perioperative outcomes were compared between the learning and proficiency phases. Between April 2020 and November 2022, one hundred patients (56 men, 44 women) were included in this study. Based on the CUSUM curve of operation time, the learning curve for RPD was divided into two phases: phase I was the learning phase (cases 1-33) and phase II was the proficiency phase (cases 34-100). The operation time during the proficiency phase was significantly shorter than that during the learning phase. In the learning phase of RPD, no significant increases were observed in estimated blood loss, conversion to laparotomy, severe complications, postoperative pancreatic hemorrhage, clinical pancreatic fistula, or other perioperative complications compared to the proficiency phases of either RPD or LPD. A surgeon with extensive prior experience in LPD can safely surmount the RPD learning curve without increasing morbidity in the learning phase. The proficiency was significantly improved after accumulating experience of 33 RPD cases.

Comprehensive analysis of the association between inflammation indexes and complications in patients undergoing pancreaticoduodenectomy.

During clinical practice, routine blood tests are commonly performed following pancreaticoduodenectomy (PD). However, the relationship between blood cell counts, inflammation-related indices, and postoperative complications remains unclear. We conducted a retrospective study, including patients who underwent PD from October 2018 to July 2023 at the First Hospital of Chongqing Medical University, and compared baseline characteristics and clinical outcomes among different groups. Neutrophil count (NC), platelet count (PLT), lymphocyte count (LC), systemic immune-inflammation index (SII), platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR), and the product of platelet count and neutrophil count (PPN) were derived from postoperative blood test results. We investigated the association between these indicators and outcomes using multivariable logistic regression and restricted cubic spline analysis. The predictive performance of these indicators was assessed by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve and decision curve analysis (DCA). A total of 232 patients were included in this study. Multivariate logistic regression and restricted cubic spline analysis showed that all indicators, except for PLT, were associated with clinical postoperative pancreatic fistula (POPF). SII, NLR, and NC were linked to surgical site infection (SSI), while SII, NLR, and PLR were correlated with CD3 complication. PLT levels were related to postoperative hemorrhage. SII (AUC: 0.729), NLR (AUC: 0.713), and NC (AUC: 0.706) effectively predicted clinical POPF. In patients undergoing PD, postoperative inflammation-related indices and blood cell counts are associated with various complications. NLR and PLT can serve as primary indicators post-surgery for monitoring complications.

An analysis of the effectiveness of stapler closure combined with a titanium clip in distal pancreatectomy.

Postoperative pancreatic fistula is the most common and severe postoperative complication of distal pancreatectomy. Treatment of pancreatic stump to reduce the incidence of postoperative pancreatic fistula is crucial. This study evaluated the effectiveness of stapler closure combined with a titanium clip in distal pancreatectomy. Prospectively collected data of consecutive patients who underwent distal pancreatectomy from April 2013 to May 2020 with pancreatic transection performed by the bare stapler method (131 patients), stapler + hand-sewn closure method (199 patients), and stapler + titanium clip method (209 patients) were reviewed retrospectively and compared between groups. No statistically significant differences were observed in basic data among the three groups. There were also no significant differences among the three groups in terms of the intraoperative data or tumor pathological types, except for the number of laparoscopic treatment cases (23, 53, and 80 for bare stapler method, stapler + hand-sewn closure method, and stapler + titanium clip method, respectively; P < 0.05) and pancreatic neuroendocrine tumor cases (15, 29, and 12, respectively; P < 0.05). There were no significant differences in postoperative complications or parameters, except for the number of clinical pancreatic fistula cases (31, 27, and 13 for bare stapler method, stapler + hand-sewn closure method, and stapler + titanium clip method, respectively; P < 0.05) and postoperative length of hospital stay (11.6 ± 8.3, 10.6 ± 9.7, and 9.3 ± 6.9days, respectively; P < 0.05). The stapler + titanium clip group had a significantly lower number of clinical pancreatic fistula cases and shorter postoperative length of hospital stay than the other groups. The univariate analysis showed that pancreatic resection line thickness was an independent risk factor for clinical pancreatic fistula after operation. Stapler closure combined with titanium clips to reinforce the pancreatic stump is simple and easy to implement, effectively reduces the incidence of clinical pancreatic fistula, and shortens the postoperative length of hospital stay.

