Distal Pancreatectomy Patients Research Articles

Efficacy of Distal Pancreatectomy Combined With Modified DuVal Procedure in Patients With a High Risk of Postoperative Pancreatic Fistula.

The incidence of postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) remains high. The present study aimed to clarify the efficacy of our modified DuVal (mDuVal) pancreatojejunostomy following DP in patients with a high risk of POPF. The medical records of 346 consecutive patients who underwent DP between 2006 and 2016 were retrospectively reviewed. Perioperative features were compared between 24 patients undergoing mDuVal (mDuVal group) and 322 patients undergoing standard DP (standard DP group). Preoperative American Society of Anesthesiologists physical status 1 was more frequent in the standard group than in the mDuVal group (P = .02). The start of a solid diet after operation was significantly earlier in the mDuVal group than in the standard DP group (P = .01), while there were no significant differences between the groups for clinically relevant POPF, amylase concentration in the drainage fluid on postoperative day 1 and days 3-5, time to drain removal, additional intervention for POPF, overall complications, or postoperative hospital stay. The mDuVal procedure could be an option for patients with a high risk of POPF to improve the outcomes after DP. Further investigation involving large study populations is necessary to clarify the efficacy of this procedure.

Comparison of perioperative short-term outcomes and oncologic long-term outcomes between open and laparoscopic distal pancreatectomy in patients with pancreatic ductal adenocarcinoma.

PurposeLaparoscopic distal pancreatectomy (LDP) is widely performed but its efficacy and safety are not established for malignant lesions. This study was aimed to compare outcomes of LDP and open distal pancreatectomy (ODP) in pancreatic ductal adenocarcinoma (PDAC).MethodsPatients who underwent distal pancreatectomy for PDAC between 2009 and 2017 were enrolled. The preoperative clinical stage was evaluated and propensity score matching (PSM) was performed using age, sex, The American Joint Committee on Cancer 8th clinical T stage, and other organ involvement.ResultsIn 186 patients enrolled, 35 (18.8%) received LDP. The ODP group showed larger tumor size and frequent involvement of other organs in preoperative images. However, after PSM, these differences were balanced. R0 resection (90.5% vs. 94.3%, P = 0.730), harvested lymph nodes (14.3 vs. 12.6, P = 0.380) and pathologic T stage (P = 0.474) were comparable between ODP and LDP groups, respectively. LDP demonstrated shorter operation time, less postoperative pain, and shorter hospitalization (14.4 days vs. 11.1 days, P = 0.026). In terms of long-term oncologic outcomes, median overall survival (32 months vs. 28 months, P = 0.724) and disease-free survival (18 months vs. 19 months, P = 0.926) were comparable.ConclusionLDP demonstrated better short-term outcomes and comparable long-term outcomes compared with ODP. LDP is a safe and feasible procedure for PDAC.

Comparisons of Short-term and Long-term Outcomes Between Open and Laparoscopic Distal Pancreatectomy in Patients with Pancreatic Ductal Adenocarcinoma

Safety and feasibility of laparoscopic distal pancreatectomy (LDP) in regards to the pancreatic adenocarcinoma (PDAC) were not well-known. The present study aimed to compare the short-term and long-term outcomes of LDP with those of open distal pancreatectomy (ODP).

Robotic Central Pancreatectomy with Roux-en-Y Pancreaticojejunostomy

Purpose: Central pancreatectomy is a parenchyma-sparing alternative to distal pancreatectomy in patients with a benign of low-grade malignant tumor in the body of the pancreas. The aim of central pancreatectomy is to prevent postoperative life-long endocrine and exocrine insufficiency. Due to the high rate of postoperative pancreatic fistula after central pancreatectomy, many surgeons do not routinely use central pancreatectomy in patients who would be eligible. This is the first description of a standardized approach to robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy reconstruction in an adolescent. Method: We demonstrate a video of the technical approach of a robotic assisted central pancreatectomy with Roux-en-Y pancreaticojejunostomy in an adolescent. The surgery was performed using the da Vinci Xi system. Results: The case involves a 16-year-old boy with an incidental finding in the body of the pancreas. The operation time was 248 min with 20 ml blood loss. The postoperative course was uneventful. No clinically relevant pancreatic fistula or other postoperative complications occurred. Pathology assessment revealed a radically resected solid pseudo papillary tumor. Conclusion: Robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy seems feasible and can be safely applied in selected patients in experienced centers.

Proximal versus distal resection in adenocarcinoma of the pancreatic neck: does it matter?

