Prevention Of Fistula Research Articles

Risk factors and prevention of postoperative pancreatic fistula after insulinoma enucleation:a retrospective study from a high-volume center

Background/ObjectivesEnucleation is an effective surgical method to treat pancreatic insulinoma, however, the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) is high. We aim to investigate the risk factors for CR-POPF which have not been well characterized and develop effective methods to prevent CR-POPF after enucleation. MethodsThis retrospective cohort study included 161 patients diagnosed with insulinoma from June 2016 to July 2020 in Peking Union Medical College Hospital. The risk factors for CR-POPF were evaluated and the role of prophylactic pre-operative pancreatic stent to prevent the occurrence of CR-POPF after enucleation of pancreatic insulinoma were explored. ResultsA cohort of 161 insulinoma cases were reviewed. The CT or MRI imaging reports could be tracked in 108 cases. A total of 96 patients underwent surgery, while 81 experienced pancreatic enucleation. Univariate and multivariate analyses showed that the distance from insulinoma to the main pancreatic duct (MPD) ≤2 mm was an independent risk factor for CR-POPF (p = 0.003, OR = 6.011, 95% Cl 1.852–19.512). The pre-operative pancreatic stent substantially reduced the incidence of CR-POPF in patients with tumor located in proximity to (distance ≤2 mm) the MPD (CR-POPF of the stented group vs the non-stented group: 37.5% vs 71.4%, p = 0.028). ConclusionsThe distance from insulinoma to MPD ≤2 mm is a predictive factor for CR-POPF after enucleation. Pancreatic duct stenting may benefit patients with insulinoma in proximity to the MPD by enabling a lower CR-POPF rate, so it should be considered before the enucleation of the insulinoma in proximity to the MPD (distance ≤2 mm).

Prevention, prediction, and mitigation of postoperative pancreatic fistula.

Prevention, prediction, and mitigation of postoperative pancreatic fistula.

Methods of preventing the occurrence of postoperative complications in patients with pancreaticoduodenectomy.

The aim of this study was to develop a prevention system that allows to reduce frequency of pancreatic fistula and severe postoperative complications after pancreaticoduodenectomy. The results of 143 pancreatic head resections were analyzed at our department, in the period from January 2017 to December 2019. In the main group we proposed pancreatic fistula prevention system and assessment of sarcopenia that were applied in 56 patients during a year (from November 2018 to December 2019). In patients with high risk of pancreatic fistula we performed pancreato-jejunostomy with external drainage of the main pancreatic duct (stent) during the reconstructive stage after pancreatoduodenectomy. The comparison group was comprised of 87 patients. They were operated in the period from January 2017 to October 2018 without assessment of the pancreatic fistula risk and presence of sarcopenia. Decision on the type of pancreatic anastomosis was based on surgeon's preference. The level of postoperative complications was significantly higher in the comparison group 26 (29.9%) and 7 (12.5%) in the main group (χ2=5.8, P=0.01). The level of postoperative pancreatic fistula grade B or C was in 15 (17.2%) of 26 patients in the comparison group, which is significantly higher than in the main group, where the fistula gr. B occurred in 1 (1.8%) patient (χ2=8.19, P=0.004). The developed prevention system allowed to significantly reduce the incidence of postoperative pancreatic fistula from 17.2% to 1.8% and the number of severe postoperative complications from 29.9% to 12.5%.

Anterograde intraoperative pancreatic stent placement and round ligament patch to prevent pancreatic fistula after distal pancreatectomy

Postoperative pancreatic fistula in distal pancreatectomy is one of the most important complications in this surgery and it is associated with high morbidity and mortality. Pancreatic fistula after distal pancreatectomy remains an unsolved problem and none preventive procedure has been shown effectively.We present a new technique that combine pancreatic stent placement with round ligament autologous patch over pancreatic edge.A guide is introduced through Wirsung duct prior to stent placement. After stent assessment, Wirsung duct is closed. Finally, falciform ligament autologous patch is placed over pancreatic edge. After 6–8 weeks, the stent is removed by oral endoscopy.This technique introduces a new issue on the pancreatic fistula prevention.