Estimation of pancreatic fibrosis and prediction of postoperative pancreatic fistula using extracellular volume fraction in multiphasic contrast-enhanced CT.

To investigate the diagnostic performance of the extracellular volume (ECV) fraction in multiphasic contrast-enhanced computed tomography (CE-CT) for estimating histologic pancreatic fibrosis and predicting postoperative pancreatic fistula (POPF). Eighty-five patients (49 men; mean age, 69years) who underwent multiphasic CE-CT followed by pancreaticoduodenectomy with pancreaticojejunal anastomosis between January 2012 and December 2018 were retrospectively included. The ECV fraction was calculated from absolute enhancements of the pancreas and aorta between the precontrast and equilibrium-phase images, followed by comparisons among histologic pancreatic fibrosis grades (F0‒F3). The diagnostic performance of the ECV fraction in advanced fibrosis (F2‒F3) was evaluated using receiver operating characteristic curve analysis. Multivariate logistic regression analysis was used to evaluate the associations of the risk of POPF development with patient characteristics, histologic findings, and CT imaging parameters. The mean ECV fraction of the pancreas was 34.4% ± 9.5, with an excellent intrareader agreement of 0.811 and a moderate positive correlation with pancreatic fibrosis (r = 0.476; p < 0.001). The mean ECV fraction in advanced fibrosis was significantly higher than that in no/mild fibrosis (44.4% ± 10.8 vs. 31.7% ± 6.7; p < 0.001), and the area under the receiver operating characteristic curve for the diagnosis of advanced fibrosis was 0.837. Twenty-two patients (25.9%) developed clinically relevant POPF. Multivariate logistic regression analysis demonstrated that the ECV fraction was a significant predictor of POPF. The ECV fraction can offer quantitative information for assessing pancreatic fibrosis and POPF after pancreaticojejunal anastomosis. • There was a moderate positive correlation of the extracellular volume (ECV) fraction of the pancreas in contrast-enhanced CT with the histologic grade of pancreatic fibrosis (r = 0.476; p < 0.001). • The ECV fraction was higher in advanced fibrosis (F2‒F3) than in no/mild fibrosis (F0‒F1) (p < 0.001), with an AUC of 0.837 for detecting advanced fibrosis. • The ECV fraction was an independent risk factor for predicting subclinical (odds ratio, 0.81) and clinical (odds ratio, 0.80) postoperative pancreatic fistula.

Comparison of the Safety and Effectiveness Between Laparoscopic and Open Pancreatoduodenectomy: A Systematic Review and Meta-Analysis

Background: Due to the significant heterogeneity in previous studies, concerns persist regarding the safety and effectiveness of laparoscopic pancreatoduodenectomy (LPD). Therefore, with the publication of new researches, a comprehensive systematic review is needed to evaluate the potential benefits of laparoscopic pancreatoduodenectomy. We aimed to compare safety and effectiveness of laparoscopic and open pancreatoduodenectomy (OPD) from the published studies, and investigate the source of heterogeneity from the surgeons’ and patients’ perspectives. Methods: We searched PubMed, Cochrane, Embase, and Web of Science databases for relevant studies published before February 1, 2021 comparing laparoscopic and open pancreatoduodenectomy. The database search yielded a total of 6,578 articles, and 81 articles were full-text reviewed. Studies of laparoscopic-assisted surgery were not included. The primary outcome was mortality. Three independent reviewers screened and extracted the data, and resolved disagreements by consensus. Studies were evaluated for quality using ROB2·0 and ROBINS-I. Meta-analyses were conducted in random-effect and fixed-effect models. Different meta-analyses were conducted according to the different designs of the studies. The sensitivity analyses and meta-regression were conducted to explore the source of heterogeneity. This study was registered with PROSPERO, ID CRD42021234579. Findings: We analyzed 34 studies involving 46,729 patients (4,705 LPD and 42,024 OPD). LPD was associated with lower mortality in overall studies (odds ratio [OR] 0·800, 95% confidence interval [CI] 0·659–0·973, P=0·025, I2=0·0%) and unmatched studies (OR 0·774, 95%CI 0·628–0·954, P=0·017, I2=0·0%). However, no differences in mortality were seen in RCTs (randomized controlled trial) (risk ratio 1·080, 95%CI 0·473–2·466, P=0·854, I2=13·4%) and matched studies (OR 0·904, 95%CI 0·515–1·587, P=0·726, I2=0·0%). Sensitivity analysis found that mortality was also similar between the two groups in elderly patients, patients with pancreatic ductal adenocarcinoma (PDAC), high-volume hospitals, and low-volume hospitals (all P >0·05). However, LPD showed non-inferiority in length of stay (LOS), severe complications, clinical relevant-postoperative pancreatic fistula, clinical relevant-biliary leak, intra-abdominal infection, readmission, overall survival, and 2-year relapse. Elderly patients benefited marginally from LPD, while patients with PDAC and patients in high-volume hospitals benefit significantly. Meta-regression confirmed that baseline differences including the proportion of males, age, proportion of biliary drainage, diagnosis of PDAC, and lesion size between LPD and OPD groups had a significant impact on LOS, severe complications, ICU stay, estimated intraoperative blood loss, and lymph node harvest (all P <0·05). Interpretation: Our study found no significant difference between LPD and OPD with respect to mortality. LPD should be suggested according to the non-inferiority in LOS, complications, and overall survival. Meanwhile, the elderly patients benefited marginally from LPD, while the patients with PDAC and patients in high-volume hospitals benefit significantly. Funding: National Natural Science Foundation of China and Tongji Hospital, Huazhong University of Science and Technology, China Declaration of Interest: None to declare.

