Complications Of Pancreatic Surgery Research Articles

Reduction of Postoperative Complications in Pancreatic Surgery by Standardizing Perioperative Management: An Observational Cohort Study

Introduction: Resection for pancreatic malignancy remains the gold standard for cure. Postoperative morbidity continues to be high even after technical innovations. This study evaluates the effectiveness of a standard perioperative pancreatic oncological surgery step-by-step protocol in reducing organ-specific complications. Methods: In this observational cohort study, we analyzed the outcomes of oncologic pancreatic head resections from 2015 to 2022 after the implementation of a standard perioperative fail-safe protocol and compared these data with a historical cohort (2013–2014). In the study group, all patients were treated with preoperative limited mechanical bowel preparation, administration of a somatostatin analog, and a “pancreatic duct tube” in pancreatoduodenectomy. The primary outcome measure was the occurrence of postoperative organ-specific complications. Results: A total of 151 patients were included in this study. The rate of postoperative pancreatic fistula (grade B and C) in the fail-safe group was 4.2%. Other organ-specific complications as postoperative hemorrhage (2.5%) and delayed gastric emptying (9.2%) also occurred less frequent than before implementation of the fail-safe protocol. Conclusion: The use of this standardized fail-safe protocol for oncologic pancreatoduodenectomy can lead to a low postoperative morbidity with improved surgical outcomes.

Extracellular volume fraction derived from dual-energy CT: a potential predictor for acute pancreatitis after pancreatoduodenectomy.

To investigate the value of extracellular volume (ECV) fraction and fat fraction (FF) derived from dual- energy CT (DECT) for predicting postpancreatectomy acute pancreatitis (PPAP) after pancreatoduodenectomy (PD). This retrospective study included patients who underwent DECT and PD between April 2022 and September 2022. PPAP was determined according to the International Study Group for Pancreatic Surgery (ISGPS) definition. Iodine concentration (IC) and FF of the pancreatic parenchyma were measured on preoperative DECT. The ECV fraction was calculated from iodine map images of the equilibrium phase. The independent predictors for PPAP were assessed by univariate and multivariable logistic regression analysisand receiver operating characteristic (ROC) curve analysis. Sixty-nine patients were retrospectively enrolled (median age, 60 years; interquartile range, 55-70 years; 47 men). Of these, nine patients (13.0%) developed PPAP. These patients had lower portal venous phase IC, equilibrium phase IC, FF, and ECV fraction, and higher pancreatic parenchymal-to-portal venous phase IC ratio and pancreatic parenchymal-to-equilibrium phase IC ratio, compared with patients without PPAP. After multivariable analysis, ECV fraction was independently associated with PPAP (odd ratio [OR], 0.87; 95% confidence interval [CI]: 0.79, 0.96; p < 0.001), with an area under the curve (AUC) of 0.839 (sensitivity 100.0%, specificity 58.3%). A lower ECV fraction is independently associated with the occurrence of PPAP after PD. ECV fraction may serve as a potential predictor for PPAP after PD. DECT-derived ECV fraction of pancreatic parenchyma is a promising biomarker for surgeons to preoperatively identify patients with higher risk for postpancreatectomy acute pancreatitis after PD and offer selective perioperative management. PPAP is a complication of pancreatic surgery, early identification of higher-risk patients allows for risk mitigation. Lower DECT-derived ECV fraction was independently associated with the occurrence of PPAP after PD. DECT aids in preoperative PAPP risk stratification, allowing for appropriate treatment to minimize complications.

The impact of lymphangiograpy on chyle leakage treatment duration after pancreatic surgery.

Chyle leakage (CL) is a common complication in pancreatic surgery. Lymphangiography is a therapeutic option for CL in cases of conservative treatment failure. This study investigated the effect of lymphangiography on the healing time of CL. We retrospectively evaluated 283 patients who underwent pancreatic resection between January 2016 and June 2022. The risk factors for CL and the treatment period were evaluated according to whether or not lymphangiography was performed. Of the 29 patients (10.2%) that had CL, lymphangiography was performed in 6. Malignant disease, the number of harvested lymph nodes, and drain fluid volume on postoperative day 2 were identified as independent risk factors for CL. Lymphangiography was associated with the cumulative healing rate of CL, and patients who underwent lymphangiography had a significantly shorter treatment period. No lymphangiography-related adverse events were observed. Lymphangiography is a feasible and safe treatment option for CL. The CL treatment period after pancreatic surgery was significantly shorter in patients who underwent lymphangiography than in those who did not. Our results suggest that lymphangiography may contribute to early improvement of persistent CL.