Decision points in pancreatoduodenectomy: Insights from the contemporary experts on prevention, mitigation, and management of postoperative pancreatic fistula

BackgroundDespite abundant, high-level scientific evidence, there is no consensus regarding the prevention, mitigation, and management of clinically relevant pancreatic fistula after pancreatoduodenectomy. The aim of the present investigation is three-fold: (1) to analyze the multiple decision-making points for pancreatico-enteric anastomotic creation and fistula mitigation and management after pancreatoduodenectomy, (2) to reveal the practice of contemporary experts, and (3) to indicate avenues for future research to reduce the burden of clinically relevant pancreatic fistula. MethodsA 109-item questionnaire was sent to a panel of international pancreatic surgery experts, recognized for their clinical and scientific authority. Their practice habits and thought processes regarding clinically relevant pancreatic fistula risk assessment, anastomotic construction, application of technical adjuncts, and mitigation strategies, as well as postoperative management, was explored. Sixteen clinical vignettes were presented to reveal their certain approaches to unique situations—both common and uncommon. ResultsSixty experts, with a cumulative 48,860 pancreatoduodenectomies, completed the questionnaire. Their median pancreatectomy/pancreatoduodenectomy case volume was 1,200 and 705 procedures, respectively, with a median career duration of 22 years and 200 indexed publications. Although pancreatico-jejunostomy reconstruction with transperitoneal drainage is the standard operative approach for most authorities, uncertainty emerges regarding the employment of objective risk stratification and adaptation of practice to risk. Concrete suggestions are offered to inform decision-making in intimidating circumstances. Early drain removal is frequently embraced, while a step-up approach is unanimously invoked to treat severe clinically relevant pancreatic fistula. ConclusionA comprehensive conceptual framework of 4 sequential phases of decision-making is proposed—risk assessment, anastomotic technique, mitigation strategy employment, and postoperative management. Basic science studies and outcome analyses are proposed for improvement.

Initial Experience with Biodegradable Pancreatic Stents in the Prevention of Postoperative Pancreatic Fistula after Cephalic Pancreaticoduodenectomy

Background: Postoperative Pancreatic Fistula (POPF) remains the most important morbidity after pancreaticoduodenectomy. There is no consensual technique for pancreatic reconstruction and many surgeons use a transanastomotic drain. Currently, the stents used are not degradable and they can cause obstruction, stricture and pancreatitis. The use of biodegradable stents that disappear a few months after the intervention could have a role in the prevention of pancreaticojejunostomy complications. The aim of the study was to evaluate technical success of implantation and safety of newly available biodegradable stents in 16 patients undergoing cephalic duodenopancreatectomy. Materials and Methods: A single-center prospective non-randomized study was conducted with patients undergoing PD. A total of 16 patients were included. A duct-to-mucosa end-to-side anastomosis was performed for the pancreaticojejunal anastomosis and the biodegradable stent (Archimedes) was placed from the pancreatic duct to the jejunum. Results: One of the patients developed POPF, which was successfully treated with interventional radiology drainage and somatostatin analogues. Completed degradation occurred after 3 months in all cases. There was no mortality at 30 days after PD. Conclusion: Based on our experience, the use of resorbable internal pancreatic prostheses could be a valid alternative to prevent POPF after a pancreaticoduodenectomy, also avoiding the main complications related to the use of non-absorbable prostheses.

Study Protocol of the PreFiPS Study: Prevention of Postoperative Pancreatic Fistula by Somatostatin Compared With Octreotide, a Prospective Randomized Controlled Trial.