Updated Meta-analysis of Minimally Invasive Versus Open Surgery for Pancreatic Neuroendocrine Neoplasms.

The aim of this study was to compare the short-term and long-term outcomes of minimally invasive surgery (MIS) with those of open pancreas surgery (OPS) for the treatment of pancreatic neuroendocrine neoplasms (pNENs). Studies reporting the effects of MIS and OPS for pNENs, published on PubMed, Embase, and Cochrane Library before May 2020 were reviewed. Seventeen cohort studies with a total of 1853 patients were eligible for analysis, including 655 patients in the MIS group and 1198 patients in the OPS group. The estimated blood loss, postoperative hospitalization time, overall complications, severe complications, spleen preservation, mortality, and recurrence in the MIS group were lower than those in the OPS group. The R0 rate, 3-year overall survival (OS), and 5-year OS in the MIS group were higher than those in the OPS group. There were no significant differences in operative time, postoperative pancreatic fistula, clinical postoperative pancreatic fistula, postoperative bleeding, reoperation, readmission, and 1-year OS. Minimally invasive surgery can reach lower recurrence rate, higher long-term survival rate, and better outcomes in terms of estimated blood loss, postoperative hospitalization time, R0 rate, mortality, overall complications, and severe complications for pNENs. More high quality studies need to be conducted for further verification.

Effect of polyglycolic acid mesh for prevention of pancreatic fistula after pancreatectomy: A systematic review and meta-analysis.

Postoperative pancreatic fistula (POPF) is the most common and intractable complication after partial pancreatectomy, with an incidence of 13% to 64%. Polyglycolic acid (PGA) mesh is a new technique that is designed to prevent POPF, and its effect has been evaluated in several randomized controlled trials and some retrospective cohort studies. In this study, we systematically and comprehensively analyzed the efficacy of PGA mesh based on reported studies.We searched Medline, Embase, and Cochrane Library databases in English between January 2010 and October 2019. Analysis was performed by using Review Manger 5.3 software.Three RCTs and 8 nonrandomized studies were eligible with a total of 1598 patients including 884 PGA group patients and 714 control group patients. For pancreatoduodenectomy (PD), distal pancreatectomy (DP), and the 2 partial pancreatectomy (PD or DP), we found significant statistical differences in overall POPF (relative risk [RR] = 0.75, 95% confidence interval [CI] = 0.61-0.91, P = .004; RR = 0.74, 95% CI = 0.57-0.96, P = .02; RR = 0.76, 95% CI = 0.64-0.89, P = .0009, respectively) and clinical pancreatic fistula (PF) (RR = 0.5, 95% CI = 0.37-0.68, P < .00001; RR = 0.31, 95% CI = 0.21-0.46, P < .00001; RR = 0.41, 95% CI = 0.32-0.52, P < .00001, respectively) in favor of PGA. For partial pancreatectomy, significant statistical differences were found in overall complications (RR = 0.77, 95% CI: 0.67-0.88, P = .0002) and estimated blood loss (weighted mean difference [WMD] = -53.58; 95% CI: -101.20 to -5.97, P = .03) in favor of PGA. We did not find significant differences regarding operative time (WMD = -8.86; 95% CI: -27.59 to 9.87, P = .35) and hospital stay (WMD = -2.73; 95% CI: -7.53 to 2.06, P = .26).This meta-analysis shows the benefits of the PGA mesh technique regarding POPF, clinical PF, and postoperative complications. This still needs to be verified by more randomized control trials.

