Clinical Postoperative Pancreatic Fistula Research Articles

Prevalence of Malnutrition and the Value of Predicting Pancreatic Fistula in Patients with Laparoscopic Pancreatoduodenectomy.

Background: Pancreatoduodenectomy is a standard surgical procedure for periampullary tumors. With recent improvements in perioperative management, postoperative mortality has decreased significantly in recent years; however, postoperative pancreatic fistula (POPF) is still one of the most prevalent and dangerous complications. The purpose of this study was to analyze the prevalence of malnutrition and the value of predicting POPF in patients with laparoscopic pancreatoduodenectomy (LPD). Methods: We retrospectively analyzed the perioperative data of 747 patients undergoing LPD in the Department of Hepatobiliary and Pancreatic Surgery, The First Hospital of Jilin University, China. Simultaneously, we analyzed the prevalence rate of malnutrition with three different nutritional assessment scores and explored the independent risk variables for POPF to identify potential predictive value. Results: Malnutrition was observed in 20.1% of patients with the prognostic nutritional index (PNI), 85.0% of patients with the controlling nutritional status (CONUT) score, and 73.1% of patients with the NRI score. Univariate and multivariate analyses all showed that the risk factors for POPF were pancreatic texture, pancreatic duct diameter, abdominal infection, body mass index (BMI), nomogram-revised risk index (NRI), and PNI. The receiver operating characteristic curve indicated that the BMI/PNI ratio was capable of predicting the occurrence of clinical POPF following LPD, with an area under the curve of 0.708. Conclusions: Compared with no malnourished patients, malnutrition is associated with a higher risk of POPF among patients with LPD. In addition, the BMI/PNI ratio has some predictive value in the development of POPF following LPD.

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.

Preoperative risk assessment for postoperative pancreatic fistula (POPF): Image-based calculation of duct-to-parenchyma (D/P) ratio and an Alignment of Duct and Mucosa (ADAM) anastomosis may lead to a low POPF rate-results from 386 patients.

Postoperative pancreatic fistula (POPF) is the most critical complication after pancreatoduodenectomy (PD). Preoperative identification of high-risk patients and optimal pancreatic reconstruction technique can be a way to reduce postoperative complications. A series of 386 patients underwent PD over a 10-year period (2009-2019). On routinely performed preoperative computed tomography (CT) images, the ventro-dorsal diameters of duct (D) and parenchyma (P) were measured in the cutting plane at the superior mesenteric vein. Then, the ratio of both values was calculated (D/P ratio) Double-layer pancreatojejunostomy with alignment of duct and mucosa (ADAM) by two monofilament threads (MFT) was performed in 359 patients and pancreatogastrostomy (PG) in 27 patients. The incidence of POPF was diagnosed according to the International Study Group for Pancreatic Fistula criteria. The overall rate of POPF was 21% (n = 80), and the rate of clinically relevant type B/C fistulas 6.5% (n = 25). A D/P ratio of <0.2 was significantly associated with type B/C fistula (11%, p < 0.01). In low-risk patients (D/P ratio >0.2), type B/C fistula occurred only in 2%, and in high-risk patients (D/P ratio <0.2) in 9%. ADAM anastomosis was performed safely by two different surgeons. A PG anastomosis had double-digit POPF rates in all groups. Preoperative CT imaging with D/P measurement may predict the risk of POPF development. A cut off D/P ratio of <0.2 was significantly associated with clinical relevant POPF. ADAM anastomosis may be an option for pancreatojejunostomy. However, preoperative knowledge of the D/P ratio could guide decision-making for primary pancreatectomy when pancreatic reconstruction is critical.

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.

Safety and efficacy of robot-assisted versus open pancreaticoduodenectomy: a meta-analysis of multiple worldwide centers.

