High Risk Of Pancreatic Fistula Research Articles

Preoperative Radiotherapy on the Transection Margin in Patients at High Risk of Pancreatic Fistula after Pancreatoduodenectomy (FIBROPANC): A Multicenter Phase II Study

Preoperative Radiotherapy on the Transection Margin in Patients at High Risk of Pancreatic Fistula after Pancreatoduodenectomy (FIBROPANC): A Multicenter Phase II Study

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%.

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%.

Effect of Hydrocortisone vs Pasireotide on Pancreatic Surgery Complications in Patients With High Risk of Pancreatic Fistula

Both hydrocortisone and pasireotide have been shown in randomized clinical trials to be effective in reducing postoperative complications of pancreatic surgery, but to date no randomized clinical trial has evaluated the effectiveness of pasireotide compared with hydrocortisone. To assess the noninferiority of hydrocortisone compared with pasireotide in reducing complications after partial pancreatectomy. A noninferiority, parallel-group, individually randomized clinical trial was conducted at a single academic center between May 19, 2016, and December 17, 2018. Outcome collectors and analyzers were blinded. A total of 281 patients undergoing partial pancreatectomy were assessed for inclusion. Patients younger than 18 years, those allergic to hydrocortisone or pasireotide, patients undergoing pancreaticoduodenectomy with hard pancreas or dilated pancreatic duct, and patients not eventually undergoing partial pancreatectomy were excluded. Modified intention-to-treat analysis was used in determination of the results. Treatment included pasireotide, 900 μg, subcutaneously twice a day for 7 days or hydrocortisone, 100 mg, intravenously 3 times a day for 3 days. The primary outcome was the Comprehensive Complication Index (CCI) score within 30 days. The noninferiority limit was set to 9 CCI points. Of the 281 patients (mean [SD] age, 63.8 years) assessed for eligibility, 168 patients (mean [SD] age, 63.6 years) were randomized and 126 were included in the modified intention-to-treat analyses. Sixty-three patients received pasireotide (35 men [56%]; median [interquartile range] age, 64 [56-70] years) and 63 patients received hydrocortisone (25 men [40%]; median [interquartile range] age, 67 [56-73] years). The mean (SD) CCI score was 23.94 (17.06) in the pasireotide group and 30.11 (20.47) in the hydrocortisone group (mean difference, -6.16; 2-sided 90% CI, -11.73 to -0.60), indicating that hydrocortisone was not noninferior. Postoperative pancreatic fistula was detected in 34 patients (54%) in the pasireotide group and 39 patients (62%) in the hydrocortisone group (odds ratio, 1.39; 95% CI, 0.68-2.82; P = .37). One patient in the pasireotide group and 2 patients in the hydrocortisone group died within 30 days. In subgroup analyses of patients undergoing distal pancreatectomy, the CCI score was a mean of 10.3 points lower (mean [SD], 16.03 [11.94] vs 26.28 [21.76]; 2-sided 95% CI, -19.34 to -2.12; P = .03) and postoperative pancreatic fistula rate was lower (37% vs 67%; P = .02) in the pasireotide group compared with the hydrocortisone group. In this study, hydrocortisone was not noninferior compared with pasireotide in patients undergoing partial pancreatectomy. Pasireotide may be more effective than hydrocortisone in patients undergoing distal pancreatectomy. ClinicalTrials.gov identifier: NCT02775227; EudraCT identifier: 2016-000212-16.

Prevention of pancreatic fistula after pancreatoduodenectomy

Prospective randomized investigation of the efficiency of somatostatin analogues and glucocorticoids in pancreatic fistula prevention after pancreatoduodenectomy by using. In period from December 2018 till March 2020 78 patients underwent pancreatoduodenectomy for pancreatobilliary tumors in department of abdominal surgery of National Medical Research Center of Surgery named after A.V. Vishnevsky. Intraoperative frozen section investigation of pancreatic functioning acinar structures (FAS) was held for all patients. 38 patients had more than 40% of FAC and were related with high risk of pancreatic fistula (PF), while 40 patients with less than 40% FAC were included in low risk of PF group. In both groups patients were randomized to main and control subgroups. In main subgroup of high risk group patients combination of somatostatin analogues and glucocorticoids was used, while in control subgroup patients received only somatostatin analogue. In low risk of PF group patients of main subgroup preventively got somatostatin analogue, while control group patients had no specific prophylaxis of PF. To assess the effect of drug prophylaxis on the development of pancreatic fistula we used logistic regression models with the inclusion of the drug use factor as an independent variable. 25 patients were included in main subgroup of high risk group. Clinically relevant pancreatic fistula (CRPF) developed in 14 (56%) cases. From 13 patients of control subgroup CRPF developed in 5 (38%) cases. In main subgroup of low risk group 18 patients were included and 3 (16%) of them had CRPF. In control subgroup were 22 patients and there were no cases of CRPF. In our series combination of somatostatin analogue and glucocorticoid didn't show efficiency in prevention of CRPF in high risk patients, although difference between subgroups wasn't statistically significant (p=0.34). In low risk group patients prophylactic use of somatostatin analogue also didn't show decline of CRPF incidence and the difference between subgroups also wasn't statistically significant (p=0.46).