Presenter: Shelby L Allen MD | Indiana University Background: Adenocarcinoma isolated to the neck of the pancreas is relatively uncommon, and tumors in this location present a unique challenge to the surgeon. Surgical resection can be done in the form of either a pancreatoduodenctomy or a distal pancreatectomy, depending on specific tumor and patient characteristics. The aim of this study was to explore current practices as well as evaluate surgical and oncologic outcomes for patients undergoing pancreatic resection for cancers of the pancreatic neck. Methods: This was a case series of patients treated at a single institution. NSQIP data was obtained on all patients undergoing pancreatic resection for malignant tumors of the pancreas at our institution from 2013 to 2020. Because a specific CPT code does not exist for neck-based tumors, chart review was utilized to identify cases of pancreatic ductal adenocarcinoma of the neck based on surgeon operative reports and surgical pathology reports. The pancreatic neck was defined as the parenchyma anterior to the superior mesenteric vessels, and between the gastroduodenal artery (GDA) and left border of the superior mesenteric artery. Tumors that involved the neck but that extended into the head or body of the pancreas, or that encased the GDA, were excluded from the analysis. Patients were then divided into groups based on type of resection (pancreatoduodenectomy vs. distal pancreatectomy) and outcomes were compared between the two groups. Data were analyzed using Fisher’s exact test, Mann-Whitney-U test and equality of medians as appropriate. Results: Of a total of 720 patients undergoing surgery for malignant neoplasm of the pancreas, 9 patients had ductal adenocarcinoma isolated to the neck of the pancreas. Four patients (44%) underwent pancreatoduodenectomy (PD) and 5 patients (56%) underwent distal pancreatectomy with splenectomy (DPS). All patients undergoing PD received some form of neoadjuvant chemotherapy, while only 2 patients undergoing DPS (40%) received neoadjuvant treatment. The mean lymph node harvest was 24 in the PD group vs 20 in the DPS group (p=0.556). The incidence of nodal metastases (N1 disease or higher) was similar between the two groups (50% in PD group vs 40% in DPS group, p=0.99). One patient in the PD group had invasive carcinoma at the final pancreatic margin, and two patients in the DPS group had positive pancreatic margins (25% vs. 40%, p=0.52). The mean overall survival (OS) was 14.9 months in the PD group vs 11.4 months in the DPS group (p=0.57). Conclusion: There is no significant difference in oncologic outcomes between pancreatoduodenectomy and distal pancreatectomy for patients with ductal adenocarcinoma of the pancreatic neck. The decision regarding type of resection to perform should be individualized based on patient factors, tumor characteristics and surgeon experience.

Exocrine insufficiency associated with partial pancreatectomy from the nationwide marketscan database

Presenter: Alexander Thomas MD | Columbia University Background: Though exocrine insufficiency after partial pancreatectomy is common, the true incidence, predictors, and timing are not well established. Improving the understanding of this disease process is key for preoperative risk assessment and patient counseling, postoperative recovery and long-term care. Using medication claims data from a national database, this study aimed to compare patients who filled prescriptions for pancreas enzyme replacement therapy (PERT) before surgery to 24 months after surgery, and to evaluate risk factors for disease development. Methods: A retrospective study using the IBM Watson Health MarketScan database was performed to examine patterns of peri-pancreatectomy exocrine replacement therapy. This database includes pharmaceutical claims for approximately 50 million privately insured patients and 6 million Medicaid beneficiaries annually. Included patients underwent pancreatectomy between 2008-2016 and had continuous insurance coverage from 6 months before to 24 months after surgery. Medication use prevalence was evaluated at select time points. Multivariable models explored associations between clinical characteristics and medication use. Results: Of 4706 total patients, 2848 underwent pancreaticoduodenectomy (PD) and 1858 underwent distal pancreatectomy (DP). Within 180-31 days before surgery, 188 (6.6%) PD and 72 (3.88%) of DP patients had filled prescriptions for PERT (p40 (p<0.0001). Cancer, obesity and history of alcohol use were not found to be significant. Figure 1 shows PERT use at various time points and demonstrates that after a sharp initial postoperative rise, prevalence plateaus from 31-180 days after surgery through the end of the two-year follow-up. Conclusion: Findings from this large national series confirm that type of surgery is a key driver in the development of postoperative pancreatic exocrine insufficiency. Patients who undergo PD are more likely to develop exocrine insufficiency requiring PERT than those who undergo DP. Outcomes in the immediate 31-180 days following surgery seem to predict total postoperative prevalence out to two years. The higher proportion of exocrine insufficiency in preoperative PD patients also points to the effect of the underlying pathology on normal parenchyma. Data from this study can be used to better counsel patients on their individualized risk of post-pancreatectomy insufficiency and guide providers in their management.

