Drain Amylase Research Articles

Abdominal drain amylase on the first day after pancreatectomy: a predictive factor for pancreatic fistula.

To analyze abdominal drain on the first postoperative day and evaluate its predictive nature for the diagnosis of Pancreatic Fistula exclusion, seeking to establish a cutoff point from which lower values demonstrate safety in excluding the possibility of this complication. From August 2017 to June 2020, data from 48 patients undergoing pancreatic resection were collected and analyzed from a prospective cohort. The patients were divided into two groups, one group consisting of patients who did not develop PF (Group A), and the other composed of patients who developed PF (Group B). The receiver operation characteristic curve was constructed, and cutoff points were evaluated by calculating sensitivity and specificity. Group A brought 30 patients together (62.5%) and Group B brought 18 patients together (37.5%). The 444 U/L value was the most satisfactory cutoff point for the receiver operation characteristic curve (CI 0.690-0.941), with a sensitivity of 94.4% and a specificity of 60%, thus being able to select 18 of 30 patients who did not succumb to PF. Abdominal drain on the first postoperative day can be used as a predictive factor in the diagnosis of PF exclusion (CI 0.690-0.941), with the value of 444 U/L being the best performance cutoff point.

Platelet/lymphocyte ratio on day-1 after pancreatectomy was predictive factor for pancreatic fistula

Introduction: The safety of pancreatectomy (Pt) regarding the surgical technique and perioperative care management has increased recently, but postoperative pancreatic fistula (POPF) is a lethal complication. We aimed to evaluate the risk factors of operative and postoperative findings for PF after Pt. Methods: Between Nov 2014 and Dec 2018, 103 patients who underwent Pt at our center were prospectively examined and classified into Group A, those with no fistula/biochemical leak (n=97), or B, those with grade B/C POPF (n=6) . Operative (operative time, bleeding volume, blood transfusion, abdominal cavity washing volume), and 1- and 3-day postoperative (white blood cells; Neutropils, lymphocytes; hemoglobin (Hb); Plate; Creatine; Albmin; Total Bilirubin; amylase; C-reactive protein(CRP); neutrophil/lymphocyte ratio; prognostic nutritional index, platelet/lymphocyte ratio (PLR), CRP/Alb ratio (CAR); drain amylase; drainage cell counts, volume, bacteria) factors were collected and analyzed at postoperative day1, and day3. Post-Pt POPF predictors were evaluated using univariate and multivariate analyses. Results: The mean patient age was 68.7 y ( 67 men, 36 women). The diseases were pancreatic cancer (n=46), intraductal papillary mucinous neoplasms (n=13), bile duct cancer (n=10), papilla Vater cancer (n=8), chronic pancreatitis (n=7), neuroendocrine neoplasms (n=7), and others (n=12). Surgical procedures included PD (n=74) and DP (n=29). PF grade B/C was noted in 6 patients (5.8%), without grade C. Univariate analysis showed that POPF predictors were Hb-day1(p=(p=0.016),PLR-day1 (p=0.011), CAR-day1 (p=0.012), CRP-day1 (p=0.011). Multivariate analysis showed that PLR-day1 was independent risk factor for POPF(p=0.034). Conclusions: PLR-day1 (33.5≦) was early risk predictor for POPF after Pt.

Drain Amylase Levels in the Early Diagnosis of Gastric Leak after Laparoscopic Sleeve Gastrectomy

Objectives: Laparoscopic sleeve gastrectomy is gaining popularity as a bariatric option. Gastric leak is the most dreaded septic complication after this procedure. This study investigated levels of drain amylase that could be useful for predicting gastric leak before its clinical presentation. Subjects and Methods: This prospective observational study was carried out in 167 patients who underwent sleeve gastrectomy for morbid obesity between February 2014 and March 2020. Measurement of drain amylase levels (DALs) was adapted as a routine procedure. The results of the receiver operative characteristic (ROC) curve analysis revealed an optimal drain amylase levels cutoff point of 814.18 IU/L. Consequently, the DALs were classified as DALs <814.18 or DALs ≥814.18 for all subsequent analyses. Results: Gastric leak occurred in 6 patients. Drain amylase levels of 167 patients were tested. The mean value for patients without leak was 71.13 ± 72.11 IU/L; for patients with leak, it was 4,687 ± 6,670 IU/L (p < 0.001). Using ROC curve analysis, the mean ± standard error of the area under the curve for DALs on postoperative day 1 was 0.9927 ± 0.0075, CI = 0.978–1.00, and a cutoff level at 814.18 IU/L for predicting gastric leak achieved 83.33% sensitivity and 100% specificity with positive predictive value of 100% and negative predictive value 99.38%. All patients with a leak, but one, had a drain amylase level >814.18 IU/L. Conclusion: The determination of drain amylase levels after sleeve gastrectomy is a significant indicator of gastric leak with high sensitivity and specificity.