The objective of the study is to compare the safety and efficacy of robot-assisted pancreaticoduodenectomy (PD) with open PD. The PubMed, EMBASE and Cochrane Library databases were searched for the literature available from their respective inception dates up to May 2020 to find studies comparing robot-assisted pancreaticoduodenectomy (RPD) with open pancreaticoduodenectomy (OPD). The RevMan 5.3 statistical software was used for analysis to evaluate surgical outcome and oncology safety. The combination ratio (RR) and weighted mean difference (WMD) and their 95% confidence intervals (CIs) were calculated using fixed-effect or random effect models. 18 cohort studies from 16 medical centers were eligible with a total of 5795 patients including 1420 RPD group patients and 4375 OPD group patients. The RPD group fared better than the OPD group in terms of estimated blood loss (EBL) (WMD = - 175.65, 95% CI (- 251.85, - 99.44), P < 0.00001), wound infection rate (RR = 0.60, 95% CI (0.44, 0.81), P = 0.001), reoperation rate (RR = 0.61, 95% CI (0.41, 0.91), P = 0.02), hospital day (WMD = - 2.95, 95% CI (- 5.33, - 0.56), P = 0.02), intraoperative blood transfusion (RR = 0.56, 95% CI (0.42, 0.76), P = 0.0001), overall complications (RR = 0.78, 95% CI (0.64, 0.95), P = 0.01), and clinical postoperative pancreatic fistula (POPF) (RR = 0.54, 95% CI (0.41, 0.70), P < 0.0001). In terms of lymph node clearance (WMD = 0.48, 95% CI (- 2.05, 3.02), P = 0.71), R0 rate (RR = 1.05, 95% CI (1.00, 1.11), P = 0.05), postoperative pancreatic fistula (RR = 1, 95% CI (0.85, 1.19), P = 0.97), bile leakage (RR = 0.99, 95% CI (0.54, 1.83), P = 0.98), delayed gastric emptying (DGE) (RR = 0.79, 95% CI (0.60, 1.03), P = 0.08), 90-day mortality (RR = 0.82, 95% CI (0.62, 1.10), P = 0.19), and severe complications (RR = 0.98, 95% CI (0.71, 1.36), P = 0.91), and there were no significant differences between the two groups. Robotic surgery was inferior to open surgery in terms of operational time (WMD = 80.85, 95% CI (16.09, 145.61), P = 0.01). RPD is not inferior to OPD, and it is even more advantageous for EBL, wound infection rate, reoperation rate, hospital stay, intraoperative transfusion, overall complications and clinical POPF. However, these findings need to be further verified by high-quality randomized controlled trials.

Association between intraoperative and postoperative epidural or intravenous patient-controlled analgesia and pancreatic fistula after distal pancreatectomy.

This study aimed to elucidate the association between postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) and clinicopathological factors and intraoperative and postoperative epidural or intravenous patient-controlled analgesia (IV-PCA). We reviewed data of 116 patients who underwent distal pancreatectomy at Gunma University Hospital from October 2000 to October 2019. Clinical POPF was defined as the International Study Group of Pancreatic Fistula grade B or C. Intraoperative and postoperative analgesia included fentanyl-mediated IV-PCA (n = 37, 32%), fentanyl-mediated epidural analgesia (n = 39, 34%), and morphine-mediated epidural analgesia (n = 40, 34%). All patients had received analgesia. Clinical POPF occurred in 34 of the 116 (29%) DP cases. Male sex (P = 0.035) and the length of operation time (P = 0.0070) were significant risk factors of clinical POPF. Furthermore, a thick pancreas was more likely to cause clinical POPF than a thin one (P = 0.052). No statistically significant difference was found between other factors, including intraoperative and postoperative analgesia (P = 0.95), total median oral morphine equivalents (P = 0.23), and clinical POPF. Intraoperative and postoperative epidural analgesia and IV-PCA are not associated with clinical POPF after DP. Our results suggest that morphine and fentanyl can be used as IV-PCA or epidural analgesia.