Surgical Outcomes of Distal Pancreatectomy in Elderly Patients

The extent to which age impacts surgical outcomes remains poorly characterized. This study aims to evaluate the impact of age on 30-day outcomes in patients after distal pancreatectomy. Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2017), distal pancreatectomy patients were identified and age-stratified, groups A (≤75years) and B (>75years). Outcomes included 30-day mortality, morbidity, readmissions, operative time (min), and hospital length of stay (LOS, days). Of 3042 total patients identified, 1686 (55.4%) were women. A total of 2649 patients (87.1%) were in group A. Overall, both groups had similar baseline characteristics with the exception of the following: diabetes mellitus (24.8% vs. 30.0%, P = .03), smoking (19.3% vs. 4.8%, P < .001), congestive heart failure (.5% vs. 1.8%, P = .010), hypertension (HTN) (47.9% vs. 72.5%, P < .001), bleeding disorders (3.1% vs. 5.3%, P = .036), the American Society of Anesthesiologists (ASA) (III-V) scores (67.6% vs. 85.5%, P < .001), and body mass index (29.2 [±6.7] vs. 27.4 [±5.6], P = .001).Deep surgical site infection was higher in group A (12.1% vs. 6.6%, P = .001), while acute renal failure (ARF) and postoperative myocardial infarction (MI) were higher in group B. 30-day readmissions were higher in group A (17.4% vs. 12.2%, P = .011) despite no statistically significant difference in LOS (7.10 [±6.36] vs. 7.30 [±4.93] days, P = .553) or overall morbidity (29.4% vs. 28.8%, P = .859). Those undergoing distal pancreatectomy experienced similar overall morbidity and mortality outcomes regardless of age. However, those older than 75years had more cardiovascular risk factors, which may have contributed to their higher rates of postoperative ARF and MI.

Laparoscopic distal pancreatectomy in patients with poor physical status

BackgroundLaparoscopic distal pancreatectomy (LDP) is advantageous over open surgery in the treatment of benign pancreatic lesions and low-grade malignancies. Yet the evidence on the relationship between comorbidities and the outcomes of LDP remains scarce. MethodsPatients who had undergone LDP for all indications between April 1997 and December 2019 were included. Preoperative physical status was defined according to the American Society of Anesthesiology (ASA) criteria. Perioperative outcomes were compared between the patients with high (ASA III–IV) and low/moderate anesthetic risk (ASA I–II). ResultsA total of 605 patients were eligible for analysis including 190 with ASA III–IV and 415 with ASA I–II. The former was associated with older age, male gender, preexisting medical conditions, greater total number of comorbidities and red blood cell transfusion. The rate of medical complications was significantly higher in high-risk patients. Multivariable analysis identified ASA III–IV and operative time as independent predictors for medical complications. Overall/severe morbidity, surgical complications and mortality rates were similar. ConclusionsPoor physical status defined as ASA grades III–IV predicts medical complications, but has a limited impact on surgical complications and severe morbidity of LDP. Thus, it should not be considered as a contraindication for LDP.

Pancreatic Regeneration and Changes in Endocrine Function after Pancreatectomy

Background: Limited evidence is available on the regeneration of and functional changes to remnant pancreas after pancreatectomy. Therefore, we investigated the correlation between changes in volume and endocrine function in the remnant pancreas. Methods: Ninety patients undergoing pancreaticoduodenectomy (PD) and 45 undergoing distal pancreatectomy (DP) from January 2009 to December 2017 were included in this prospective study. Computed tomography was used to determine the volume of remnant pancreas 3 months, 1 year, and 2 years after pancreatectomy. Findings: The remnant pancreas volume compared to the initial residual pancreas was 80·79%, 68·67%, and 65·34% in the PD patients (p<0·001), and 106·25%, 106·62%, and 110·43% (p=0·019) in the DP patients at 3 months, 1 year, and 2 years, respectively. The DP patients had a higher incidence of new-onset diabetes than PD patients (33·3% vs. 22·7%). In addition, PD patients had more pancreatic duct dilatation with severe atrophy of the remnant pancreas (p=0·027), whereas DP patients had better pancreas regeneration (p=0·084) with spleen preservation. The changes in pancreas volume did not correlate with postoperative new-onset diabetes. Interestingly, the PD group had significantly greater restoration of endocrine function based on secretion of C-peptide. Interpretation: Pancreatic regeneration is more predominant after DP than PD. The distal portion of the pancreas had greater restoration capacity, corresponding with a lower rate of new-onset diabetes. Funding Statement: The study was supported by Taiwan Ministry of Science and Technology (MOST108-2321-B-006-014), Ministry of Health and Welfare (MOHW 107-TDU-B-212-114026A), and HSU-YUAN Education Foundation (HY-2018-001). Declaration of Interests: The authors reported no conflict of interest. Ethics Approval Statement: IRB approved by the Institutional Review Board of the National Cheng Kung University Hospital (approval number of B-ER-108-312).