Postoperative management of clinically relevant pancreatic fistula in our institute

Introduction: Drain amylase levels are determined and drain bacterial culture results are obtained on days 1 and 3 postoperatively. In cases that drain fluid is aseptic, all drains are basically removed early regardless of fluid volume and amylase level. In contrast, in cases with drain fluid infection, the target drain is replaced with an 18-22Fr silicone drain once a stable fistula formation is confirmed. When intraabdominal abscess is detected after the drain removal, a 10-12Fr polyethylene percutaneous pigtail catheter is introduced under CT guidance.

Postoperative Day 3 Drain Amylase (PoD3DA) vs Fistula Risk Score (FRS): predicting clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreatico-duodenectomy (PD)

Background: Clinically relevant Postoperative pancreatic fistula (CR-POPF) remains the most common cause of perioperative morbidity following pancreatico-duodenectomy (PD). Early and accurate prediction of CR-POPF can be helpful in postoperative drain management as well as stratifying patients for ERAS protocol. Both FRS and postoperative drain amylase levels have been analyzed in past. Present study sought to assess the utility of POD-3DA level as a predictor of CR-POPF in comparison with FRS.

Optimal Timing to Assess Drain Amylase Concentration after Elective Gastrectomy.

PurposeWhile the amylase concentration of the drainage fluid (dAmy) has been reported to be a predictor of postoperative pancreas-related complications (PPRC), the optimal timing for its measurement has not been fully investigated.Materials and MethodsThe clinicopathological data of 387 patients who underwent elective gastrectomy for gastric cancer were reviewed. Laboratory data, including dAmy on postoperative days 1 (dAmy1) and 3 (dAmy3), and serum C-reactive protein (sCRP) concentrations on postoperative days 1 (sCRP1) and 3 (sCRP3) were compared between patients with PPRC and without PPRC.ResultsNineteen of the 387 patients (4.9%) developed PPRC. The optimal cutoff values of dAmy1, dAmy3, sCRP1, and sCRP3 were 1514 IU/L, 761 IU/L, 8.32 mg/dL, and 15.15 mg/dL, respectively. The area under the curve of dAmy1 was greater than that of dAmy3 (0.915 vs. 0.826), and that of sCRP3 was greater than that of sCRP1 (0.820 vs. 0.659). In the multivariate analysis, dAmy1 (P<0.001) and sCRP3 (P=0.004) were significant predictors of PPRC, while dAmy3 (P=0.069) and sCRP1 (P=0.831) were not. Thirteen (41.9%) of 31 patients with both dAmy1 ≥1,545 IU/L and sCRP3 ≥15.15 mg/dL had PPRC ≥Clavien-Dindo II. In contrast, among 260 patients with both dAmy1 <1,545 IU/L and sCRP3 <15.15 mg/dL, none developed PPRC.ConclusionsdAmy1 was more useful than dAmy3 in predicting PPRC. The combination of dAmy1 and sCRP3 may be a useful criterion for the removal of drains on postoperative day 3.