Usefulness of Drain Lipase to Predict Postoperative Pancreatic Fistula After Distal Pancreatectomy

Postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) is a worrisome and life-threatening complication. The aim of this study was to clarify the risk factors and to find the early detective method of POPF after DP. From January 2010 through December 2014, 37 patients underwent DP and were enrolled in this study to examine the factors predictive of clinical POPF after DP. POPF was defined and classified according to the International Study Group of Pancreatic Surgery guideline 2016. Biochemical leakage occurred in 14 (37.8%) patients, grade B POPF in 16 (43.2%) patients, and no grade C POPF in any patient. Clinical POPF (grade B/C) occurred in 43.2% of patients. Multivariate analysis revealed pancreatic thickness ≥ 14 mm to be the independent preoperative risk factors predictive of POPF. Receiver operating characteristic curves showed that the drain lipase ≥ 800 IU/L on postoperative day 4 could distinguish clinical POPF from non-clinical POPF effectively. Sensitivity, specificity, and accuracy were 93.8%, 70.0%, and 80.6% respectively. Pancreatic thickness ≥ 14 mm was the independent preoperative predictive risk factors for POPF. A drain lipase level of ≥800 IU/L on POD 4 was useful to find clinical POPF after DP.

Feasibility, Morbidity and Mortality in Two Hundred Consecutive Cases of Pancreaticogastrostomy After Pancreaticoduodenectomy

BackgroundPostoperative mortality associated with pancreaticoduodenectomy (PD) in high-volume hospitals is below 5%, yet morbidity rates range between 45% and 60%. Recent studies show a lower incidence of complications and postoperative pancreatic fistula (POPF) in pancreaticogastrostomy (PG). The primary objective was to assess the incidence and predictive factors for complications: POPF, post-pancreatectomy hemorrhage (PPH) and delayed gastric emptying (DGE) following the criteria of the ISGPS and Clavien-Dindo classifications. MethodsA prospective observational study that included all patients who underwent PD between 2008 and 2016. PG was the surgical procedure of choice for PD reconstruction. ResultsTwo hundred forty-nine (249) patients underwent surgery with intention of performing a PD. The feasibility of PG was 90.5%. One hundred and six (53%) patients had complications, 36 (18%) were severe (Clavien-Dindo grade ≥ III). Death within 90 postoperative days was 4%. DGE was the most frequent complication (22.5%), followed by PPH (21%). The clinical POPF rate was 15% (6% Clavien-Dindo grade ≥ III). The primary risk factors associated with complications were age >70 years (1.9 [1–3.55]), being male (1.89 (1; 3.6]) and soft pancreatic texture (3.38 [1.5; 7.37]). ConclusionsIn this paper, we report a feasibility study for PG (90.5%). The primary risk factors associated with complications are age >70 years, being male and soft pancreatic texture. Soft pancreatic texture is also associated with the development and severity of POPF.

Factibilidad y morbimortalidad en doscientos casos consecutivos de pancreaticogastrostomía después de duodenopancreatectomía

BackgroundPostoperative mortality associated with pancreaticoduodenectomy (PD) in high-volume hospitals is below 5%, yet morbidity rates range between 45% and 60%. Recent studies show a lower incidence of complications and postoperative pancreatic fistula (POPF) in pancreaticogastrostomy (PG). The primary objective was to assess the incidence and predictive factors for complications: POPF, post-pancreatectomy hemorrhage (PPH) and delayed gastric emptying (DGE) following the criteria of the ISGPS and Clavien-Dindo classifications. MethodsA prospective observational study that included all patients who underwent PD between 2008 and 2016. PG was the surgical procedure of choice for PD reconstruction. ResultsTwo hundred forty-nine patients underwent surgery with intention of performing a PD. The feasibility of PG was 90.5%. One hundred and six (53%) patients had complications, 36 (18%) were severe (Clavien-Dindo grade ≥III). Death within 90 postoperative days was 4%. DGE was the most frequent complication (22.5%), followed by PPH (21%). The clinical POPF rate was 15% (6% Clavien-Dindo grade ≥III). The primary risk factors associated with complications were age >70 years (1.9 [1-3.55]), being male (1.89 [1; 3.6]) and soft pancreatic texture (3.38 [1.5; 7.37]). ConclusionsIn this paper, we report a feasibility study for PG (90.5%). The primary risk factors associated with complications were age >70 years, being male and soft pancreatic texture. Soft pancreatic texture is also associated with the development and severity of POPF.