The quest for optimization of laparoscopic pancreaticoduodenectomy with pancreaticogastrostomy

Background: Pancreatic reconstruction remains the Achilles heel of pancreaticoduodenectomy (PD), especially in minimally invasive surgery. We developed a novel 3D-laparoscopic pancreaticoduodenectomy (3D-LPD) procedure with umbrella-pancreaticogastrostomy (uPG) plus roux-en-y gastroenterostomy (RY-GE) reconstruction, and analysed its outcomes in a prospective non-randomized single-centre cohort study (NCT02671357). Methods: Between March 2014 and March 2017, we performed LPD in 102 consecutive patients. We optimized the LPD procedure in 3 stages and routinely placed a pancreatic stent to secure duct patency. In the 1ststage, we performed LPD as a copy of our standard open PD procedure with telescope-PG plus iso-peristaltic gastroenterostomy (n=21). In the 2ndstage we used a uPG reconstruction instead of telescope-PG (n=29), and in the final stage a uPG plus RY-GE reconstruction instead of the standard iso-peristaltic gastroenterostomy (n=52). Results: In the final-stage LPD clinical pancreatic fistula (cPOPF) occurred in 4%, haemorrhage (PPH) in 4%, and severe complications (TOSGS ≥3a) in 10%. None of the patients developed delayed gastric emptying (DGE). In the 1st- and 2nd-stage LPD the rates of cPOPF were 48% and 31% (p<0.001), PPH 33% and 14% (p=0.003), severe complications 57% and 31% (p<0.001), and DGE 5% and 38% (p<0.001), respectively. Median (range) LOS after final-stage LPD was 9 (3-70) days, as compared to 23 (11-56) days after 1st-stage and 22 (10-72) days after 2nd-stage LPD (p<0.001). Postoperative mortality throughout the 3 stages of LPD was 2%. A 52-year old male patient died due to cPOPF with haemorrhage on day 29 after 1st-stage LPD. An 81-year old female patient died on day 3 after the final-stage LPD due to cardiac arrest based on autopsy-proven cardiac amyloidosis. Conclusions: LPD with uPG plus RY-GE is associated with excellent clinical outcomes and no DGE. Further investigation is warranted before considering replacement of current reconstruction Methods in pancreaticoduodenectomy.

Has the pancreatic fistula already occurred in the operation? An intraoperative predictive factor of clinical relevant-postoperative pancreatic fistula after the distal pancreatectomy

PurposeThe aim of this study was to assess the predictive effect of intraoperative amylase value from pancreatic remnant on the development of clinical relevant-postoperative pancreatic fistula after distal pancreatectomy. MethodsPatients undergoing distal pancreatectomy between June 2017 and October 2018 were studied retrospectively. The intraoperative amylase value was measured followed by drain fluid for amylase on postoperative day 3. The analysis of clinical relevant-postoperative pancreatic fistula predictors was carried out using the logistic regression. The receiver operating characteristic analysis was performed to evaluate the discriminative capacity of intraoperative amylase value as a predictive risk factor. ResultsThe study population consisted of 40 patients. The clinical relevant-postoperative pancreatic fistula occurred in 13 patients, no grade C pancreatic fistula (PF). The intraoperative amylase value correlated significantly with clinical relevant-postoperative pancreatic fistula. An intraoperative amylase value >3089 U/L was proposed as the cut-off level to predict clinical relevant-postoperative pancreatic fistula by the receiver operating characteristic curve. The sensitivity, specificity and accuracy of this level were respectively 84.6%, 88.9% and 88.5%. The multivariate logistic regression analysis revealed that intraoperative amylase value and suture closure for the pancreatic stump were the significant predictive risk factors for the clinical relevant-postoperative pancreatic fistula. ConclusionThe intraoperative amylase value can be early and easily measured as a predictive risk factor, which seems useful for postoperative management of clinical relevant-postoperative pancreatic fistula after distal pancreatectomy. While, the stapler closure might be a feasible way for the pancreatic transection during the operation.