Organ Space Surgical Site Infections Predict Outcomes Following Pancreato-duodenectomy

Introduction: Organ space surgical site infections (OSSSIs) represent a major source of morbidity in patients undergoing pancreatoduodenectomy. This study aimed to determine relationships between OSSSIs and length of stay (LOS) and, in cancer patients, overall survival (OS). Methods: Data from consecutive patients undergoing pancreato-duodenectomy was gathered (October 2014-October 2019). OSSSIs were defined as CT confirmed intra-abdominal collections treated with antibiotics and/or percutaneous drainage. Reconstruction was by pancreato-jejunostomy with routine post-operative abdominal drainage and measurement of drain amylase on day 3. Linear regression analysis determined the relationship between OSSSIs and in-hospital LOS. Cox regression analysis determined the relationship between OSSSIs and OS. Results: In 377 patients (male: 211 [56%], mean [SD] age 55 [10] years) there were 71 (18%) OSSSIs following pancreato-duodenectomy. Median (IQR) length of stay was 14 (10-19) days and OS of 79% at 1 year for cancer patients (n=312). OSSSIs were associated with a prolonged total length of stay (β[SE] 11.2[2.2], p<0.00001) and critical care length of stay (2.1[0.5], p<0.00001) but did not predict OS (HR [95% CI] 0.91 [0.59-1.39], p=0.655). OSSSIs that occurred in association with post-operative pancreatic fistulas (POPF) predicted poorer OS (HR [95% CI] 0.36 [0.15-0.89], p=0.027). However, clinically significant (grade B or C) POPF occurring in the absence of an OSSSI was not a predictor of survival (0.53 [0.17-1.68], p=0.281). After adjusting for other significant predictors of cancer survival (Tumour, Nodal and Metastatic status, and commencement of adjuvant chemotherapy) only POPF related OSSSIs (0.28 [0.11-0.73], p=0.009) and the presence of distant metastases (0.36 [0.14-0.90], p=0.028) were significant. Conclusions: POPF related OSSSIs are a major determinant of outcomes following pancreato-duodenectomy. Due attention ought to be given to promptly addressing sepsis in patients with POPFs and minimising the risk of POPFs occurring altogether.

Postoperative pancreatic fistula after gastrectomy for gastric cancer.

Postoperative pancreatic fistula is one of the most severe complications after gastric cancer surgery, and can cause critical patient conditions leading to surgery‐related death. Fortunately, the incidence of postoperative pancreatic fistula after gastrectomy seems to be decreasing with changes in operative procedures. The rate was reported at about 30% after open gastrectomy with Appleby's method in 1997, but lately has improved below 1% for robotic gastrectomy in 2019. For the diagnosis of postoperative pancreatic fistula, drain amylase concentration has been demonstrated to be beneficial and some reports have proposed the optimal cut‐off values of drain amylase to predict major postoperative pancreatic fistula. There have been many reports identifying risk factors for postoperative pancreatic fistula, including overweight patients, pancreatic anatomy, blunt trauma from compression of the pancreas, and thermal injuries caused by the continuous use of energy devices. And importantly, laparoscopic gastrectomy has been shown to be more often associated with postoperative pancreatic fistula than open gastrectomy in the prospective national clinical database in Japan. Hence, further sophistication of surgical techniques to reduce pancreas compression would have great promise in reducing postoperative pancreatic fistula after laparoscopic gastrectomy.

Diagnosing anastomotic leak post-esophagectomy: a systematic review.

Esophagectomy is the gold-standard treatment for esophageal cancer; however, postoperative anastomotic leakage remains the primary concern for surgeons. No consensus exists on the optimal investigations to predict an anastomotic leak. This systematic review aims to identify a single test or combination of tests with acceptable sensitivity and specificity to identify anastomotic leak after esophagectomy and to formulate a diagnostic algorithm to facilitate surgical decision-making. A systematic review of PubMed and EMBASE databases was undertaken to evaluate diagnostic investigations for anastomotic leak post-esophagectomy. Each study was reviewed and where possible, the sensitivity, specificity, positive predictive value, and negative predictive value were extracted. The review identified 3,204 articles, of which 49 met the inclusion criteria. Investigations most commonly used for diagnosis of anastomotic leak were: C-reactive protein (CRP), oral contrast imaging, computed tomography (CT), pleural drain amylase concentration, and the 'NUn score'. The sensitivity of CRP for detecting anastomotic leak varied from 69.2% to 100%. Oral contrast studies sensitivities varied between 16% and 87.5% and specificity varied from 20% to 100%. Pleural drain amylase sensitivities ranged between 75% and 100% and specificity ranged from 52% to 95.5%. The NUn score sensitivities ranged from 0% to 95% and specificity from 49% to 94.4%. No single investigation was identified to rule out anastomotic leak in asymptomatic patients. However, the authors propose a diagnostic algorithm incorporating CRP, pleural drain amylase concentration, and CT with oral contrast to aid clinicians in predicting anastomotic leak to facilitate safe, timely discharge post-esophagectomy.