Best methods to minimize pancreatic fistula after pancreatoduodenectomy: 15 years experience

Background: Postoperative pancreatic fistula(POPF) remains the most life-threaten major complication after pancreatoduodenectomy(PD). Despite numerous trials comparing anastomosis method and duct stent type, there are no consensus regarding the ideal surgical technique. In this study, we retrospectively analyzed the surgical outcomes after PD at single center. Methods: Between June 2001 and May 2015, 500 consecutive patients received PD at Gangnam severance hospital. All patients received same procedure. Duct to mucosa Pancreaticojejunostomy with internal stenting was performed. We analyzed operative time, estimated blood loss, length of hospital stay and complications. Results: Operation time, estimated blood loss, length of hospital stay and clinical relevant POPF rate decreased steadily and first plateau was noted after 100 cases. After 100 cases, Average clinical relevant POPF rate was 6.75%. Conclusion: Consistent practice of standardized technique may decrease the rate of clinical relevant POPF. It is important to stabilize surgical methods before comparing new anastomosis methods.

Best methods to minimize pancreatic fistula after pancreatoduodenectomy: 15 years experience

Background: Postoperative pancreatic fistula(POPF) remains the most life-threaten major complication after pancreatoduodenectomy(PD). Despite numerous trials comparing anastomosis method and duct stent type, there are no consensus regarding the ideal surgical technique. In this study, we retrospectively analyzed the surgical outcomes after PD at single center. Methods: Between June 2001 and May 2015, 500 consecutive patients received PD at Gangnam severance hospital. All patients received same procedure. Duct to mucosa Pancreaticojejunostomy with internal stenting was performed. We analyzed operative time, estimated blood loss, length of hospital stay and complications. Results: Operation time, estimated blood loss, length of hospital stay and clinical relevant POPF rate decreased steadily and first plateau was noted after 100 cases. After 100 cases, Average clinical relevant POPF rate was 6.75%. Conclusion: Consistent practice of standardized technique may decrease the rate of clinical relevant POPF. It is important to stabilize surgical methods before comparing new anastomosis methods.

Is there any different risk factor for clinical relevant pancreatic fistula according to the stump closure method following left-sided pancreatectomy?

Backgrounds/AimsConsistency on risk factors for postoperative pancreatic fistula (POPF) after left-sided pancreatectomy (LP) according to the stump closure methods has not been revealed. Appropriate surgical stump closure method after LP is still in debate. This study investigates risk factors for POPF according to the closure methods in LP.MethodsA total of 49 consecutive patients underwent LP with a stapler closure (ST) or hand-sewn closure (HS) between June 2001 and September 2016. The risk factors of pancreatic fistulas were investigated in 49 LPs according to stump closure methods, HS (n=19), and ST (n=30).ResultsThere was no significant difference in the incidence of overall POPF (HS 42.1% vs. ST 50.0%) and clinical relevant POPF (CR-POPF) (HS 5.3% vs. ST 6.7%) between two groups. In the ST group, the pancreas was significantly thick in patients with CR-POPF (27 mm vs. 17 mm) and the tumor was also larger (58 mm vs. 27 mm). In the HS group, the operation time was longer in CR-POPF group (515 min vs 292 min). In univariate analysis, wider diameter of the pancreatic duct (27 mm vs 16 mm) was associated with POPF in the HS group. There was no meaningful risk factor for POPF in the ST group.ConclusionsIncidence of overall POPF between the ST and HS group were clinically insignificant in this study. The thickness of the pancreas and the tumor diameter are factors significantly associated with CR-POPF in the ST group. Long operation time was the only factor associated with CR-POPF in the HS group.

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.