High risk pathogens and risk factors for postoperative pancreatic fistula after pancreatectomy; a retrospective case-controlled study.

Although the rates of surgical site infection are decreasing, surgical site infection after pancreatectomy remains frequent because of postoperative pancreatic fistula. Recent studies suggested a relationship between postoperative pancreatic fistula and pathogens cultured from drainage fluids after pancreatectomy. This study aimed to assess and evaluate high-risk pathogens cultured from postoperative drainage fluids for postoperative pancreatic fistulas or severe postoperative complications after pancreatectomy. We retrospectively enrolled patients who underwent pancreaticoduodenectomy or distal pancreatectomy between 2012 and 2019. We assessed clinical characteristics and microbiological results of drainage cultures of pancreaticoduodenectomy or distal pancreatectomy patients, and we investigated the risk factors for clinically relevant postoperative pancreatic fistulas and Clavien-Dindo status using univariate and multivariate analyses. Finally, we detected high-risk pathogens from drainage cultures and analyzed the correlation between these pathogens and the severity of clinically relevant postoperative pancreatic fistula or Clavien-Dindo status. Four hundred and twenty-nine patients were enrolled: 257 underwent pancreaticoduodenectomy and 172 underwent distal pancreatectomy. Clinically relevant postoperative pancreatic fistulas and Clavien-Dindo status≥III were more frequently seen in pancreaticoduodenectomy patients than in distal pancreatectomy patients, namely grade C postoperative pancreatic fistula, which was observed in 19 pancreaticoduodenectomy patients. The most common pathogen found from drainage cultures was Enterococcus species, followed by Enterobacter species and Candida species. All pathogens were associated with clinically relevant postoperative pancreatic fistulas; however, Candida species was a dominant microorganism of clinically relevant postoperative pancreatic fistulas grade C, Clavien-Dindo status≥IV, and hemorrhage due to pseudoaneurysm. The presence of Candida species in the drainage fluid culture after pancreaticoduodenectomy can be a predictive factor of severe infectious complications, including postoperative pancreatic fistulas; thus, we should regularly collect cultures from drainage fluids and monitor for Candida infection.

Endoscopic management of symptomatic walled-off omental fat necrosis.

Endoscopic management of symptomatic walled-off omental fat necrosis.

Post-operative pancreatic fistula following splenectomy with or without distal pancreatectomy at cytoreductive surgery in advanced ovarian cancer

ObjectiveSplenectomy with or without distal pancreatectomy may be necessary at time of cytoreductive surgery to achieve complete cytoreduction in advanced ovarian cancer. However, these procedures have been associated with peri-operative...

Early drain removal after major pancreatectomy reduces postoperative complications: a single-center, randomized, controlled trial

Abstract Objectives: Timing of drain removal and its effects on complications after major pancreatectomy remain controversial. We designed this study to assess whether early drain removal after major pancreatectomy influences the incidence of complications in the patients with low risk of postoperative pancreatic fistula (POPF). Methods: This is a single-center randomized controlled trial (RCT). A total of 144 patients undergoing pancreaticoduodenectomy (PD) and distal pancreatectomy (DP) who met the criteria, including drain amylase on postoperative day (POD) 1 and 3 less than 5000 U/L and drain output within POD 3 less than 300 mL/d, were randomly assigned to early drain removal (POD 3) or standard drain removal (≥POD 5). The primary outcome was major complications (Clavien-Dindo grades 2–4), and the secondary outcome was POPF, reintervention treatment, readmission, and total medical expense within 3 months after surgery. Results: A total of 5 patients in early drain removal group had at least 1 major complications (grades 2–4), compared to 15 patients in standard drain removal group (P = .028). The incidence of grade B/C pancreatic fistula was not significantly different (2.8% vs 0%). Multivariate analysis demonstrated that early drain removal was an independent factor associated with a reduced risk of major complications (P = .039, odds ratio = 0.314). Majority of major complications occurred in PD patients, and only very few cases occurred in DP patients. Stratified analysis showed that early drain removal significantly reduced the major complications only in the patients undergoing PD. Conclusion: This single-center RCT shows early drain removal on POD 3 is safe for both DP and PD patients, under our criteria. Early drain removal could reduce the incidence of major complications in patients undergoing PD.