How we secure safety of laparoscopic pancreatoduodenectomy: comparison with open pancreatoduodenectomy for similar disease

Introduction: Laparoscopic pancreatoduodenectomy (LPD) is still a challenging operation and its safety and feasibility are controversial. We demonstrate our institutional procedure to obtain satisfactory results comparing to open pancreatoduodenectomy (OPD) for similar disease (benign and low-grade malignant tumor). Methods: From 2016, 14 consecutive patients underwent LPD for 6 PNET, 3 IPMN and 5 Duodenal tumors. Our techniques are following; 2 surgeons who have experienced over 200 laparoscopic digestive surgeries and 200 OPD perform Operator or Scopist alternatively; Scopist provides a good field of vision as first assistant; usage of 3-dimentional visualization; via mini-laparotomy (7cm) a pancreatico-jejunostomy and duodeno-jejunostomy are performed; a choledoco-jejunostomy is performed laparoscopically. All patients revealed soft pancreatic texture and the Fistula Risk Score (FRS) demonstrated 5 high and 9 moderate-risk patients in LPD and 4 high and 6 moderate in OPD. Results: Mean operation time was not different between the groups (LPD, 284 min; OPD, 289 min). Mean blood loss was significantly greater in OPD (LPD, 181 ml; OPD, 461 ml; p = 0.024). Median postoperative hospital stay was not different between the groups, but shorter in LPD (LPD, 15d; OPD, 21d). There were no differences in postoperative complications (LPD, 43%; OPD, 40%) and clinical pancreatic fistula (LPD, 36%; OPD, 30%). There were no reoperation and mortality in both groups. Conclusion: LPD offers the equivalent surgical outcome with OPD, while achieve less intraoperative blood loss and shorter hospital stay. The candidates of this surgery correspond to high FRS, thus we have to continue the meticulous surgery using partially open method to minimize morbidities.

The role of Hong's single-stitch duct to mucosa pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy

Objective: To investigate the role of "Hong's single-stitch duct to mucosa pancreaticojejunostomy(HSDMP)" in laparoscopic pancreaticoduodenectomy (LPD). Methods: The clinical data including perioperative and short-term outcomes of 51 cases of LPD with HSDMP which performed in Zhejiang Provincial People's Hospital(33 cases) and Frist Clinical Hospital of Jilin University(18 cases) between April and October 2016 were reviewed retrospectively. There were 31 male patients and 20 female patients. The mean age was(59±11)years. Body mass index (BMI) was 18 to 28 kg/m(2) and the average BMI was (23.2±4.4)kg/m(2). Preoperative diagnosis: 18 cases with pancreatic mass, 26 cases with peri-ampullary tumor, 3 cases with intra-ductal papillary mucinous neoplasms, 2 cases with duodenal carcinoma, 2 cases with serous cystadenoma. Results: Fifty-one patients accepted LPD using HSDMP. One patient underwent LPD combined with resection of superior mesentery vein. The mean operation time was (307±69)minutes, the mean diameter of pancreatic duct for reconstruction was (3.1±1.1)mm.The mean operation time for HSDMP was (34±5) minutes, the estimated blood loss was (170±127)ml. Twelve cases(23.5%) had pancreatic fistula according to International Study Group definition, including 9 cases(17.6%) of grade A and 3 cases (5.9%) of grade B. Five cases(9.8%) had delayed gastric empty, 5 cases(9.8%) had bile leakage and 2 cases(3.9%) had pulmonary infection postoperative.All these complications were treated by non-surgical strategies. One patient(2.0%) suffered from postoperative intra-abdominal bleeding and recovered after reoperation. Pathologic results showed pancreatic ductal adenocarcinomas in 20 cases(39.2%), non-pancreatic original peri-ampullary tumors in 23 cases(45.1%), intra-ductal papillary mucinous neoplasms in 3 cases(5.9%), duodenal carcinoma in 2 cases(3.9%), serous cystadenoma in 2 cases(3.9%) and neuroendocrine tumors in one case(2.0%). Conclusions: HSDMP could not only reduce the incidence of clinical pancreatic fistula, but also save operation time. It is a feasible and safe method for pancreaticojejunostomy.