Three Thousand Consecutive Pancreaticoduodenectomies in a Tertiary Cancer Center: A Retrospective Observational Study.

(1) Aim: To evaluate clinicopathological features and postoperative outcomes including survival in patients who underwent pancreaticoduodenectomy (PD) for periampullary diseases. (2) Methods: We retrospectively reviewed 3078 cases of PD performed in our center for 25 years. Periampullary diseases were divided into benign and malignancy groups. All cases were also classified by location. The time of 25 years was divided to different periods (5 years per period) to compare outcomes. Overall survival was compared between subdivided periods. (3) Results: Hospitalization became significantly shorter from 28.0 days in the 1st period to 13.8 days in the 5th period. Overall complication rate was significantly increased since the 3rd period. The rate without postoperative pancreatic fistula (POPF) was high at 98.7% in the 1st period. This might be because drain amylase on the 3rd day after PD was not routinely checked in the past. Thus, POPF was not detected. In survival analysis of adenocarcinoma of pancreas, bile duct, and ampulla, overall survival was found to be improved significantly in recent years. (4) Conclusions: Our study revealed that outcomes were improved with increasing number of PDs performed. Although POPF and overall complications showed increases more recently, those were detected and managed, resulting in shorter hospitalization and improved outcomes.

Image Guided Percutaneous Drainage of Intra-Abdominal Collections

Background: Intra-abdominal collections and abscesses are commonly encountered in surgical practice. They contribute to significant morbidity and mortality, hence, need to be addressed expeditiously. Percutaneous catheter drainage (PCD) is an important treatment modality that is now in vogue. Aim: This study was carried out to assess the outcomes of image guided PCD of intra-abdominal collections/ abscesses. Materials and Methods: This prospective study was carried out at a tertiary centre on patients who underwent image guided drainage of intra-abdominal collections/ abscesses from Jul 2014 to Dec 2016. Data was collected by following up the patients both clinically and radiologically. Results: 31 patients underwent PCD. Procedure was successful in 77.4%. Complete resolution was observed in all post-operative collections. Collections resolved after a single drainage procedure in 71% while the remaining 29% required multiple drainage procedures. Liver abscesses were the commonest, with multiple foci. Organisms were isolated in 13%, Escherichia coli being the commonest isolate. Higher leucocyte counts, lower levels of drain amylase and shorter duration of antibiotics were significantly associated with the success of the procedure. There were no complications other than an isolated case of biliary fistula following drainage of liver abscess. Ultrasonography was found to be at par with CT scan for PCD. Conclusion: Image guided PCD is a safe and efficacious procedure for the treatment of intra-abdominal collections and abscesses. It has a high success rate, especially in postoperative collections. The procedure has low morbidity and low complication rates. High leucocyte count, short duration of antibiotic exposure and low levels of drain fluid amylase are independent predictors of favourable outcome after percutaneous drainage.

Innovations in pancreatic anastomosis technique during pancreatoduodenectomies

PurposePancreatic fistula following pancreatic resections is still a relevant complication. The present work shows the efforts of a single institute to decrease this problem.MethodsA total of 130 patients (63 men, 67 women) with a mean age of 60 (range: 23–81) years were operated on between January 2013 and March 2020. The most frequent type of pancreatic resection was a Whipple procedure with partial antrectomy. During all operations, an innovative method was used, namely a modification of the purse-string suture pancreatojejunostomy. Moreover, an early drain removal policy was applied, based on the drain amylase level on the first and subsequent postoperative days.ResultsMean postoperative hospital stay was 13 days (range: 7–75). The overall morbidity rate was 43.8%; the clinically relevant (grade B/C) pancreatic fistula (CR-POPF) rate was 6.9%. Delayed gastric emptying (DGE) was observed in 4% of the patients. The ratio of operative mortality was 0.7%; the reoperation rate was 5.3%. Based on the drain amylase level on the first postoperative day, two groups could be established. In the first one, the drain was removed early, on the fourth day in average (range: 2–6). In the other group, the drain was left in situ protractedly or reinserted later on.ConclusionA single center’s experience proves that the refinement of the technique can improve the results of pancreatic surgery.