Minimally invasive correction of complications of pancreatic surgery

Minimally invasive correction of complications of pancreatic surgery

Observational retrospective study on amylase dosage and severity of pancreatic fistula

Background: Pancreatic fistula is a complication in pancreatic surgery. It is important to predict its occurrence to guide postoperative management. There are few studies on the correlation between amylase levels in the drainage fluid and the risk of pancreatic fistula. The aim of the study was to determine whether the amylase level on postoperative day 3 can predict the severity of pancreatic fistula. Material and methods: A retrospective study was performed in patients who underwent duodenopancreatectomy to evaluate the relationship between the amylase value in intra-abdominal drainage on postoperative day 3 and the severity of pancreatic fistula. The relationship between surgical and conventional biochemical results was analyzed. Student's t-test was used for statistical analysis with a value of p&lt;0.05 considered significant. Results: No significant differences or statistically significant correlations were found between the groups evaluated. Conclusion: Isolated measurement of amylase in draining fluid in the early postoperative period is not sufficient but is very useful in predicting the occurrence of FP associated with complications and prolonged hospital stay. Further research is required to reduce its incidence.

External validation of scores predicting postoperative fistula after pancreatogastrostomy for pancreatoduodenectomy reconstruction. A single center experience

BackgroundClinically relevant postoperative pancreatic fistula (CR-POPF) is the most frequent complication of pancreatic surgery and can be fatal. Selection and stratification of patients according to the risk of POPF are important for the perioperative management. Predictive metrics have been developed and validated in pancreatojejunostomy. Aim of this study is to assess whether the most used prognostic scores can be predictive of fistula following Wirsung-pancreaticogastrostomy (WPG) for pancreatoduodenectomy (PD)reconstruction. MethodThis single-center prospective observational study included 212 PDs between January 2008 and October 2022 with a standardized WPG. All component variables of the six scores were separately validated in our cohort. The overall predictive ability of the six fistula scores was measured and compared with the receiver operating characteristics curves (ROC) method and expressed by the area under the ROC-curve (AUC). Univariate and multivariate logistic regression analyses were performed considering all risk factors in the scores in order to identify variables independently correlated with POPF in the WPG. ResultsCR-POPF occurred in 36 of 212 (17 %) patients. All scores showed poor prognostic stratification for the development of CR-POPF. The occurrence of CR-POPF was associated with nine factors: male gender (p = 0.003); BMI (kg/m2) (p = 0.005); ASA (%) (p = 0.003); Soft pancreatic texture (%) (p = 0.003), Pathology (p = 0.008); MPD (p = 0.011); EBL (mL) (p = 0.021); Preop. Bilirubin (mg/dl) (p = 0.038); Preop. Glucose (mg/dl) (p = 0.0369). Male gender (OR: 5.54, CI 1.41–21.3) and soft consistency of the remnant pancreas (OR: 3.83, CI 1.14–12.8) were the only independent prognostic factors on multivariate analysis. ConclusionsOur study including exclusively pancreatogastrostomies failed to validate the most used predictive scores for POPF. We found that only male gender and soft pancreatic texture are associated with POPF. Specific predictive scores following pancreatogasgtrostomy are needed.

Re-assessing the role of peri-operative nutritional therapy in patients with pancreatic cancer undergoing surgery: a narrative review.