Background: Pancreatic fistula (PF), i. e., a failure of the pancreatic anastomosis or closure of the remnant pancreas after distal pancreatectomy, is one of the most feared complications after pancreatic surgery. PF is also one of the most common complications after pancreatic surgery, occurring in about 30% of patients. Prevention of a PF is still a major challenge for surgeons, and various technical and pharmacological interventions have been investigated, with conflicting results. Pancreatic exocrine secretion has been proposed as one of the mechanisms by which PF occurs. Pharmacological prevention using somatostatin or its analogs to inhibit pancreatic exocrine secretion has shown promising results. We can hypothesize that continuous intravenous infusion of somatostatin-14, the natural peptide hormone, associated with 10–50 times stronger affinity with all somatostatin receptor compared with somatostatin analogs, will be associated with an improved PF prevention.Methods: A French comparative randomized open multicentric study comparing somatostatin vs. octreotide in adult patients undergoing pancreaticoduodenectomy (PD) or distal pancreatectomy with or without splenectomy. Patients with neoadjuvant radiation therapy and/or neoadjuvant chemotherapy within 4 weeks before surgery are excluded from the study. The main objective of this study is to compare 90-day grade B or C postoperative PF as defined by the last ISGPF (International Study Group on Pancreatic Fistula) classification between patients who receive perioperative somatostatin and octreotide. In addition, we analyze overall length of stay, readmission rate, cost-effectiveness, and postoperative quality of life after pancreatic surgery in patients undergoing PD.Conclusion: The PreFiPS study aims to evaluate somatostatin vs. octreotide for the prevention of postoperative PF.

Prophylactic Glycopyrrolate Administration to Aid Otolaryngology Residents in Prevention of Post-laryngectomy Pharyngocutaneous Fistula.

Pharyngocutaneous fistula (PCF) after laryngectomy occurs when there is a failure in the pharyngeal repair resulting in a salivary leak (Dedivitis et al. in Acta Otorhinolaryngol Ital 27(1):2-5, 2007). In the post-operative period this complication is not only a challenge to the surgeon but also distressing to the patient and his family. We conducted a retrospective cum prospective study, to research the effect of starting prophylactic glycopyrrolate intravenous injection in total laryngectomy. Fifty patients underwent total laryngectomy with modified radical neck dissection over a period of 5years by the trainee otolaryngologists. Of these 25 patients were started on glycopyrrolate for 7 post-operative days. And 25 control patients, who were not given glycopyrrolate. All the patients were observed for evidence of PCF. Of the total 50 patients, only 1 patient in study group and 12 patients in the control group developed PCF. This was statistically significant (p value 0.0039). Tumor stage, site, and gender were found to have no statistically significant correlation with development of PCF. The prophylactic administration of glycopyrrolate was found to reduce the odds of development of PCF in total laryngectomy cases. There was associated blurring of vision and constipation amongst the cases subjects, which was only transient with complete recovery on cessation of drug.

Lanreotide for the prevention of postoperative pancreatic fistula: phase II clinical trial results

Lanreotide for the prevention of postoperative pancreatic fistula: phase II clinical trial results

Pasireotide for the prevention of pancreatic fistula after pancreatoduodenectomy: comparison with a historical cohort

Background: Pasireotide, a somatostatin analogue, aims to reduce the risk of pancreatic fistula after pancreatoduodenectomy. Based on a reduced fistula rate (9 vs. 21%, p=0.006) in a randomized trial, we started the use of postoperative pasireotide twice daily for 7 days after pancreatoduodenectomy. Methods: All consecutive patients who underwent pancreatoduodenectomy from 2012 to 2018 were analyzed. Transition to pasireotide was in February 2015. The primary endpoint was the development of an International Study Group on Pancreatic Fistula (ISGPF) grade B or C fistula. Multivariable analysis was performed for pancreatic fistula with adjustment for BMI, duct size, and pancreatic texture (hard/fibrotic versus soft/normal). Results: During this 6-year period, 387 patients underwent pancreatoduodenectomy; 143 patients (37%) before and 244 patients (63%) after pasireotide introduction. Most patients (83%) underwent an open pancreatoduodenectomy and in most patients (98%) 1 or 2 drains were left. In total, 227 patients (93%) received at least one dosage of pasireotide. The median number of pasireotide dosage was 14 (IQR: 9 - 14). Pasireotide was mostly (67%) discontinued early because of nausea and vomiting. Grade B or C fistula occurred in 28 patients (20%) before versus 51 patients (21%) after pasireotide introduction with an unadjusted Odds Ratio (OR) of 1.09 (95% CI: 0.65 - 1.82) and an adjusted OR of 1.16 (95% CI: 0.64 - 2.09). Conclusions: The rate of clinical relevant pancreatic fistula did not change after introduction of pasireotide prophylaxis following pancreatoduodenectomy.