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.

PANasta Trial: Cattell Warren versus Blumgart techniques of pancreatico-jejunostomy following pancreato-duodenectomy—A double-blinded multi-centered trial, trial results.

4619 Background: Pancreatic anastomosis failure following pancreatic head excision, for suspected pancreatic cancer, leads to longer recovery and failure to start or complete adjuvant chemotherapy. The aim of this study is to evaluate whether a Blumgart anastomosis (BA) reduces the post operative pancreatic fistula (POPF) rate compared to a more traditional Cattell-Warren anastomosis (CWA). Methods: Patients with suspected pancreatic cancer, undergoing elective pancreato-duodenectomy were randomized intra-operatively to either a BA or a CWA. Anastomoses were constructed according to prior agreed techniques and an operative manual describing key surgical steps. Quality control of these key steps and adherence to the arm of randomization was ensured by operative photographs. Surgical drain amylase was measured post-operatively to establish the primary end point of POPF. These were graded A (biochemical) or B and C (clinically relevant, CR-POPF). Secondary endpoints included: Entry in adjuvant therapy, hospital stay, mortality and survival. Overall survival was estimated using the method of Kaplan Meier and defined as the time from randomisation until death by any cause with alive patients censored at the end of study date. Results: Between May 5 2015 and August 7 2017, 238 patients were randomized, 2 patients withdrew, leaving 236 patients for analysis (112 BA, 124 CWA). Median age was 70 years, 63% were men. Median time from diagnosis to randomization (surgery) was 33 days for both arms. In the BA arm there were 28 POPF’s (15-A, 10-B and 3-C) and 32 in the CWA arm (18-A, 12-B and 2-C), p = 0.887. In total 27 patients (11.4%) developed a CR-POPF, BA 13 (5.5%), CWA 14 (5.9%), p = 0.857. 75% of eligible patients entered chemotherapy, with a median (IQR) time to the start treatment of 2.55 (2.27, 3.15) months for the BA group and 2.87 (2.56, 3.75) for the CWA group. Median hospital stay (IQR) in days was 13 (10-24) for BA and 14.5 (10-22) for CWA, p = 0.232. The overall surgical related mortally at 90 days was 1.7%. 44 study deaths were observed, 35 were due to disease progression (BA 19, CWA 16). A hazard ratio (95% CI) of 0.72 (0.4, 1.311) shows better, but not statistically significant survival for the CWA group. Conclusions: This is the largest surgical trial ever conducted comparing these techniques and there was no significant difference in the POPF rate between the BA and CWA anastomoses. In a UK population the clinically relevant POPF rate is 11% and 75% of eligible patients enter chemotherapy. Clinical trial information: ISRCTN52263879 .

Role of drain amylase levels assay and routinary postoperative day 3 abdominal CT scan in prevention of complications and management of surgical drains after pancreaticoduodenectomy.

To asses drains amylase (DA) cut-offs for the risk of clinically relevant postoperative pancreatic fistula (POPF) and define the optimal timing of drains removal based on daily DA assay and abdominal CT scan finding after pancreatoduodenectomy (PD). Different algorithms able to identify patients at higher risk of POPF and to assess the optimal time for drains removal after PD have been proposed. The most accurate DA cut-offs in the assessment of the risk of clinically relevant POPF were retrospectively identified. Data from a prospective trial for optimal timing of drains removal were analyzed. Then, to validate the cut-offs identified in the first phase, they were applied to the patients enrolled in the prospective trial. Patients with POD1 DA ≥ 666 U/L were at higher risk of clinically relevant POPF (p 0.0001). POD3 DA value ≥ 252 U/L predicted 88% of clinical relevant fistulas. POD3 DA level ≥ 207 U/L was able to predict 68% of biliary fistulas. Patients with abdominal collection ≥ 5 cm, showed a significantly higher rate (60% vs. 23%, p < 0.001) of biliary fistula. Timing of drains removal did not influence complications. Drains amylase levels predict clinically relevant POPF. Drains should be maintained up to POD3; in case of POD1 DA levels < 666 U/L and POD3 DA levels < 252 U/L drains could be removed. In case of POD3 DA levels, ≥ 207 the routine use of abdominal CT scan in the same day could be justified to detect collections ≥ 5 cm and maintain drains beyond the POD3.