231-LB: Importance of Intestinal Environment and Cellular Plasticity of Beta Cells in the Development of Post-Pancreatectomy Diabetes

To elucidate the pathogenesis of post-pancreatectomy diabetes (PPDM), we carried out a prospective observational study in patients without diabetes undergoing partial pancreatectomy, investigating the effects of gut microbiota, incretins, and short-chain fatty acids (SCFAs) on postsurgical glucose metabolism. In addition, we analyzed histologically the resected pancreas to investigate whether increased cellular-plasticity and expansion of the islets could predict the development of PPDM. Forty-eight patients without diabetes, who underwent either pancreatoduodenectomy (PD) (n=20) or distal pancreatectomy (DP) (n=28), were included. To assess the post-surgical glucose metabolism, 75-g oral glucose tolerance test (OGTT) was performed every 6 months. Microbiome composition and SCFAs in feces were examined before and 6 months after the surgery. We also underwent immunostainings of insulin, glucagon, and ALDH1A3 (a progenitor cell marker) in the resected pancreatic samples obtained from patients following DP. During the follow-up (median 2.50 years), 2 out of 18 patients with PD and 16 out of 28 patients with DP developed PPDM. Microbiota shifted to a higher relative abundance of Proteobacteria after PD. After PD, fecal butyrate and plasma GLP-1 concentrations were significantly increased, which were not increased after DP. In all patients, postsurgical change in butyrate was strongly correlated with increased GLP-1 secretion. In DP patients, expansion of both α- and β-cell areas in the resected pancreas were significantly associated with the development of PPDM, and HR (95% CI) of ALDH1A3 positive cells (%) for PPDM was 1.127 (1.000-1.270). This study demonstrates that incidence of PPDM is much lower after PD than that after DP, which may be explained by marked changes in intestinal environment after PD. On the other hand, high cellular-plasticity and expansion of the islets in the resected pancreas can predict the development of PPDM after DP. Disclosure R. Bouchi: None. T. Fukuda: None. T. Takeuchi: None. K. Amo-Shiinoki: None. K. Tanabe: None. Y. Tanizawa: None. T. Yamada: Research Support; Self; Astellas Pharma Inc., Daiichi Sankyo, Eli Lilly Japan K.K., Kissei Pharmaceutical Co., Ltd., Kowa Company, Ltd., Kyowa Hakko Kirin Co., Ltd., Mitsubishi Tanabe Pharma Corporation, MSD, Novartis Pharma K.K., Novo Nordisk Inc., Ono Pharmaceutical Co., Ltd., Sanofi, Sanwa Kagaku Kenkyusho, Sumitomo Dainippon Pharma Co., Ltd., Taisho Pharmaceutical Co., Ltd., Takeda Pharmaceutical Company Limited. Y. Ogawa: Research Support; Self; Mitsubishi Tanabe Pharma Corporation. Speaker’s Bureau; Self; Daiichi Sankyo, Mitsubishi Tanabe Pharma Corporation. Funding Ministry of Education, Culture, Sports, Science and Technology of Japan (15K19507); Japan Foundation for Applied Enzymology; Takeda Science Foundation; AstraZeneca

The predictive value of procalcitonin for postoperative early pancreatic fistula

BackgroundTo investigate the early prediction value of procalcitonin (PCT) in pancreatic fistula (POPF) after pancreatoduodenectomy (PD).MethodRetrospective analysis of clinical data of 67 patients undergoing pancreaticoduodenectomy (PD) and 19 patients undergoing distalpancreatectomy (DP) were performed in the Department of Hepatobiliary Surgery, Leshan People’s Hospital from January 2017 to December 2018. All patients were divided into POPF group and non-POPF group depending on the presence of pancreatic fistula. And fistulas were classified according to the ISGPF classification scheme. Plasma PCT levels, serum CRP concentration, and WBC counts were assessed preoperatively and on postoperative days (PODs) 1, 3, and 5. Statistical analyses were performed with statistical software. The ROC curve was used to analyze the efficacy of PCT and CRP in POPF prediction after surgery and determine their Cut-off value.ResultThere were no statistically significant differences identified in age, gender, BMI, diabetes, abdominal surgery history, preoperative laboratory data, operation time, intraoperative bleeding volume, tumor nature and medical expenses of PD patients between the two groups (P > 0.05). While the incidence of postoperative hyperglycemia, postoperative ICU rate and postoperative hospital stay were statistically significant (P < 0.05). The AUC for PCT diagnosis of pancreatic fistula 1 day after surgery was 0.77 (95% CI: 0.675 ~ 0.860). Compared with CRP [0.53 (95% CI: 0.420 ~ 0.639)] and WBC [0.60 (95% CI: 0.490 ~ 0.705)], the optimal cut-off value (cut-off) was 0.67 μg/L. At this time, the sensitivity and specificity of detecting pancreatic fistula were 73.68 and 76.12%, respectively. The results at 3 days after surgery were similar to those at 5 days after surgery. And DP patients had similar results as PD patients.ConclusionThe PCT is valuable for early prediction of pancreatic fistula after Pancreaticoduodenectomy.