Effect of polyglycolic acid mesh for prevention of pancreatic fistula following segmental pancreatectomy: a systematic review

Background: Postoperative pancreatic fistula (POPF) is the most common and intractable complication after segmental pancreatectomy, with an incidence of 13-64%.Polyglycolic acid (PGA) mesh is a new technique that is designed to prevent POPF, but its effect has been evaluated only in a small number of patients and in retrospective studies. In this study, we systematically and comprehensively analyzed the efficacy of PGA based on reported research.

Injection of incobotulinum toxin A for the prevention of postoperative salivary fistula and sialocele

The study included 100 patients with tumors of parotid glands treated by superficial parotidecthomy. Fifty patients received incobotulinum toxin A preoperatively, while control group consisted of 50 patients without preoperative injections. Salivary fistulas formed in 17% of cases in control group. Discharging of saliva through the postoperative wound for 6 days after surgical treatment were noticed in the control group in 30% of cases. There were no complications such as forming of salivary fistula and sialocele and no saliva flow from the postoperative wound on the 4th day after surgical treatment in the main group. Conclusion. The use of botulinum toxin type A proved an efficient and effective way for prevention of postoperative salivary fistulas and sialocele.

A single-surgeon series of 93 patients undergoing pancreatectomy with pasireotide for prevention of pancreatic fistula

Presenter: Michael Cavnar MD | University of Kentucky Background: In a single-institution randomized placebo-controlled study, pasireotide reduced postoperative pancreatic fistula (PF) by half (Whipple [PD], 21 vs 10%; Distal pancreatectomy [DP], 23 vs 7%). Three single-institution, non-randomized studies reported PF in 26% (PD/DP), 16% (PD/DP), and 7% (PD), with no difference compared to historical controls. We aimed to estimate the rate of PF with pasireotide at our institution. Methods: Starting in the first year of faculty practice, a single surgeon administered pasireotide to all patients without contraindication undergoing pancreatectomy. Charts were reviewed retrospectively for clinical information, with PF assessed as defined by the International Study Group for Pancreatic Fistula (ISGPF). The first and second halves of the cohort were compared to assess changes associated with the learning curve. Results: 93 patients with a median age of 63 underwent pancreatectomy (n=56 PD, n=37 DP) over 30 months (Table). PD were performed open, and 11 of 37 DP laparoscopically/robotically. 56% were male, and 97% had a surgical drain. Pancreatic diseases with typically firm gland texture, i.e. pancreatic ductal adenocarcinoma (n=44) or chronic pancreatitis (n=2) made up 51% of the cohort. Pancreatic duct size >4mm was observed in 54% (PD only) and firm glands were found in 44% of the whole cohort. Pasireotide was administered for a median of 13 doses, with 17% stopping the drug early, usually due to intractable nausea. Median length of stay was 7 days, and 26% were re-admitted. Clinically relevant (ISGPF grade B/C) PF was seen in 24.7% of the entire group. Despite similar risk factors in the first and second halves of the cohort, there was a lower PF rate in the later period (34.8 vs 14.9%, p=0.03), with significantly fewer re-admissions (39.1 vs 12.8%, p=0.005). Conclusion: Here we show that for a single high-volume pancreatic surgeon administering pasireotide, PF rates were reduced with increasing experience, with the second half rates reaching comparable levels to the published series of pasireotide. Further study without pasireotide will serve as a control for future comparison.

Initial Experience with Biodegradable Pancreatic Stents in the Prevention of Postoperative Pancreatic Fistula after Cephalic Pancreaticoduodenectomy

Initial Experience with Biodegradable Pancreatic Stents in the Prevention of Postoperative Pancreatic Fistula after Cephalic Pancreaticoduodenectomy

Methods of Preventing of Postoperative Complications in Patients after Pancreaticoduodenectomy