Pancreatic cancer is the most common medical condition that requires pancreatic resection. Over the last three decades, significant improvements have been made in the conditions and procedures related to pancreatic surgery, resulting in mortality rates lower than 5%. However, it is important to note that the morbidity in pancreatic surgery remains r latively high, with a percentage range of 30-60%. Pre-operative malnutrition is considered to be an independent risk factor for post-operative complications in pancreatic surgery, such as impaired wound healing, higher infection rates, prolonged hospital stay, hospital readmission, poor prognosis, and increased morbidity and mortality. Regarding the post-operative period, it is crucial to provide the best possible management of gastrointestinal dysfunction and to handle the consequences of alterations in food digestion and nutrient absorption for those undergoing pancreatic surgery. The European Society for Clinical Nutrition and Metabolism (ESPEN) suggests that early oral feeding should be the preferred way to initiate nourishing surgical patients as it is associated with lower rates of complications. However, there is ongoing debate about the optimal post-operative feeding approach. Several studies have shown that enteral nutrition is associated with a shorter time to recovery, superior clinical outcomes and biomarkers. On the other hand, recent data suggest that nutritional goals are better achieved with parenteral feeding, either exclusively or as a supplement. The current review highlights recommendations from existing evidence, including nutritional screening and assessment and pre/post-operative nutrition support fundamentals to improve patient outcomes. Key areas for improvement and opportunities to enhance guideline implementation are also highlighted.

The guideline for prevention and treatment of common complications after pancreatic surgery (2022)

In order to further standardize the prevention and treatment of postoperative complications of pancreatic surgery, the editorial board of the Chinese Journal of Surgery organized relevant experts to formulate this guideline under the promotion of the Study Group of Pancreatic Surgery in China Society of Surgery of Chinese Medical Association and Pancreatic Disease Committee of China Research Hospital Association. According to the grading of recommendations assessment, development, and evaluation system, this guide discusses the hot issues on postoperative complications such as pancreatic fistula, biliary fistula, chylous fistula, post-pancreatectomy hemorrhage, abdominal infection, delayed gastric emptying, etc., quantitatively evaluates the level of evidence in clinical studies, and forms recommendations after repeatedly consulting. It is hoped to provide reference for pancreatic surgeons in the prevention and treatment of postoperative complications.

Physiological stress level and screening for malnutrition as preoperative predictors of postoperative complications in pancreatic surgery: a retrospective study

BackgroundAssessment of ‘physiological stress levels’ and ‘nutritional status’ before surgery is important for predicting complications and indirect interventions on the pancreas. The aim of this study was to determine neutrophil–lymphocyte ratio (NLR) and nutritional risk index (NRI) indicators before surgery to predict 90-day complications and mortality in a cohort of patients with complicated chronic pancreatitis and cancer of the head of the pancreas.MethodsWe evaluated preoperative levels of NLR and NRI among 225 subjects treated at different centres located in three countries. Short-term outcomes included length of hospital stay, postoperative complications, and mortality at 90 days and were appreciated based on NLR and NRI. The level of physiological stress was divided according by the formulas: neutrophil–lymphocyte ratio (NLR) = (neutrophil count, %)/(lymphocyte count, %). The nutritional state of the patients was divided according to the INR: NRI = (1.519 × serum albumin, g/L) + (41.7 × present weight, kg / usual weight, kg)].ResultsAll patients were operated. An analysis of the operations performed in three institutions demonstrated mortality in chronic pancreatitis and pancreatic pseudocysts in 1.4%, in chronic pancreatitis and the presence of an inflammatory mass mainly in the pancreatic head in 1.2%, and in cancer of the pancreatic head in 5.9%. The mean preoperative NLR was normal in 33.8% of the patients, the mild physiologic stress level was 54.7%, and the moderate was 11.5% before surgery. 10.2% of patients had a normal nutritional status, 20% had mild, 19.6% had moderate, and 50.2% had severe malnutrition. In a univariate analysis, at the cutoff of NLR ≥ 9.5 (AUC = 0.803) and the cutoff of NRI ≤ 98.5 (AUC = 0.801), increasing the risk of complications was observed (hazard ratio, 2.01; 95% CI, 1.247–3.250, p = 0.006), but at the cutoff of NRI ≤ 83.55 (AUC = 0.81), we observed a survival difference in operated patients (hazard ratio, 2.15; 95% CI, 1.334–3.477, p = 0.0025).ConclusionsOur study demonstrated that NLR and NRI were predictors of postoperative complications, but only NRI was a predictor of 90-day mortality in patients after surgery.

Completion Pancreatectomy as a Treatment Option for Complications Following Pancreatoduodenectomy.