Overall Postoperative Morbidity and Pancreatic Fistula Are Relatively Higher after Central Pancreatectomy than Distal Pancreatic Resection: A Systematic Review and Meta-Analysis.

Objective To compare the intraoperative and postoperative outcomes of central pancreatectomy (CP) with distal pancreatectomy (DP). Methods A systematic literature search was performed on electronic databases from MEDLINE, Embase, and PubMed from 1998 to 2018. Statistical analysis and meta-analysis were performed using statistics/data analysis (Stata®) software, version 12.0 (StataCorp LP, College Station, Texas 77845, USA). Dichotomous variables were analyzed by estimation of relative risk (RR) with a 95 percent (%) confidence interval (CI) and continuous variables were analyzed by standardized mean differences (SMD) with 95% CI. Results Twenty-four studies with 593 CP and 1226 DP were included in the meta-analysis. CP had significantly longer operation time (SMD: 1.03; 95% CI 0.62 to 1.44; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; P < 0.01). Estimated blood loss was significantly lower in CP (SMD: −0.34; 95% CI −0.58 to −0.09; P = 0.007). Overall postoperative morbidity (RR: 1.30; 95% CI: 1.13 to 1.50; P < 0.001), overall pancreatic fistula (RR: 1.41; 95% CI: 1.20 to 1.66; P < 0.001), clinically relevant fistula (RR: 1.64; 95% CI: 1.25 to 2.16; P < 0.001), and postoperative hemorrhage (RR: 1.90; 95% CI: 1.18 to 3.06; P < 0.05) were all significantly higher after CP. On long-term follow-up, DP patients were more likely to have postoperative exocrine (RR: 0.56; 95% CI: 0.37 to 0.84; P < 0.05) and endocrine (RR: 0.27; 95% CI: 0.18 to 0.40; P < 0.001) insufficiency. There was no statistically significant difference in transfusion requirement, postoperative mortality, reoperation, and tumor recurrence. Conclusion CP is associated with significantly higher morbidity and clinically relevant pancreatic fistula. CP should only be reserved for selected patients who require postoperative pancreatic function preservation.

Use of erector spinae fascial plane blocks in open pancreatic surgery

Presenter: Hannah Wilcox | University of New Mexico Health Sciences Center Background: Bilateral erector spinae fascial plane blocks (ESPB) are a novel method of regional analgesia. The use of ESPB in abdominal surgery has sparked interest as an adjunct to opioid-sparing post-operative pain regimens. In this study, we describe our initial experience of ESPB in open pancreatectomy procedures. Methods: A retrospective analysis of a prospectively-maintained database was performed of all patients from August 2018 to March 2019 who received bilateral-ESPB for post-operative pain control after open pancreatectomy. Ultrasound-guided ESPB at the T7 or T8 level was performed in a cranial to caudal direction with infiltration of liposomal bupivacaine. Patient demographics, intraoperative and postoperative factors, including quality end points and intravenous morphine milligram equivalent (MME) requirements, were examined. Results: Twenty-nine patients met inclusion criteria, including 21 pancreaticoduodenectomy and 8 distal pancreatectomy patients. All incisions were via midline laparotomy. Diagnosis in 15 patients (52%) was ductal adenocarcinoma. Mean patient age was 66 years, and 48% were male (n=14). Average patient BMI was 28.7. Mean anesthesia preparation time was 82 minutes. Return of bowel function was a mean of 3.5 days post-operatively and urinary catheter removal was 1.8 days. Median hospital length of stay was 6.5 days. Seven patients were readmitted within 30 days of surgery (24%) and there were no deaths. Ten patients (34%) had complications within 30 days of surgery which included 3 superficial site infections, 2 organ space infections, 1 patient with atrial fibrillation, 1 patient with bleeding and 3 other causes. There were no recorded adverse events related to the ESPB procedure. No patients required rescue thoracic epidural catheter placement or intravenous patient controlled analgesia (PCA). Mean MME for first 72 hours after surgery was 40 mEq and 82 mEq for the entire inpatient stay. Nine patients received a mean of 18 mEq of opioid medications in the first 24 hours after surgery, followed by no further opioids. Three patients did not require any opioids after surgery. Conclusion: ESPB presents an effective and safe mode of regional analgesia in patients undergoing open pancreatectomy and shows promise as a key element in opioid-sparing post-operative pain regimens. The expanded role of ESPB in major abdominal surgery warrants further investigation.