Purpose: To develop a prevention system that allows to reduce frequency of postoperative pancreatic fistula and severe postoperative complications after pancreaticoduodenectomy. Methods: In our department results of 152 pancreaticoduodenectomy were analyzed in the period from January 2017 to November 2019. In the main group we proposed pancreatic fistula prevention system and assessment of sarcopenia that were applied in 60 patients during a year (from November 2018 to November 2019). In patients with high risk of pancreatic fistula we performed pancreato-jejunostomy with external drainage of the main pancreatic duct (stent) during the reconstructive stage after pancreaticoduodenectomy. The comparison group was comprised of 90 patients. They were operated in the period from January 2017 to October 2018 without assessment of the pancreatic fistula risk and presence of sarcopenia. Decision on the type of pancreatic anastomosis was based on surgeon's preference. Results: The level of postoperetive complications was significantly higher in the comparison group 28 (30.4%) and 9 (15.0%) in the main group (c2 = 4.7, p = 0.03). The level of postoperative pancreatic fistula grade B or C was in 17 (18.5%) in the comparison group, which is significantly higher than in the main group, where the fistula gr. B occurred in 3 (5.0%) patient (c2 = 5.8, p = 0.01). Conclusions: The developed prevention system allowed to reduce significantly the incidence of postoperative pancreatic fistula from 18.5% to 5.0% and the number of postoperative complications from 30.4% to 15.0%.

Surgeon experience contributes to improved outcomes in pancreatoduodenectomies at high risk for fistula development

BackgroundPancreatoduodenectomies at high risk for clinically relevant pancreatic fistula are uncommon, yet intimidating, situations. In such scenarios, the impact of individual surgeon experience on outcomes is poorly understood. MethodsThe fistula risk score was applied to identify high-risk patients (fistula risk score 7–10) from 7,706 pancreatoduodenectomies performed at 18 international institutions (2003–2020). For each case, surgeon pancreatoduodenectomy career volume and years of practice were linked to intraoperative fistula mitigation strategy adoption and outcomes. Consequently, best operative approaches for clinically relevant pancreatic fistula prevention and best performer profiles were identified through multivariable analysis models. ResultsEight hundred and thirty high-risk pancreatoduodenectomies, performed by 64 surgeons, displayed an overall clinically relevant pancreatic fistula rate of 33.7%. Clinically relevant pancreatic fistula rates decreased with escalating surgeon career pancreatoduodenectomy (–49.7%) and career length (–41.2%; both P < .001), as did transfusion and reoperation rates, postoperative morbidity index, and duration of stay. Great experience (≥400 pancreatoduodenectomies performed or ≥21-year-long career) was a significant predictor of clinically relevant pancreatic fistula prevention (odds ratio 0.52, 95% confidence interval 0.35–0.76) and was more often associated with pancreatojejunostomy reconstruction and prophylactic octreotide omission, which were both independently associated with clinically relevant pancreatic fistula reduction. A risk-adjusted performance analysis also correlated with experience. Moreover, minimizing blood loss (≤400 mL) significantly contributed to clinically relevant pancreatic fistula prevention (odds ratio 0.40, 95% confidence interval 0.22–0.74). ConclusionSurgeon experience is a key contributor to achieve better outcomes after high-risk pancreatoduodenectomy. Surgeons can improve their performance in these challenging situations by employing pancreatojejunostomy reconstruction, omitting prophylactic octreotide, and minimizing blood loss.

Colocación intraoperatoria anterógrada de stent pancreático y plastia de ligamento redondo para prevenir la fístula pancreática tras la pancreatectomía distal

Postoperative pancreatic fistula in distal pancreatectomy is one of the most important complications in this surgery and it is associated with high morbidity and mortality. Pancreatic fistula after distal pancreatectomy remains an unsolved problem and none preventive procedure has been shown effectively.We present a new technique that combine pancreatic stent placement with round ligament autologous patch over pancreatic edge.A guide is introduced through Wirsung duct prior to stent placement. After stent assessment, Wirsung duct is closed. Finally, falciform ligament autologous patch is placed over pancreatic edge. After 6-8 weeks, the stent is removed by oral endoscopy.This technique introduces a new issue on the pancreatic fistula prevention.