Pancreatoduodenectomy remains a complex abdominal operation for hpb surgeons. Significant complications keep on occurring to many patients undergoing Whipple procedure. We present ten patients, who required completion pancreatectomy in the early postoperative period after Whipples procedure, due to postoperative complications. Indications for completion pancreatectomy included: Sepsis secondary to uncontrolled GRADE C postoperative pancreatic fistula, pancreatic leak and bleeding, postoperative hemorrhage, pancreatic leak with gastrointestinal anastomosis dehiscence, and hepaticojejunal anastomosis dehiscence combined with hemorrhage. Completion pancreatectomy was carried out at a mean interval of 9 days following Whipple procedure. Six patients (60%) survived the operation and discharged from the hospital, with a median survival of 21.3 months. Four patients (40%) died in the early post-operative period due to sepsis (10%) and multiple organ failure (30%). Completion pancreatectomy after pancreatoduodenectomy is rarely indicated and it can be considered as a salvage procedure in the management of severe life-threatening post pancreatic surgery complications.

Drain fluid and serum amylase concentration ratio is the most reliable indicator for predicting postoperative pancreatic fistula after distal pancreatectomy

BackgroundPostoperative pancreatic fistula (POPF) is a major complication of pancreatic surgery. Drain fluid amylase concentration (DAC) is considered a predictive indicator of POPF. However, other indicators related to postoperative drain fluid amylase status exist, and the most reliable indicator for predicting POPF remains unclear. The object of this study is to identify the single most accurate indicator related to drain fluid amylase status of POPF after distal pancreatectomy (DP).MethodsThis single-institution retrospective study included 122 patients who underwent DP. The study was conducted between 2010 and 2022 at Gifu University Hospital. We statistically analyzed DAC, drain fluid amylase amount (DAA) calculated by multiplying DAC and daily drainage volume, and drain and serum amylase concentration ratio (DSACR) to assess the correlation with POPF.ResultsBased on the definition and grading of the International Study Group of Pancreatic Fistula, 24.6 (%) of the 122 patients had Grades B and C POPF. The result of the receiver operating characteristic (ROC) curve for predicting POPF after DP, DSACR had the highest area under curve(AUC) value among DAC, DAA, and DSACR both POD1 and POD3. The cutoff value of DSACR on POD1 was 17 (AUC 0.69, sensitivity 80.0%, specificity 58.2%, and accuracy 63.6%). The cutoff value of DSACR on POD3 was 22 (AUC 0.77, sensitivity 77.7%, specificity 73.3%, and accuracy 73.6%). Overall, DSACR on POD3 had the highest AUC value. Furthermore, a multivariate logistic regression analysis revealed that pancreatic texture (soft; odds ratio [OR] 9.22; 95% confidence interval [CI] 2.22–44.19; p < 0.01) and DSACR on POD3 (> 22; OR 8.76; 95% CI 2.78–31.59; p < 0.001) were independently associated with POPF after DP.ConclusionsDSACR is the most reliable indicator of drain fluid amylase status for predicting POPF after DP.

Utility of the Use of Hemostatics in the Prevention of Complications in Pancreatic Surgery

Utility of the Use of Hemostatics in the Prevention of Complications in Pancreatic Surgery

Visceral adiposity measurements as predictors of post-operative complications in pancreatic surgery

Background: Sarcopenia is characterized by progressive and generalized loss of skeletal muscle mass and quality. It has been well-established as an independent risk factor for post-surgical morbidity in certain disease processes. Several visceral adiposity measurements have been proposed as markers of sarcopenia however there is no consensus as to which is the most accurate in predicting post-operative morbidity. The objective of this study is to investigate the correlation between different visceral adiposity measurements and post-operative complications in patients undergoing pancreatic surgery for both benign and malignant disease.

Impact of Preoperative Biliary Profile Alteration on Complications in Pancreatic Surgery

Impact of Preoperative Biliary Profile Alteration on Complications in Pancreatic Surgery