Pancreatic exocrine insufficiency after pancreaticoduodenectomy is more prevalent with pancreaticogastrostomy than with pancreaticojejunostomy. A retrospective multicentre observational cohort study

ObjectiveRecently, pancreaticogastrostomy (PG) has attracted renewed interest as a reconstruction technique after pancreaticoduodenectomy (PD), as it may imply a lower risk of clinical pancreatic fistula than reconstruction by pancreaticojejunostomy (PJ). We hypothesise that pancreatic exocrine insufficiency (PEI) is more common during clinical follow-up after PG than it is after PJ. Research design and methodsThis study compares the prevalence of PEI in patients undergoing PD for malignancy with reconstruction by PG versus reconstruction by PJ. PEI during the first year of follow-up was defined as the intake of pancreatic enzyme replacement therapy (PERT) within one year postoperatively and/or an abnormal exocrine function test. ResultsA total of 186 patients, having undergone surgery at two university hospitals, were included in the study. PEI during the first year postoperatively was present in 75.0% of the patients with PG, compared to 45.7% with PJ (p < 0.001). Intake of PERT within one year after surgery was found to be more prevalent in the PG group, i.e. 75.8% versus 38.5% (p < 0.001). There was a trend towards more disturbed exocrine function tests after PG (p = 0.061). ConclusionsPEI is more common with PG reconstruction than with PJ reconstruction after pancreaticoduodenectomy for malignancy.

Robot-assisted laparoscopic versus open middle pancreatectomy: short-term results of a randomized controlled trial.

This first prospective randomized controlled trial was performed to compare short-term outcomes of robot-assisted laparoscopic middle pancreatectomy (RA-MP) with open middle pancreatectomy (OMP). RA-MP is a novel minimally invasive surgical technique for benign or borderline tumors in the pancreatic neck or body. Its short-term effectiveness and safety remain unknown, compared to OMP. Patients eligible for MP from August 2011 to November 2015 were randomized into the RA-MP or OMP group. The primary endpoint was length of hospital stay (LOS). Secondary endpoints were intraoperative parameters, and postoperative and recovery variables. A total of 100 patients were included into the study to analyze primary and secondary endpoints. Demographic characteristics and pathological parameters were similar in both groups. Furthermore, LOS was significantly shorter (15.6 vs. 21.7days, P=0.002), median operative time was reduced (160 vs. 193min, P=0.002), median blood loss was lower (50 vs. 200mL, P<0.001), rate of clinical postoperative pancreatic fistula (POPF) was lower (18 vs. 36.0%, P=0.043), nutritional status recovery was better, off-bed return to activity was expedited (3.1 vs. 4.6days, P<0.001), and resumption of bowel movement was faster (3.5 vs. 5.0days, P<0.001) in the RA-MP group, compared to the OMP group. RA-MP was associated with significantly shorter LOS, reduced operative time, blood loss and clinical POPF rate, and expedited postoperative recovery, compared to OMP.

Impact of octreotide on pancreatic fistula after pancreaticoduodenectomy: a prospective study

To investigate the effect of utilizing octreotide during perioperative period on pancreatic fistula after pancreaticoduodenectomy (PD). Three hundreds and six patients admitted from January 2010 to October 2014, who prepared to undergo pancreaticoduodenectomy (PD) were randomly divided into octreotide group (147 cases) and control group (159 cases). In octreotide group, octreotide was used in subcutaneous injection instantly after PD, each 8 hours until postoperative 10(th) day, and patients in control group were injected with the same volume of saline. Differences of pancreatic fistula (Grade A, Grade B, Grade C), hospitalization days and treatment cost were compared. χ(2) test, t-test and Fisher exact test were used to analyzed to the data, respectively. No statistical significance (P>0.05) between two groups in the incidence of pancreatic fistula after PD (Grade A: 8.8% vs. 10.2%, Grade B: 2.7% vs. 4.4%, Grade C: 0.7% vs. 1.3%; χ(2)=0.197, 0.700, 0.288; P=0.657, 0.403, 0.591), the length of hospitalization((12.1±1.2)days vs. (13.0±1.2)days)(t=1.711, P=0.104) and treatment cost (79 700±6 700 vs. 77 600±5 200)(t=1.378, P=0.185). When accompanied with high risk factors, such as soft texture of pancreas, pancreatic duct size less than 3 mm, BMI≥25 kg/m(2) and diabetes, compared with control group, octreotide group had the lower incidence rate of pancreatic fistula and clinical correlative pancreatic fistula(all P<0.05) after PD. Generally, octreotide makes no contribution to reduce the incidence of pancreatic fistula after PD. However, for patients who is accompanied with high risk factors, such as soft texture of pancreas, pancreatic duct size less than 3 mm, BMI≥25 kg/m(2) and diabetes, octreotide can effectively prevent pancreatic fistula after PD.