Effect of Anastomosis Technique on Pancreatic Fistula Formation in Proximal Pancreaticoduodenectomy.

To find out the association between the pancreatic fistula development and the pancreaticoduodenectomy anastomosis technique performed in three different ways; namely, telescopic pancreatojejunostomy (PJ), ducto-mucosal Wirsungo jejunostomy (WJ), and Peng's variant of the telescopic technique. A descriptive study. Izmir Katip Celebi Universitesi Hospital, Turkey, from January 2011 to January 2018. A total of 144 proximal pancreaticoduodenectomy procedures were performed at the study centre. Patients' data was obtained from the outpatient files and hospital information system, retrospectively; and divided into three groups according to the pancreatic anastomosis techniques. All three groups were compared in terms of eight parameters. Preoperative parameters were age, gender, and serum direct bilirubin values; whereas, postoperative parameters were pathology, pancreatic fistula, drain amylase, serum albumin value and early mortality. All variables by anastomosis type belonging to three groups differed for fistula rates (p=0.384), pathology types (p=0.142), preoperative bilirubin (p=0.631) and postoperative albumin (p=0.516) levels, early mortality (p=0.242) parameters without reaching statistical significance (p>0.05); however, the low anastomosis leak rates in Peng's technique were remarkable. POPF (post-operative pancreatic fistula) developed in 34% patients under 60 years vs. 17.6% patients over 60 years of age (p=0.029); and 13.7% females vs. 29.9% of male patients (p=0.032). No factors other than age and gender were found to be significant alone in the development of pancreatic fistula after proximal pancreaticoduodenectomy. Key Words: Postoperative pancreatic fistula, Pancreaticoduodenectomy, Pancreatojejunostomy, Telescopic pancreatojejunostomy (PJ), Ducto-mucosal Wirsungo jejunostomy (WJ), Peng's telescopic technique.

Proposal of a Clinically Useful Criterion for Early Drain Removal After Pancreaticoduodenectomy

PurposeThis study aimed to establish a reliable criterion for early drain removal after pancreaticoduodenectomy (PD) based on predictive factors of clinically relevant postoperative pancreatic fistula (CR-POPF) available on postoperative day 3 (POD3). MethodsA total of 300 consecutive patients who underwent PD with pancreaticojejunostomy at our hospital from 2011 to 2015 were analyzed retrospectively. CR-POPF was defined as POPF grade B or C according to the definition by ISGPF. Clinicopathological factors available on or before POD3 were analyzed to identify predictors of CR-POPF. Using obtained predictors, we developed a criterion for no CR-POPF and internally validated its relevance in 100 consecutive patients. ResultsThe incidence rates of CR-POPF, severe complications (Clavien–Dindo ≥ grade IIIa), and postoperative mortality were 35%, 9.6%, and 0.3%, respectively. Multivariate analysis showed that drain amylase (d-AMY) levels ≥ 350 IU/l on POD3, C-reactive protein (CRP) levels ≥ 14 mg/dl on POD3, preoperative endoscopic retrograde biliary drainage, and no portal vein resection were significant predictors of CR-POPF. Using the strongest predictors (i.e., d-AMY and CRP), we established a criterion for no CR-POPF: d-AMY levels < 350 IU/l and CRP levels < 14 mg/dl on POD3. The incidence rates of CR-POPF were 6%, 38%, and 88% in patients who fulfilled both of (n = 149), each of (n = 74), and none of (n = 77) the two factors, respectively. In the internal validation cohort, the positive predictive value of CR-POPF was 89%. ConclusionsA simple two-factor criterion available on POD3 after PD has a reliable predictive ability. In patients who fulfill this criterion, early drain removal is considered safe.