Management of Refractory Pancreatic Fistula: A Review of Literature

Background Chronic non-healing or refractory pancreatic fistulae are rare complications of pancreatic surgery (pancreaticoduodenectomy, distal pancreatectomy) or pancreatitis. Materials and Methods We conducted a thorough literature search of electronic databases such as PubMed, Google Scholar, BioMed Central, and Cochrane Library using the keywords and medical subject headings (MeSH) terms “chronic pancreatic fistula”, “post-operative fistula”, “fistula management” and “refractory pancreatic fistula”. The purpose of this review is to evaluate the management options for refractory pancreatic fistula (PF). Results Literature reveals that refractory pancreatic fistulae have been managed by techniques like endoscopic ultrasound (EUS)-guided techniques like transmural puncture by clamping, puncture of the fistula tract, transmural placement of pigtail stent, and EUSguided pancreaticogastrostomy. Other techniques are postoperative endoscopic pancreatic stent placement in Grade C pancreatic fistula, intestinal decompression catheter insertion into the jejunum, embedding fistulojejunostomy, and fistulojejunostomy. Conclusion In conclusion, embedding fistulojejunostomy, EUS-guided transmural puncture by clamping, and EUS-guided transmural placement of pigtail stent are effective techniques for the management of refractory pancreatic fistulae. Yet further studies in a larger population are recommended.

Post pancreatic surgery complications; surgeon vs interventional interventional radiologists.

Even at high-volume centres, pancreatic resections are linked with a high rate of complications, as well as significant morbidity and mortality. In the management of these occurrences, a multidisciplinary approach is required, and interventional radiology plays an important role in the treatment of patients who develop post-surgical problems. The current review was planned to provide an overview of interventional radiological techniques that can be used to treat various types of problems following pancreatic resection. Percutaneous fluid collection drainage, percutaneous transhepatic biliary operations, artery embolisation, venous interventions, and fistula embolisation are feasible therapeutic alternatives with fewer problems than a re-look surgery. They also have a shorter hospital stay and faster recovery.

S2597 Gastrointestinal Hemorrhage From Hepaticojejunal Varices: A Rare Complication of Pancreaticoduodenectomy

Introduction: Ectopic varices are portosystemic collaterals that form outside the esophageal-gastric region and frequently pose a diagnostic and therapeutic challenge. Rarely, bleeding from ectopic varices can occur as a complication of pancreatic surgery. We describe a case of gastrointestinal bleeding from ectopic hepaticojejunal varices after pancreaticoduodenectomy. Case Description/Methods: A 66-year-old man with a history of intraductal papillary mucinous neoplasm (PMN) with high-grade dysplasia status post Whipple procedure two years previously, presented to the hospital with melena. His Whipple procedure had been complicated by splenic vein thrombosis and disease recurrence, necessitating further debridement three months prior to presentation. On examination, his vital signs were stable and there were no stigmata of liver disease. His laboratory tests were notable for a hemoglobin 8.0 g/dL (from baseline of 11 g/dL), platelets 174 × 109/L, BUN 29 mg/dL, INR 1.0. He initially underwent EGD and colonoscopy, which were unremarkable. A second look endoscopy was performed and deep intubation of the afferent limb revealed ectopic varices with stigmata of recent bleeding at the hepaticojejunostomy (Panel A). Cross-sectional imaging demonstrated a patent splenic vein but chronic occlusion of the portal and proximal superior mesenteric veins with cavernous transformation, extensive upper abdominal varices and splenomegaly (Panel B). There was no clinical or radiologic evidence of cirrhosis. After multidisciplinary discussion, an endovascular approach was deemed technically infeasible given extensive chronic mesenteric thrombus and a surgical approach was deemed prohibitively high-risk. The patient ultimately underwent endoscopic injection of 2-octyl cyanoacrylate into the ectopic varices and has remained without recurrent bleeding in over 5 months of follow-up. Discussion: Hemorrhage from ectopic jejunal varices following pancreatic surgery has previously been described in only a few case reports. Given the potential for vascular injury and local inflammation, these procedures can result in mesenteric venous thrombosis with subsequent ectopic variceal formation. If present, defining the vascular supply of varices with early multi-disciplinary involvement is paramount to their management. Multiple treatments have been reported, including portal venous stenting, embolization, and local sclerotherapy or cyanoacrylate injection as in this case.Figure 1.: (A) Ectopic varices (yellow arrows) are noted in the afferent limb at the hepaticojejunostomy. (B) Coronal view of computed tomography scan of abdomen demonstrating large upper abdominal collaterals (red arrow) that drain close to the afferent limb (white arrow).

Risk Factor Identification for Delayed Gastric Emptying after Distal Pancreatectomy-An Evaluation of 1688 Patients Based on the German StuDoQ|Pancreas Registry.