Signal intensity of the pancreas on magnetic resonance imaging:Prediction of postoperative pancreatic fistula after adistalpancreatectomy using a triple-row stapler.

The aim of this study was to evaluate the impact of the pancreatic signal intensity (SI) on magnetic resonance imaging (MRI) findings for predicting the development of pancreatic fistula (PF) after a distal pancreatectomy (DP) involving a triple-row stapler closure. A multivariate logistic regression analysis was used to identify risk factors for clinical PF, as defined by the International Study Group on Pancreatic Fistula grade B or C. The pancreas-to-muscle SI ratio was evaluated using fat-suppressed T1-weighted MRI. Of the 41 enrolled patients, 8 (19.5%) developed clinical PF. The pancreatic thickness (≥15mm) and SI ratio (≥1.3) were identified as independent predictors of clinical PF in a multivariate analysis. Clinical PF was observed in one patient with a thick pancreas and a low SI ratio (14.3%), whereas it was observed in 60% of the patients with a thick pancreas and a high SI ratio. The area under the receiver operating characteristic curve for a predictive model consisting of the two factors was 0.87 (95% confidence interval, 0.75 to 0.99), the level of which tended to be greater than that for pancreatic thickness alone (0.81, p=0.09). The SI ratio as evaluated using MRI might be useful for predicting clinical PF in patients with the pancreatic thickness ≥15mm after DP involving a stapler closure.

Safety and efficacy of early drain removal and triple-drug therapy to prevent pancreatic fistula after distal pancreatectomy.

Prior studies suggested that early drain removal prevented the development of pancreatic fistula (PF) after pancreaticoduodenectomy (PD), but there has been no corresponding prospective trial for distal pancreatectomy (DP). The purpose of this study was to determine the safety and efficacy of early drain removal and triple-drug therapy (TDT) with gabexate mesilate, octreotide and carbapenem antibiotics to prevent PF after DP in patients at high-risk of developing PF. A total 71 patients who underwent a DP were enrolled. We prospectively divided them into two groups: the late-removal group, in which the drain remained in place for at least for 5 days postoperatively (n=30) and the early-removal group in which the drain was removed on postoperative day 1 (POD1) (n=41). For the patients with a high drain amylase level (≥10,000IU/L) and patients with symptomatic intraperitoneal fluid collection, our original TDT was introduced. The primary endpoint was the safety and efficacy of this management, and the secondary endpoint was the incidence of PF. The incidence of clinical PF was significantly lower in the early-removal group (0% vs. the late removal 16%; p<0.001). In the early-removal group, TDT was administered to 12 patients (29%) and none of the patients needed additional treatment after TDT. Postoperative management after DP with early drain removal and TDT was safe and effective for preventing PF.

Preoperative diabetes as a protective factor for pancreatic fistula after pancreaticoduodenectomy: a meta-analysis

The role of diabetes mellitus (DM) in pancreatic fistula (PF) or clinical relevant PF (CR-PF) after pancreaticoduodenectomy (PD) or pylorus-preserving pancreaticoduodenectomy (PPPD) is unclear. We conducted a meta-analysis to investigate the relationship between DM and PF or CR-PF. Embase, MEDLINE and Cochrane databases were searched systematically for relevant articles from January 2005 to June 2013. The selected studies that examined clinical risk factors of PF or CR-PF were included. We created pooled estimates for our outcomes using the random-effects model. Sixteen observational clinical studies were included. Pooling of PF rates from ten studies revealed that DM was associated with a decreased risk of PF (P=0.01). CR-PF rates from 8 studies showed no significant difference between DM and control group (P=0.14). DM is not a risk factor for PF in patients undergoing PD or PPPD. On the contrary, patients without DM are at a higher risk of PF because the pancreases in these patients have more fatty tissue and the pancreas is soft.

Division of surgeon workload in pancreaticoduodenectomy: striving to decrease post-operative pancreatic fistula.