Sarcopenia in pancreatic surgery. Systematic review

Background: Attention has increased about sarcopenia as an important predictor of postoperative outcomes following major surgery. On the one hand, the study of muscle mass in patients undergoing pancreatic surgery could be an effective way to stratify surgical risks. On the other hand, patients with pancreatic diseases have a high risk for sarcopenia due to their underlying pathologies. Material & Methods: We perform a systematic review of the literature, according PRISMA guidelines, to search articles about sarcopenia and pancreatic surgery. Results: Sixteen articles comparing patients undergoing pancreatic surgery with and without sarcopenia were included. All of them were case series, including 5071 patients. Sarcopenia diagnosis criteria and cut off values in all these series are diverse. 1408 of them (27.76%) were classified like sarcopenic patients. Twelve studies were carried out exclusively in oncological patients, eleven of them only include oncological patients undergoing pancreatic surgery and the other one published by Buettner et al also study sarcopenia influence in hepatic cancer and CRC patients. Only 3 studies include patients with benign pathology undergoing pancreas resection in addition to oncological patients. Benign pathologies represent a 2.15% of the studied population (98/4562). And the last one, Fukuda et al report the only study about sarcopenia influence in pancreatic transplantation. Table 1 shows the impact of sarcopenia on postoperative outcomes and mortality. Only 3 studies find a higher risk of pancreatic fistula in patients with sarcopenia. Sandini et al reports a higher trend of abdominal abscesses in sarcopenic patients. No difference where observed according to other morbidities. Conclusion: The impact of sarcopenia on morbidity and perioperative mortality in pancreatic resections is still unclear. It is necessary to unify criteria both in the definition and in the cut off values. Prospective studies and consensus on sarcopenia diagnosis should be achieve.

3024 Post Whipple's Pancreatitis: Post Procedure Inflammatory Changes Sub-Serving a Diagnostic Challenge

INTRODUCTION: Making an accurate diagnosis of pancreatitis in the post-operative setting after a Whipple's procedure can be difficult. Acute pancreatitis inflammatory changes occurring in the peripancreatic area may be indistinguishable from post-operative peripancreatic inflammation hence creating a diagnostic challenge. CASE DESCRIPTION/METHODS: A 54-year-old woman with a past medical history of Type 2 diabetes mellitus, hypothyroidism, and pancreatic head neuroendocrine tumor status post-Whipple's procedure with a residual mild postoperative pancreatic fluid collection which was drained three years ago. She presented with epigastric pain of 5 days duration. She was hemodynamically stable, serum lipase was elevated to 2,752. Abdominal CT done 2 weeks prior to admission for cancer surveillance revealed a stent in the main pancreatic duct. Repeat abdominal CT scan demonstrated the stent and showed acute interstitial pancreatitis. MRI/MRCP done showed mildly ectatic pancreatic duct with a linear structure concerning for a retained stent. She underwent ERCP and the stent could not be visualized with no intervention performed. She was managed with intravenous fluids and analgesics for pancreatitis and subsequently had her diet advanced as tolerated. DISCUSSION: The true incidence of post-Whipple's pancreatitis is unknown, and there are many difficulties in making an accurate diagnosis of pancreatitis. Postoperative findings after pancreaticoduodenectomy can include inflammatory changes and fat stranding, which can make the differentiation between pancreatitis and post-operative changes challenging. Serum levels of amylase and lipase are unreliable in the postoperative period. In severe cases, an abdominal CT would be needed to make the diagnosis of postoperative pancreatitis. Post-Whipple's pancreatitis can have significant prognostic implications, including a higher risk of pancreatic fistula and a higher risk of delayed gastric emptying.