Construction of nomogram to predict postoperative pancreatic fistula after distal pancreatectomy utilizing the ACS-NSQIP pancreatectomy targeted database

Presenter: Jonathan Pastrana Del Valle MD | Beth Israel Deaconess Medical Center Background: Distal pancreatectomy is widely employed in the treatment of benign and malignant conditions of the body and tail of the pancreas. Postoperative pancreatic fistula is a frequent and potentially morbid complication after this operation, occurring in up to 20% of distal pancreatectomy patients. Effective methods for predicting and preventing postoperative pancreatic fistula are still sought. While effective risk assessment models have been developed for postoperative pancreatic fistula after pancreaticoduodenectomy, to our knowledge, a similar model for distal pancreatectomy does not exist. The aim of this study was to investigate factors associated with postoperative pancreatic fistula following distal pancreatectomy and to create a risk model to predict this complication using data from the ACS-NSQIP database. Methods: Patients who underwent distal pancreatectomy from 2014 to 2017 were selected from the ACS-NSQIP pancreatectomy targeted database. Clinically relevant (grade B or C) fistulas were identified using the 2016 ISGPS definitions. We utilized chi square tests on categorical variables and logistic regression on continuous variables to assess associations of preoperative and intraoperative variables with postoperative fistula. Variables with a p<0.10 on univariable analysis were then included in a multivariable logistic regression model, and a nomogram was constructed from this model. The predictive ability of the nomogram was assessed using the concordance statistic (c-statistic), and its calibration was tested using the Hosmer-Lemeshow test. Results: A total of 7,088 patients who underwent distal pancreatectomy from 2014 to 2017 were identified in the ACS-NSIQP database. Clinically relevant postoperative pancreatic fistula were identified in 1,174 (16.6%) of the patients. Univariable analysis identified male sex, higher BMI, smoking history, congestive heart failure, disseminated cancer, low pre-operative albumin, chemotherapy within 90 days of surgery, radiation within 90 days of surgery, intra-operative drain placement, vascular resection, and histology were associated with pancreatic fistula (all p<0.05). Gland texture, pancreatic duct size, and presence of chronic pancreatitis were not significantly associated with fistula. Variables independently associated with pancreatic fistula in the multivariable model were male sex, higher BMI, smoking history, congestive heart failure, higher preoperative platelet count, intraoperative drain placement, vascular resection, and histology (all p<0.01). The nomogram constructed from this analysis is shown in panel A. The concordance statistic of the nomogram is 0.625 (ROC curve shown in panel B). The nomogram appeared well calibrated (panel C) with a Hosmer-Lemeshow p=0.723 consistent with a good fit. Conclusion: Male sex, higher BMI, smoking history, congestive heart failure, higher pre-operative platelet count, intra-operative drain placement, vascular resection, and histology are independently associated with risk of developing postoperative pancreatic fistula after distal pancreatectomy. A nomogram based on these risk factors yielded a c- statistic of 0.625 suggesting that other variables not accounted for may contribute to the risk of pancreatic fistula and/or there is some inherent unpredictability in the development of this complication. The nomogram does provide a well calibrated prediction of risk based on easily determined pre-operative and intra-operative variables, and thus may be useful in post-operative management. Further study to externally validate this nomogram is warranted.