Pancreaticojejunostomy With Externalized Stent vs Pancreaticogastrostomy With Externalized Stent for Patients With High-Risk Pancreatic Anastomosis A Single-Center, Phase 3, Randomized Clinical Trial

Importance The operative scenarios with the highest postoperative pancreatic fistula (POPF) risk represent situations in which fistula prevention and mitigation strategies have the strongest potential to affect surgical outcomes after pancreaticoduodenectomy. Evidence from studies providing risk stratification is lacking. Objective To investigate whether pancreaticojejunostomy (PJ) or pancreaticogastrostomy (PG), both with externalized transanastomotic stent, is the best reconstruction method for patients at high risk of POPF after pancreaticoduodenectomy. Design, Setting, and Participants A single-center, phase 3, randomized clinical trial was conducted at the Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy, from July 12, 2017, through March 15, 2019, among adults undergoing elective pancreaticoduodenectomy and considered at high risk for pancreatic fistula after intraoperative assessment of the fistula risk score, some of whom were randomized to undergo PG or PJ. All analyses were performed on an intention-to-treat basis. Interventions Intervention consisted of PJ or PG, both with externalized transanastomotic stent and octreotide omission. Main Outcomes and Measures The primary end point was POPF. The secondary end points were Clavien-Dindo grade 3 or higher morbidity, postpancreatectomy hemorrhage, delayed gastric emptying, and average complication burden. Results A total of 604 patients were screened for eligibility; 82 were at high risk for POPF (fistula risk score, 7-10), and 72 were randomized undergo PG (n = 36; 20 men and 16 women; median age, 65 years [interquartile range, 23-82]) or PJ (n = 36; 26 men and 10 women; median age, 63 years [interquartile range, 35-79]). There was no significant difference in the incidence of POPF between patients who underwent PG and patients who underwent PJ (18 [50.0%] vs 14 [38.9%];P = .48), but for patients who developed a POPF, the mean (SD) average complication burden was lower for those who underwent PJ than for those who underwent PG (0.25 [0.13] vs 0.39 [0.17];P = .04). The rates of postpancreatectomy hemorrhage (14 [38.9%] in the PG group vs 9 [25.0%] in the PJ group;P = .31) and delayed gastric emptying (16 [44.4%] in the PG group vs 18 [50.0%] in the PJ group;P = .81) were similar, but patients who underwent PG presented with a significantly higher incidence of Clavien-Dindo grade 3 or higher morbidity than those who underwent PJ (17 [47.2%] vs 8 [22.2%];P = .047). Conclusions and Relevance Among patients at the highest risk for POPF, those who underwent PG or PJ experienced similar rates of POPF. However, PG was associated with an increased incidence of Clavien-Dindo grade 3 or higher morbidity and with an increased average complication burden for the patients who developed a POPF. For patients at high risk for pancreatic fistula, PJ with the use of externalized stent and octreotide omission should be considered the most appropriate technical strategy. Trial Registration ClinicalTrials.gov Identifier:NCT03212196

Fistula Management in Head and Neck Cancer.

Fistulas in head and neck cancer patients are a common and challenging issue. Despite their commonality, there is little consensus regarding optimal treatment strategies or in preventative measures that might be taken preoperatively. A general knowledge and understanding of what factors correlate with fistula formation can assist a surgeon in optimizing a patient for surgery, thus decreasing prevalence. In addition, surgical techniques can aid in both the prevention and treatment of fistulas once they form. This review details risk factors for fistula formation, the use of vascularized tissue as a preventative measure, conservative and nonconservative treatment of fistulas, and possible strategies to decrease the likelihood of their formation.

Prevention of Entero-Atmospheric Fistula: The Initial Closure of the Abdomen.

Background and AimsThe “Open Abdomen” technique for difficult conditions such as trauma, necrotizing pancreatitis, severe peritonitis, reoperations and transplantations have become a very useful way to save patients. The more severe complication of this method are the enteroatmospheric fistulae with a frequency of 5–75% and a mortality up to 42%. So any effort to prevent these is very essential. The aim of this paper is to present methods of the initial (temporary) closure of the abdomen for the prevention of this catastrophe, when early approximation of the abdominal wall is not feasible.Methods and MaterialsWe present two representative case reports and we describe the use of full thickness or split skin grafts as first step for abdominal closure.Results and ConclusionsThe outcome of our patients by using tissues for temporary abdominal closure seems to have fewer problems than other methods with synthetic materials. We think that this is a reasonable option for the cases where we cannot achieve approximation of the abdominal wall edges in the early days of an open abdomen.