Extremes of BMI are associated with a higher risk of pancreatic fistula following pancreaticoduodenectomy: an analysis using the NSQIP database

Extremes of BMI are associated with a higher risk of pancreatic fistula following pancreaticoduodenectomy: an analysis using the NSQIP database

Minimally invasive versus open pancreatic enucleation. Systematic review and meta-analysis of surgical outcomes.

Parenchymal sparing procedures are gaining interest in pancreatic surgery and recent studies have reported that minimally invasive pancreatic enucleation may be associated with enhanced outcomes when compared with traditional surgery. By meta-analyzing the available data from the literature, minimally invasive surgery is not at higher risk of pancreatic fistula and offers a number of advantages over conventional surgery for pancreatic enucleation.

Modified end-to-side double-layer open pancreaticogastrostomy after Whipple procedure: surgical tips for a safe anastomosis.

Pancreatic fistula (PF) remains the Achilles' heel of pancreaticoduodenectomy (PD). Pancreaticogastrostomy (PG) appears to be associated with a lower risk of postoperative leak according to recent evidence. We started to fashion PG, especially in soft pancreas, modifying the original technique described by Bassi. At our institution, 105 PD procedures were carried out from January 2011 to December 2016; pancreatic-enteric continuity was restored by PG in 35 cases. Superior mesenteric/portal vein resection/reconstruction was necessary in three patients. A total of 34/35 patients underwent PG with an open anterior gastrostomy approach. Briefly, our double-layer PG anastomosis (illustrated by a video) starts with a posterior row of interrupted absorbable 4/0 monofilament sutures including the gastric serosa and the pancreatic capsule. It is essential to mobilize the left pancreas for 4-5cm and to shape the posterior gastrostomy shorter than the pancreatic stump. After a wide anterior auxiliary gastrostomy the pancreas is invaginated into the stomach and an interrupted row of sutures between the posterior gastric wall (full-thickness) and the body of the pancreatic stump is fashioned. The anterior gastrostomy is closed with an absorbable running suture. Finally, a further layer of sutures is applied over the posterior suture line between the gastric serosa and the pancreatic capsule. The 90-day postoperative mortality was nihil. No biliary leakage was detected and the overall PF rate was 11.4% (4/35) according to the ISGPF study group. Only one patient suffered a grade B PF (in this case, PG was carried out only through a posterior gastrostomy), whereas three patients had a minor (grade A) PF. Our modified PG proved to be safe and easy to perform, while it carried excellent outcomes even in the setting of soft pancreas. Despite the limited number of cases, such modified PG appears promising, particularly for pancreatic remnants at higher risk of PF.

Circumferential pedicled omental flap for protection of portomesenteric venous reconstruction and gastroduodenal artery stump following pancreatoduodenectomy

Abstract This video demonstrates a technique for creation of an omental tissue barrier to protect a portomesenteric vein reconstruction or gastroduodenal artery (GDA) stump. Following routine pancreatoduodenectomy reconstruction, a generous tongue of omentum is mobilized off the transverse colon ensuring to preserve the feeding branches from the left gastroepiploic artery. The omentum is then passed behind the pancreatojejunostomy above the vein repair site. It is grasped superiorly and passed anterior to the pancreatojejunostomy to exclude the GDA stump. The flap is then secured to the blind end of the jejunum with suture thereby completing the circumferential wrap. Care must be taken in obese patients to trim the flap so it can fit behind the pancreas without devascularizing it or causing tension on the pancreatojejunostomy. If a closed suction drain is desired, it can be passed from the patient's right either in front of or behind the hepaticojejunostomy and placed around the flap. This technique is most applicable to patients with moderate to high risk of pancreatic fistula (small pancreatic duct and/or soft gland) after undergoing PD with an intact omentum. This circumferential, pedicled omental flap is an easy, reproducible, and durable method to protect vascular structures and repairs from pancreatic fistulas.

Surveillance and comparison of surgical prognosis for asymptomatic and symptomatic non-functioning pancreatic neuroendocrine tumors