Preoperative body mass index-to-prognostic nutritional index ratio predicts pancreatic fistula after pancreaticoduodenectomy.

Estimating or scoring the risk of post-operative pancreatic fistula (POPF) may help with selection of high-risk patients and individualized patient consent. However, there are no simple and reliable preoperative predictors of POPF used in daily clinical practice. We investigated the utility of body mass index-to-prognostic nutritional index (BMI/PNI) ratio as a preoperative marker to predict the development of POPF in 87 patients undergoing pancreaticoduodenectomy. The overall incidence of clinical (grade B/C) POPF was 17% (15 of 87 patients). Among various pre-, intra-, and post-operative variables analyzed, higher BMI and lower PNI were identified as independent predictors for POPF by multivariate analysis. We therefore investigated BMI/PNI ratio as a preoperative predictor for POPF. BMI/PNI ratio was significantly higher in patients with POPF than in those without POPF (0.54 vs. 0.45, P=0.0007). A receiver operating characteristic (ROC) curve analysis demonstrated a fair capability of BMI/PNI ratio to predict the occurrence of POPF (area under the ROC curve 0.781). With a cut-off value of 0.5, the sensitivity, specificity, and diagnostic accuracy of BMI/PNI ratio to predict POPF was 73%, 74%, and 74%, respectively. In particular, when restricted to a subgroup of elderly (≥75 years old) male patients, the sensitivity, specificity, and diagnostic accuracy of BMI/PNI ratio was 100%, 100%, and 100%, respectively. The BMI/PNI ratio is a simple preoperative marker to predict the occurrence of POPF after pancreaticoduodenectomy.

A modified single/double-layer duct-to-mucosa pancreaticojejunostomy reduces pancreatic fistula after pancreaticoduodenectomy based on 681 cases in a single center

Objective: Postoperative pancreatic fistula (POPF) is one of the most common and intractable complications after pancreaticoduodenectomy (PD). This study aimed to evaluate the efficacy of a modified single/double-layer duct-to-mucosa pancreaticojejunostomy (PJ) for prevention of POPF. Methods: PJ was modified to:1)transpancreatic single-layer duct-to-mucosa anastomosis when pancreatic duct is of >3 mm in diameter and parenchyma is thinner, and2)pure duct-to-mucosa anastomosis followed by transpancreatic and seromuscular closure when pancreatic duct is of ≤3 mm in diameter and parenchyma is thicker. 294 consecutive patients who underwent modified PJ (diameter-based single/double-layer duct-to-mucosa anastomosis) between May 2012 and April 2014, versus a histological control of 387 patients who underwent conventional PJ between January 2010 and April 2012 were retrospectively analyzed. The clinicopathological features and surgical outcomes were compared with a particular focus on POPF.Table.Intraoperative parameters and postoperative resultsConventional (n = 387)Modified (n = 294)P ValuePPPD/PD203/184210/84P < 0.05Combined PV Ex1416NSEBL (ml)381 ± 285366 ± 192NSBlood transfusion (ml)460 ± 1230370 ± 970NSPancreatic duct ϕ (mm)3.6 ± 1.63.9 ± 2.5NSParenchyma (soft/hard)188/199132/162NSDuctal dilatation n (%)123 (31.8%)112 (38.1%)NSOperation time (mm)296 ± 53287 ± 49NSPOPF n (A:B:C)45 (20:12:13)3 (3:0:0)<0.01Intraabdominal120<0.01Bleeding nHospital stay (d)23 ± 1421 ± 9<0.05Mortality n (%)10 (1.47%)0<0.01 Open table in a new tab [Modified PJ and outcomes] Results: No significant difference was found in the baseline clinicopathological characteristics between the modified and conventional groups, except in the incidence of concurrent diabetes. Despite that a higher proportion of patients underwent pylorus-preserving pancreaticoduodenectomy (PPPD) in the modified group, there was no significant difference with respect to the intraoperative parameters, eg. blood loss, requirement of transfusion, diameter of pancreatic duct and operation time. Postoperative morbidities, including POPF (11.6% vs. 1.0%, p < 0.01), intraabdominal bleeding (3.1% vs. nil, p < 0.01), and mortality (1.47% vs. nil, p < 0.01) were significantly lower in modified group. There were no clinical relevant POPF (Grade B/C) in modified group. Conclusions: The modified PJ reduces the postoperative morbidity and mortality with zero-incidence of clinical relevant POPF.