Early postoperative drain fluid amylase in risk-stratified patients promotes tailored post-pancreatectomy drain management and potential for accelerated discharge

BackgroundFirst postoperative day drain fluid amylase (DFA1) <5000 U/L is commonly used for early drain removal. We manage patients with risk-stratified pancreatectomy care pathways determined preoperatively by risk for postoperative pancreatic fistula. We hypothesized that preoperative risk stratification would yield unique DFA1/DFA3 cutoffs for safe early drain removal. MethodsPatients with DFA1/DFA3 values after pancreaticoduodenectomy or distal pancreatectomy were identified. Patients were risk stratified as “low-risk pancreaticoduodenectomy,” “high-risk pancreaticoduodenectomy,” or “distal pancreatectomy.” Receiver operator characteristic analyses yielded clinically relevant sensitivity thresholds for International Study Group on Pancreatic Surgery grade B/C postoperative pancreatic fistulas. ResultsFrom October 2016 to April 2018, 174 patients were preoperatively stratified as low-risk pancreaticoduodenectomy (n = 78, 45%), high-risk pancreaticoduodenectomy (n = 51, 29%), and distal pancreatectomy (n = 45, 26%). B/C postoperative pancreatic fistulas developed in 3% (n = 2) of low-risk pancreaticoduodenectomies, 37% (n = 19) of high-risk pancreaticoduodenectomies, and 24% (n = 11) of distal pancreatectomies (low- vs high-risk pancreaticoduodenectomy P < .001, low-risk pancreaticoduodenectomy versus distal pancreatectomy P = .004, high-risk pancreaticoduodenectomy versus distal pancreatectomy P = .25). B/C postoperative pancreatic fistulas occurred in 16% (n = 21) pancreaticoduodenectomy patients (high- + low-risk pancreaticoduodenectomy), and B/C postoperative pancreatic fistulas were excluded in pancreaticoduodenectomy with 100% sensitivity if DFA1 ≤ 136 or DFA3 ≤ 93. DFA1 < 5000 excluded B/C postoperative pancreatic fistulas with only 57% sensitivity after pancreaticoduodenectomy. Exclusion of B/C postoperative pancreatic fistulas occurred with 100% sensitivity if DFA1 ≤ 661 or DFA3 ≤ 141 in low-risk pancreaticoduodenectomy patients, DFA1 ≤ 136 or DFA3 ≤ 93 in high-risk pancreaticoduodenectomy patients, and DFA1 < 49 or DFA3 < 26 in distal pancreatectomy patients. ConclusionPreoperative risk stratification results in unique DFA1/DFA3 thresholds to exclude B/C postoperative pancreatic fistulas, thus allowing for safe drain removal and potential for accelerated discharge. Rather than applying generic DFA cutoffs based on national databases, we propose institution-specific DFA1 and DFA3 values tailored to 3 replicable postoperative pancreatic fistula-risk pathways.

Risk Factors of Pancreatic Fistula in Distal Pancreatectomy Patients.

Introduction Benign and malignant lesions of the pancreas located at the body and tail of the pancreas are managed by the standard procedure of distal pancreatectomy (DP). The mortality associated with this procedure is reported as less than 5% in high-volume centers. The major proportion of morbidity is comprised of pancreatic fistula with a reported incidence of 5% to 60%. The most considered risk factors associated with pancreatic fistula formation are soft pancreatic texture, diameter of the pancreatic duct <3 mm, intraoperative blood loss >1000 ml and surgical techniques. Among all these factors, the modifiable factor is the surgical technique. Several surgical techniques have been developed and modified for closure of the pancreatic remnant in the recent past in order to minimize the risk of pancreatic fistula and other complications. The main objective of the study is to analyze the factors associated with formation of pancreatic fistula after distal pancreatectomy. Patients and Methods We performed a single-center retrospective study at Aga Khan University Hospital from January 2004 till December 2015. The perioperative and postoperative data of 131 patients who underwent pancreatic resection were recorded by using ICD 9 coding. 45 patients underwent distal pancreatectomy, out of which 38 were included in the study based on inclusion criteria. Variables were grouped into demographics, indications, operative details, and postoperative course. Statistical analysis software (SPSS) was used for analysis. Quantitative variables were presented as mean with standard deviation or median with interquartile range depending on the distribution of data. Study endpoints for the risk factor analysis were surgical morbidity and development of pancreatic fistula. Univariate logistic regressions were performed associated with study endpoints. P value less than 0.05 was considered significant. Results Postoperative pancreatic fistula was the most common perioperative morbidity. The significant associated risk factor for pancreatic fistula was multivisceral resection as compared to spleen-preserving distal pancreatectomy (P value 0.039). However, the technique of stump closure when opted for suture techniques was seen to be associated with a higher occurrence of postoperative pancreatic fistula. The mortality rate was 2.6%. Conclusion Postoperative pancreatic fistula is the most common complication seen after distal pancreatectomy in our series. Multivisceral resection is associated with a high incidence of pancreatic fistula and is a statistical significant predictor of pancreatic fistula.