BackgroundThe treatment of non-functioning pancreatic neuroendocrine tumors (NF-PNETs) still remains controversial. It is uncertain whether asymptomatic patients have better prognosis than symptomatic patients and whether surgery is necessary for asymptomatic patients. MethodsPatients with NF-PNETs who were managed surgically or by surveillance between June 2007 and December 2013 were retrospectively studied. The choice of surgery or surveillance was based entirely on the patient's desire. Survival prognosis was compared between asymptomatic and symptomatic patients, and evaluated among patients who were under surveillance. ResultsOf the 53 patients with NF-PNETs, 48 (90%) were treated surgically. 25 patients (47%) were symptomatic patients, 23 (43%) asymptomatic, and five (10%) detected by surveillance. Among the latter group, one patient suffered from tumor progression and four had stable disease. When compared with symptomatic NF-PNETs, asymptomatic NF-PNETs showed lower pathology grades (P = 0.006), better 3-year cumulative progression-free survival and overall survival after surgical treatment. Parenchyma-preserving resection was associated with a higher risk of pancreatic fistula (71 vs. 17%, P = 0.007). A positive lymph node status (P = 0.003) and perineural or vascular invasion (P = 0.01) were significant predictors of tumor recurrence or metastasis. Patients with grade G3 disease (P = 0.005) or a tumor size >4 cm (P = 0.019) had poor prognosis. ConclusionsCompared with symptomatic NF-PNETs, asymptomatic NF-PNETs had a lower degree of malignancy and better prognosis. Surveillance for small asymptomatic NF-PNETs needs to be further studied.

Autologous Islet Transplantation in Patients Requiring Pancreatectomy: A Broader Spectrum of Indications Beyond Chronic Pancreatitis.

Islet autotransplantation (IAT) is usually performed in patients undergoing pancreatic surgery for chronic pancreatitis. In the present series, IAT was offered also to patients undergoing pancreatic surgery for both nonmalignant and malignant diseases, having either completion pancreatectomy as treatment for severe pancreatic fistulas (n = 21) or extensive distal pancreatectomy for neoplasms of the pancreatic neck (n = 19) or pancreatoduodenectomy because of the high risk of pancreatic fistula (n = 32). Fifty-eight of 72 patients who were eligible to this broader spectrum of indication actually received IAT. There was no evidence of a higher-than-expected rate of major complications for pancreatectomy. Forty-five patients receiving IAT were still alive at the time of the last scheduled follow-up (1375 ± 365 days). Eighteen (95%) of 19 and 11 (28%) of 39 patients reached insulin independence after partial or total pancreatectomy, respectively. The metabolic results were dependent on the transplanted islet mass. Thirty-one of 58 patients had malignant diseases of the pancreas or periampullary region, and only three patients developed ex novo liver metastases after IAT (median follow-up 914 ± 382 days). Our data demonstrate the feasibility, efficacy, and safety of IAT for a broader spectrum of clinical indications beyond chronic pancreatitis.

Proposal for a Pancreatic Configuration Index for Determining Patients at High Risk of Pancreatic Fistula Following Pancreatoduodenectomy

Background/Aims: The pancreatic configuration is one of the most important factors that have an impact on the incidence of postoperative pancreatic fistula (POPF). This study sought to propose a new index, called the pancreatic configuration index (PCI), to categorize patients at a high risk for POPF. Methods: Two hundred and thirty-one patients who underwent pancreatoduodenectomies were subjected to the analysis. The pancreatic parenchymal thickness and the main pancreatic duct (MPD) diameter at the pancreatic neck were measured using axial computed tomography scan images. The PCI was calculated by dividing the axial thickness by the MPD diameter. Results: Sixty-two of the patients (26.8%) developed clinically significant POPF. Using a receiver operating characteristic curve analysis, the cut-off value of the PCI in predicting POPF was 5.3. The incidence of POFP increased depending on the PCI level. Using a multivariate analysis that included the various risk factors of POPF, a high PIC (≥5) was identified as an independent risk factor of POPF, with the highest OR at 6.50. Conclusion: The PCI is useful for stratifying patients at a high risk for POPFs. This index may be used to classify the patient population when evaluating other risk factors for POPF.

Can the measurement of amylase in drain after distal pancreatectomy predict post-operative pancreatic fistula?

IntroductionThe most frequent reason for performing a distal pancreatectomy is the presence of cystic or neuroendocrine tumors, in which the distal pancreatic stump is often soft and non fibrotic. This parenchymal consistence represents the main risk factor for post-operative pancreatic fistula. In order to identify the fistula and assessing its severity postoperative monitoring of amylase from intraperitoneal drains is important. MethodsFrom a retrospective multicentric database analysis were included 33 patients who underwent distal pancreatectomy for pancreatic neoplastic disease. ResultsPostoperative pancreatic fistula occurred in four cases. One patient had a ductal adenocarcinoma, two presented with pancreatic endocrine neoplasms and the last one had an intraductal papillary mucinous neoplasia. Two patients underwent open, the other two laparoscopic distal pancreatectomy. DiscussionPostoperative pancreatic fistulas after distal pancreatectomy worsen the quality of life, prolong the post-operative stay and delay further adjuvant therapy. In patients who underwent distal pancreatectomy literature exposed some advantages deriving from the placement of abdominal drainages only in selected cases and from their early removal. Patients presenting a high risk of pancreatic fistula had higher amylase levels of drainage fluid in the first postoperative day. ConclusionPOPF is the most frequently complication after pancreatectomy. In our analysis DFA1>5000 can be considered as a predictive factor for pancreatic fistula. For this reason, the systematic measurement of amylase in drain fluid in first-postoperative day can be considered a good clinical practice.