C-reactive protein and drain amylase accurately predict clinically relevant pancreatic fistula after partial pancreaticoduodenectomy.

C-reactive protein (CRP) and procalcitonin (PCT) have shown to be reliable predictors of inflammatory complications and anastomotic leak after colorectal surgery. Their predictive value after partial pancreaticoduodenectomy (PD) remains unclear. All consecutive pancreaticoduodenectomies (2009-2018) at our hospital were included. Drain amylase was evaluated on postoperative day (POD) 1, serum CRP and PCT were evaluated on POD 1-3. Receiver-operating characteristics curves were performed and significant cut-off values were tested using logistic regression. Among 188 patients who underwent partial PD, clinically relevant pancreatic fistulas (POPF) occurred in 30 (16%) patients, including 20 (10.6%) with Grade B and 10 (5.3%) patients with Grade C. Postoperative complications (Clavien-Dindo≥III) were reported in 46 (24.5%) patients, including Grade IIIa in 16 (8.5%), IIIb in 18 (9.6%), IVa in 3 (1.6%), IVb in 2 (1.1%) and V in 7 (3.7%) patients. Drain amylase on POD 1 showed the largest area under the curve (0.872, p < 0.001), followed by CRP (0.803, p < 0.001) and PCT on POD 3 (0.651, p < 0.011). Drain amylase on POD 1>303 U/l (OR 0.045, 95% CI 0.010-0.195, p<0.001), CRP>203mg/l (OR 0.098, 95% CI 0.041-0.235, p<0.001) and PCT>0.85μg/l (OR 0.393, 95%CI 0.178-0.869, p=0.02) were significant predictors of relevant POPF in the univariate analysis. CRP > 203 mg/l (OR 0.098, 95% CI 0.024-0.403, p = 0.001) and drain amylase > 303 U/l (OR 0.064, 95% CI 0.007-0.554, p = 0.01) remained independent predictors in the multivariable analysis. The combination of drain amylase on POD 1 and CRP on POD 3 had a sensitivity and specificity of 87.4% and 90.9% to predict relevant POPF. Drain amylase on POD 1 and CRP on POD 3 can accurately predict clinically relevant POPF after partial pancreaticoduodenectomy. The accuracy of PCT on POD 3 is limited.

Early intra-abdominal infection following pancreaticoduodenectomy:associated factors and clinical impact on surgical outcome.

Early intra-abdominal infection (IAI) following pancreaticoduodenectomy (PD) is an initial event relating to morbidities caused by postoperative pancreatic fistula (POPF). The aims of this study were to determine factors associated with IAI, and to investigate its impact on postoperative outcome.Consecutive patients, 113 in total, who underwent PD at Fukushima Medical University Hospital between January 2012 and September 2017 were included in this retrospective study. IAI was defined by positive bacterial culture from intra-abdominal drainage fluid any time through postoperative day 3 (POD3). Logistic regression analysis was used to identify the relevant factors associated with IAI. The clinical impact of the POD3 infection indicators related to POPF were assessed by multivariate analysis.The incidence of IAI, POPF, and mortality were 36.1%, 36.1%, and 0%, respectively. Independent factors associated with IAI were preoperative biliary drainage (PBD) (OR = 2.91, CI = 1.16-7.33, p = 0.023) and soft pancreas (OR = 8.67, CI = 2.37-31.77, p = 0.001). Among infection markers on POD3, the significant factors for POPF were CRP (OR = 1.18, CI = 1.08-1.30, p < 0.001), IAI (OR = 7,37, CI = 2.53-21.5, p < 0.001), and drain amylase (OR = 1.00, CI = 1.00-1.01, p = 0.001).In conclusion, PBD, soft pancreas, and higher age were associated with IAI. IAI has a significantly negative impact on postoperative outcome.

Serum and drain amylase to rule-out postoperative pancreatic fistula after pancreatoduodenectomy

Serum and drain amylase to rule-out postoperative pancreatic fistula after pancreatoduodenectomy