Delayed gastric emptying (DGE) ranks as one of the most frequent complications in pancreatic surgery. It leads to increased costs for healthcare systems, lengthened hospital stays and reduced quality of life. Data about DGE after distal pancreatectomy (DP) are scarce. The StuDoQ|Pancreas registry of the German Society of General and Visceral Surgery provided data of patients who underwent distal pancreatectomy from 1 January 2014 to 31 December 2018. The retrospective evaluation included comprehensive data: 1688 patients were enrolled; DGE occurred 160 times (9.5%); grade “A” was reported for 98 (61.3%), grade “B” for 41 (25.6%) and grade “C” for 21 (13.1%) patients. In univariate analysis pancreatic fistulas were associated with higher frequencies of intraabdominal abscesses (9.1% vs. 2%, p > 0.001), postpancreatectomy haemorrhage (8.1% vs. 3.7%, >0.001) and DGE (14.5% vs. 6%, p < 0.001). According to multivariate analysis, “abscesses with invasive therapy” (p < 0.001), “other surgical complications” (p < 0.001), prolonged “stays in ICU” (p < 0.001), lengthened duration of surgery (p < 0.001) and conventional surgery (p = 0.007) were identified as independent risk factors for DGE. Perioperative and postoperative factors were identified as risk factors for DGE. Following research should examine this highly relevant topic in a prospective, register-based manner. As there is no causal therapy for DGE, its avoidance is of major importance.

Prediction of severe postoperative complications in pancreatic surgery using the Preoperative Pancreatic Resection (PREPARE) score: a single-center observational study

Aim. To evaluate the effectiveness of the PREPARE score in predicting severe complications after pancreatic surgery.Materials and Methods. The case-control study included patients operated on the pancreas. Grade ≥III Clavien– Dindo complications were designated as “severe”. Patients were divided into two groups: “0–II degree” (control) and “III–V degree” (case). For all patients, scores were calculated, and risk categories were determined according to the PREPARE score.Results. The study included 151 patients: “0–II degree” – 102 (68%) observations, “III–V degree” – 49 (32%). ROC analysis was used for the scores (AUC = 0.616; 95% CI 0.527–0.706; p = 0.014) and for the risk categories (AUC = 0.555; 95% CI 0.463–0.648; p = 0.241) of the PREPARE score.Conclusion. The obtained data do not currently enable us to recommend the PREPARE score for predicting complications of pancreatic surgery.

The pancreas-to-muscle signal intensity ratio on T1-weighted MRI as a predictive biomarker for postoperative pancreatic fistula after distal pancreatectomy: a single-center retrospective study

BackgroundPostoperative pancreatic fistula (POPF) is one of the serious complications of pancreatic surgery. When POPF occurs and becomes severe, it causes secondary complications and a longer treatment period. We previously reported a correlation between pancreatic fibrosis and magnetic resonance imaging (MRI) findings, and MRI may have the potential to predict POPF. This study aimed to assess the predictive ability of the pancreas-to-muscle signal intensity ratio on T1-weighted MRI (SIR on T1-w MRI) for POPF after distal pancreatectomy (DP).MethodsThis single-institution retrospective study comprised 117 patients who underwent DP. It was conducted between 2010 and 2021 at the Gifu University Hospital. We statistically analyzed pre-, intra-, and postoperative factors to assess the correlation with POPF.ResultsAccording to the definition and grading of the International Study Group of Pancreatic Fistula (ISGPF), 29 (24.8%) of the 117 patients had POPF grades B and C. In the univariate analysis, POPF was significantly associated with the pancreas-to-muscle SIR on T1-w MRI, the drainage fluid amylase concentration (D-Amy) levels on postoperative day (POD) 1 and 3, white blood cell count on POD 1 and 3, C-reactive protein level on POD 3, and heart rate on POD 3. In multivariate analysis, only the pancreas-to-muscle SIR on T1-w MRI (>1.37; odds ratio [OR] 23.25; 95% confidence interval [CI] 3.93–454.03; p < 0.01) and D-Amy level on POD 3 (>737 U/l; OR 3.91; 95% CI 1.02–16.36; p = 0.046) were identified as independent predictive factors.ConclusionsThe pancreas-to-muscle SIR on T1-w MRI and postoperative D-Amy levels were able to predict the development of POPF after DP. The pancreas-to-muscle SIR on T1-w MRI may be a potential objective biomarker reflecting pancreatic status.