Preoperative diabetes as a protective factor for pancreatic fistula after pancreaticoduodenectomy: a meta-analysis

The role of diabetes mellitus (DM) in pancreatic fistula (PF) or clinical relevant PF (CR-PF) after pancreaticoduodenectomy (PD) or pylorus-preserving pancreaticoduodenectomy (PPPD) is unclear. We conducted a meta-analysis to investigate the relationship between DM and PF or CR-PF. Embase, MEDLINE and Cochrane databases were searched systematically for relevant articles from January 2005 to June 2013. The selected studies that examined clinical risk factors of PF or CR-PF were included. We created pooled estimates for our outcomes using the random-effects model. Sixteen observational clinical studies were included. Pooling of PF rates from ten studies revealed that DM was associated with a decreased risk of PF (P=0.01). CR-PF rates from 8 studies showed no significant difference between DM and control group (P=0.14). DM is not a risk factor for PF in patients undergoing PD or PPPD. On the contrary, patients without DM are at a higher risk of PF because the pancreases in these patients have more fatty tissue and the pancreas is soft.

Is Enucleation Safe When the Distance Between the Tumor and the Main Pancreatic Duct Is Less Than 3 mm? Results from a Multi-Institutional Retrospective Study

Background Enucleation of small tumors can prevent pancreatic function impairment although the incidence of postoperative pancreatic fistula is relatively high. It has been suggested that this procedure should be avoided when the distance between the tumor and the main pancreatic duct is less than 3 mm. Objective To evaluate the safety of pancreatic enucleation for tumors distant less than 3 mm from the main pancreatic duct. Methods We reviewed the databases of the Department of Surgery of Marburg University (MU) and “Sacro Cuore” (SCH) Hospital of Negrar (1990-2012). All patients underwent intra-operative ultrasound (US) to measure the distance between the main pancreatic duct and the tumor. Binary logistic regression analysis of predictors of pancreatic fistula was performed. Results Sixty patients underwent enucleation in the two institutions. There were 21 males (35%) and 39 females (65%) with a median age of 50 years. The main reason for surgery was insulinomas (60%) followed by nonfunctioning neuroendocrine tumors (22%), gastrinomas (8%) and other tumors (6%). The median operative time was 137 minutes (IQR: 120-160). The overall rate of pancreatic fistula was 48% whereas the mortality was nil. The rate of pancreatic fistula was similar among the two institutions (55% in the SCH versus 42% in the MU; P=0.305). Overall, 31 patients (52%) had a distance between the tumor and the main pancreatic duct less than 3 mm. Re-exploration was necessary in 5 patients (8%) who had a tumor distant less than 3 mm from main pancreatic duct whereas the rate of grade C pancreatic fistula was similar among the two groups (25% vs . 29%; P=0.257). The only variable associated with a higher risk of pancreatic fistula was the distance between the tumor and main pancreatic duct less than 3 mm (odds ratio: 5.51; P=0.003). Conclusions Although the distance between the main pancreatic duct and tumor less than 3 mm is associated with a higher risk of pancreatic fistula, enucleation remains acceptably safe also in this group of patients. An intra-operative US is always mandatory to improve the post-operative management other than preventing main pancreatic duct injuries.