Measure of pancreas transection and postoperative pancreatic fistula

BackgroundIn pancreaticoduodenectomy (PD), a standard protocol for pancreas transection has not been established although the method of pancreas transection might be involved in the occurrence of postoperative pancreatic fistula (POPF). This study aimed to compare whether pancreas transection by ultrasonically activated shears (UAS) or that by scalpel contributed more to POPF development. MethodsA prospective database of 171 patients who underwent PD for periampullary tumor at National Cancer Center Hospital East between January 2010 and June 2013 was reviewed. Among the 171 patients, 93 patients with soft pancreas were specifically included in this study. Surgical results and background were compared between patients with pancreas transection by UAS and scalpel to evaluate the effectiveness of UAS on reducing POPF. ResultsBody mass index, main pancreatic duct diameter, or other clinicopathologic factors that have been reported as predictive factors for POPF were not significantly different between the two groups. The incidence of all grades of POPF and that of grade B were significantly lower in the scalpel group (52%, 4%) than in the UAS group (74%, 42%). Postoperative complications ≥ grade III were also significantly fewer in the scalpel group. ConclusionsScalpel transection was less associated with POPF than UAS transection in patients who underwent PD for soft pancreas. The method of pancreas transection plays an important role in the prevention of clinical POPF.

Does international study group on pancreatic fistula (ISGPF) classification need modification after distal pancreatectomy?

Backgrounds/AimsFew reports have validated the clinical postoperative pancreatic fistula (PF) after distal pancreatectomy. The study intended to validate the predictability for clinical PF of drain amylase and lipase and to find out more appropriate postoperative day (POD) for diagnostic criterion of PF.MethodsA total of 154 patients underwent distal pancreatectomy. We used the clinical database registry system of the Gangnam Severance Hospital and Severance Hospital, Yonsei University Health System for these analyses. The receiver operating characteristic curve of the drain amylase or lipase concentration on each day was used to predict clinical PF (International Study Group on Pancreatic Fistula [ISGPF] grade B or C) and areas under the curves (AUC) were compared.ResultsAmylase and lipase AUC values poorly predicted clinical PF before POD 3 and, gradually increased until POD 5 and became well correlated with clinical PF (ISGPF grade B or C). In contrast, the prediction of clinical PF using drain lipase did not differ from that using drain amylase. The drain amylase concentration on POD 6 was most precisely correlated with clinical PF.ConclusionsClinical PF prediction was validated by using drain amylase and lipase concentrations, in which drain amylase assessment at POD 6 appeared to be an appropriate diagnostic criterion of PF after distal pancreatectomy. We suggest some modification of ISGPF definition, especially for distal pancreatectomy.

Usefulness of Drain Amylase, Serum C‐Reactive Protein Levels and Body Temperature to Predict Postoperative Pancreatic Fistula After Pancreaticoduodenectomy

Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) is a worrisome and life-threatening complication. Recently, early drain removal has been recommended as a means of preventing POPF. The present study sought to determine how to distinguish clinical POPF from non-clinical POPF in the early postoperative period after PD to aid in early drain removal. From March 2002 through December 2010, 176 patients underwent PD and were enrolled in this study to examine factors predictive of clinical POPF after PD. POPF was defined and classified according to the International Study Group of Pancreatic Surgery guideline, and grade B/C POPF was defined as clinical POPF. Grade A POPF occurred in 39 (22.2 %) patients, grade B in 19 (10.8 %) patients, and grade C in 11 (6.3 %) patients. Clinical POPF (grade B/C) occurred in 17.1 % of patients. Multivariate analysis revealed male gender and body mass index (BMI) ≥22.5 kg/m(2) to be the independent preoperative risk factors predictive of POPF. Receiver operating characteristic curves showed that the combination of drain amylase ≥750 IU/L, C-reactive protein (CRP) ≥20 mg/dL, and body temperature ≥37.5 °C on postoperative day 3 could effectively distinguish clinical POPF from non-clinical POPF. Sensitivity, specificity, and accuracy were 84.6, 98.2, and 95.7 %, respectively. Male gender and BMI ≥22.5 were the independent preoperative predictive risk factors for POPF. We assume that when amylase is <750 IU/L, serum CRP is <20 mg/dL, and body temperature is <37.5 °C the drain can safely be removed, even if POPF is indicated.

Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy for pancreatic or periampullary tumours: a multicentre randomised trial

Postoperative pancreatic fistula is the leading cause of death and morbidity after pancreaticoduodenectomy. However, the best reconstruction method to reduce occurrence of fistula is debated. We did a multicentre, randomised superiority trial to compare the outcomes of different reconstructive techniques in patients undergoing pancreaticoduodenectomy for pancreatic or periampullary tumours. Patients aged 18-85 years with confirmed or suspected neoplasms of the pancreas, distal bile duct, ampulla vateri, duodenum, or periampullary tumours were eligible for inclusion. An internet-based platform was used to randomly assign patients to either pancreaticojejunostomy or pancreaticogastrostomy as reconstruction after pancreaticoduodenectomy, using permuted blocks with six patients per block. Within each centre the randomisation was stratified on the pancreatic duct diameter (≤3 mm vs >3 mm) measured at the time of surgery. The primary endpoint was the occurrence of clinical postoperative pancreatic fistula (grade B or C) as defined by the International Study Group on Pancreatic Fistula. The study was not masked and analyses were done by intention to treat. Patient follow-up was closed 2 months after discharge from the hospital. This study is registered with ClinicalTrials.gov, number NCT00830778. Between June, 2009, and August, 2012, we randomly allocated 167 patients to receive pancreaticojejunostomy and 162 to receive pancreaticogastrostomy. 33 (19.8%) patients in the pancreaticojejunostomy group and 13 (8.0%) in the pancreaticogastrostomy group had clinical postoperative pancreatic fistula (OR 2.86, 95% CI 1.38-6.17; p=0.002). The overall incidence of postoperative complications did not differ significantly between the groups (99 in the pancreaticojejunostomy group vs 100 in the pancreaticogastrostomy group), although more events in the pancreaticojejunostomy group were of grade ≥3a than in the pancreaticogastrostomy group (39 vs 35). In patients undergoing pancreaticoduodenectomy for pancreatic head or periampullary tumours, pancreaticogastrostomy is more efficient than pancreaticojejunostomy in reducing the incidence of postoperative pancreatic fistula. Funding Johnson & Johnson Medical Devices, Belgium.

A New Surgical Technique of Transduodenal Pancreatic Juice Drainage Prevents Pancreatic Fistula following Distal Pancreatectomy

Although, a variety of techniques have been described to reduce the risk of postoperative pancreatic fistula, there is no consensus on appropriate technique for closure of the pancreatic remnant after distal pancreatectomy. We developed a new surgical technique, transduodenal pancreatic juice drainage, for preventing postoperative pancreatic fistula. The procedure involves a transduodenal approach. A pancreatic stent was inserted into the main pancreatic duct from the papilla of Vater to its the distal side, and continuous suction drainage was performed. The pancreatic parenchyma was divided using a knife, and the main pancreatic duct was ligated. The cut surface of the remaining pancreas was closed by hand suturing. This procedure was performed on 10 patients, and none of them developed clinical postoperative pancreatic fistula. We consider our transduodenal pancreatic juice drainage technique to be an effective procedure for preventing postoperative pancreatic fistula in patients who have undergone distal pancreatectomy.