BackgroundMany studies have reported factors affecting pancreatic leakage after pancreaticoduodenectomy (PD), but there have been few reports on surgeon workload and post‐operative pancreatic fistula (POPF). This study was conducted to explore whether a surgeon's workload during PD impacts the occurrence of POPF.MethodsWe retrospectively analysed 270 consecutive patients who underwent PD between January 2008 and June 2013 by a single experienced surgeon. These patients were divided into those who underwent PD entirely by a single operator (group 1) and those who received reconstructions by other operators (group 2). Duct‐to‐mucosa pancreaticojejunostomy was performed on all patients. The International Study Group on Pancreatic Fistula criteria were used to define POPF.ResultsThere were 157 patients (58.1%) in group 1 and 113 patients (41.9%) in group 2. The post‐operative morbidity rate was comparable between the two groups (55.4% versus 52.2%; P = 0.603), but the clinical pancreatic fistula (grade B/C) rate was significantly different (10.8% versus 2.7%; P = 0.011). The overall post‐operative mortality was one patient (0.4%). Significant associations were found between clinical pancreatic fistulas and soft pancreas texture (P = 0.021), preoperative serum albumin level ≤3.5 g/dL (P = 0.012), other pathology besides pancreatic cancer (P = 0.027) and a single‐operator procedure (P = 0.019). A multivariate logistic regression analysis revealed that a single operator (odds ratio: 4.2, P = 0.029) was a significant predictive risk factor for clinically relevant POPF.ConclusionDividing the surgeon's workload in PD is associated with lower rates of POPF.

Risk factors and medico-economic effect of pancreatic fistula after pancreaticoduodenectomy.

The study aimed to uncover the risk factors for the new defined pancreatic fistula (PF) and clinical related PF (CR-PF) after pancreaticoduodenectomy (PD) surgery and to evaluate the medico-economic effect of patients. A total of 412 patients were classified into two groups according to different criteria, PF and NOPF according to PF occurrence: CR-PF (grades B and C) and NOCR-PF (grade A) based on PF severity. A total of 28 factors were evaluated by univariate and multivariate logistic regression test. Hospital charges and stays of these patients were assessed. The results showed that more hospital stages and charges are needed for patients in PF and CR-PF groups than in NOPF and NOCR-PF groups (P < 0.05). The excessive drinking, soft remnant pancreas, preoperative albumin, and intraoperative blood transfusion are risk factors affecting both PF and CR-PF incidence. More professional surgeons can effectively reduce the PF and CR-PF incidence. Patients with PF and CR-PF need more hospital costs and stages than that in NOPF and NOCR-PF groups. It is critical that surgeons know the risk factors related to PF and CR-PF so as to take corresponding therapeutic regimens for each patient.

Application of air insufflation to prevent clinical pancreatic fistula after pancreaticoduodenectomy.

To introduce an air insufflation procedure and to investigate the effectiveness of air insufflation in preventing pancreatic fistula (PF). From March 2010 to August 2013, a total of 185 patients underwent pancreaticoduodenectomy (PD) at our institution, and 74 patients were not involved in this study for various reasons. The clinical outcomes of 111 patients were retrospectively analyzed. The air insufflation test was performed in 46 patients to investigate the efficacy of the pancreaticojejunal anastomosis during surgery, and 65 patients who did not receive the air insufflation test served as controls. Preoperative assessments and intraoperative outcomes were compared between the 2 groups. Univariate and multivariate analyses were performed to identify the risk factors for PF. The two patient groups had similar baseline demographics, preoperative assessments, operative factors, pancreatic factors and pathological results. The overall mortality, morbidity, and PF rates were 1.8%, 48.6%, and 26.1%, respectively. No significant differences were observed in either morbidity or mortality between the two groups. The rate of clinical PF (grade B and grade C PF) was significantly lower in the air insufflation test group, compared with the non-air insufflation test group (6.5% vs 23.1%, P = 0.02). Univariate analysis identified the following parameters as risk factors related to clinical PF: estimated blood loss; pancreatic duct diameter ≤ 3 mm; invagination anastomosis technique; and not undergoing air insufflation test. By further analyzing these variables with multivariate logistic regression, estimated blood loss, pancreatic duct diameter ≤ 3 mm and not undergoing air insufflation test were demonstrated to be independent risk factors. Performing an air insufflation test could significantly reduce the occurrence of clinical PF after PD. Not performing an air insufflation test was an independent risk factor for clinical PF.