Utility of CT in the Diagnosis of Pancreatic Fistula After Pancreaticoduodenectomy in Patients with Soft Pancreas

The purpose of this study was to evaluate the sensitivity and specificity of routine performance of CT on postoperative day 7 in patients at high risk of pancreatic fistula after pancreaticoduodenectomy. Two radiologists analyzed images from CT examinations of 50 patients with soft pancreas 7 days after pancreaticoduodenectomy. Pancreatic fistula was defined at CT as a fluid collection close to the pancreaticogastric or pancreaticojejunal anastomosis. Clinicobiologic criteria for the diagnosis of pancreatic fistula were drain output of any measurable volume of fluid on or after postoperative day 3 that had an amylase content more than three times the serum amylase activity. The final diagnosis of pancreatic fistula was rendered on the basis of clinicobiologic data at hospital discharge or at first readmission. At hospital discharge or at first readmission, 27 of 50 patients (54%) had a pancreatic fistula. On postoperative day 7, 30 patients (60%) had a total of 51 fluid collections, and CT showed a fluid collection close to the pancreaticogastric or pancreaticojejunal anastomosis in 21 of 51 cases. CT had a sensitivity of 63% (17/27 patients) and a specificity of 83% (19/23 patients) for the diagnosis of pancreatic fistula with four false-positive and 10 false-negative findings. The diagnosis of pancreatic fistula on the basis of clinicobiologic criteria on postoperative day 7 was made in 22 of 27 patients (81%), whereas five cases were false-negative. Four of these patients had CT evidence of pancreatic fistula. In patients at high risk who have undergone pancreaticoduodenectomy, systematic postoperative CT may be proposed as a complementary tool in the diagnosis of pancreatic fistula, particularly for detection of clinically occult pancreatic fistula.

Techniques, indications et résultats précoces de la conservation splénique dans les exérèses pancréatiques gauches

Study aim. Splenic preservation is rarely performed during left pancreatectomy. We compared retrospectively the early results of left pancreatectomy with and without splenic preservation to define the place of this procedure. Patients and methods. From 1979 to 1997, among 54 left pancreatectomies for another indication than adenocarcinoma, 13 were performed with and 41 without splenic preservation. The technique used for splenic preservation was prograde dissection of the left pancreas with ( n = 4) and without ( n = 9) preservation of both splenic artery and vein. The preoperative caracteristics of the patients, peroperative data, postoperative morbidity and length of stay were compared. Results. Mean operative time was longer with splenic preservation (262 ± 67 min versus 215.6 ± 59 min, p < 0.05), particularly in case of splenic vessels preservation (295 ± 38 min, p < 0.02) whereas no difference was noted with splenic vessels ligation (240 ± 76 min, p > 0.05). No mortality occurred. Prevalence of peroperative or postoperative haemorrhage, morbidity, or length of stay (intensive care unit and whole hospitalisation) did not differ with or without splenic preservation. Five patients developed pancreatic fistula without influence of splenic preservation: 1/13 (7.7%) versus 4/41 (9.7%) ; conversely, surgery following acute pancreatitis was associated with an higher risk of pancreatic fistula : 3/5 versus 2/49 ( p < 0.005). No splenic necrosis occurred after splenic preservation. Conclusion. During left pancreatectomy, splenic preservation increases the operative duration (only in case of preservation of splenic vessels) but does not increase morbidity. This technique should be used whenever possible to allow long term immunological benefits of splenic preservation.

Pancréatectomie médiane : résultats d’une série de 11 patients

Aim of the study: To report a new series of medial pancreatectomy (MP), with analysis of early and long-term results. Patients and methods: From 1990 to 1999, 11 patients (mean age= 53 years, extremes: 28–70) – including 10 non-diabetic – underwent MP for neuroendocrine tumor ( n=5), intraductal papillary mucinous tumor (IPMT) ( n=3), serous cystadenoma, metastasis from renal cell carcinoma, and focal pancreatitis. The procedure included medial resection of variable extent, frozen section, and suture of the cephalic stump. The caudal stump was either anastomosed to the posterior gastric wall ( n=9), or closed when atrophic or very small ( n=2). Results: The mean length of resection was 7 cm (extremes: 4–15). The diagnosis suspected preoperatively was confirmed in 10 cases. In one patient, a suspected adenocarcinoma was actually a focal pancreatitis. No postoperative death occurred. Seven patients experienced complications: one delayed gastric emptying and 6 pancreatic fistulas (54%), including 3 associated with intra-abdominal collection. Two patients were reoperated to drain a pancreatic fistula. The mean hospital stay was 14 days (extremes: 10–21) without complications, and 30 days (extremes: 11–90) after complications. After a mean follow-up of 45 months (extremes: 7–130), only one patient initially non-diabetic experienced post-operative diabetes and needs enzyme therapy after a 15 cm-resection for IPMT. No patient developed isolated intrapancreatic recurrence. Conclusions: MP preserves efficiently pancreatic function and is associated with a low risk of intrapancreatic recurrence. Conversely, MP is associated with an high risk of pancreatic fistula.