Incidence Of Postoperative Pancreatic Fistula Research Articles

Comparison between different predicting systems for pancreatic fistula after pancreaticoduodenectomy:which is better?

Introduction: Though the safety of PD has been significantly improved, the post-operative pancreatic fistula (POPF) always is a formidable complication. It is important to choose different peri-operative strategy to manage POPF according the risk predicting scores. There were three scoring systems to predict the risk of clinically relevant postoperative pancreatic fistula (CR-POPF), National Cancer Center Hospital (NCCH) system ; University Hospitals Birmingham (UHB) system and Fistula risk score (FRS). Though these systems were established and validated by external data, there was less comparison between each other. Method: The study was a retrospective analysis of 202 patients who underwent PD from January 2015 to October 2017 in the general surgery department of Peking University Third Hospital by the same staffs. All data were collected, including preoperative medical status, operative procedure, final pathology, gland texture, pancreatic duct diameter and predicting system scores. We defined POPF according to International Study Group of Pancreatic Fistula (ISGPF) definition. Result: The incidence of POPF was 43.1% and the incidence of CR-POPF was 29.2% in 202 patients. The ROC area under the curve (AUC) for UHB(0.802) was higher than that for FRS (0.785) and NCCH (0.739) (p<0.01). Conclusion: University Hospitals Birmingham (UHB) scoring system is better than National Cancer Center Hospital (NCCH) system and Fistula risk score (FRS) in predicting CR-POPF.

Novel single-layer continuous suture of pancreaticojejunostomy for robotic pancreaticoduodenectomy

Introduction: Robotic pancreaticoduodenectomy (RPD) is one of the most technically challenging procedures in robotic abdominal surgery. The best technique for pancreatic anastomosis after PD remains controversial, and the procedure for performing this anastomosis by a robotic approach has not been previously reported. This study aimed to evaluate the safety and feasibility of a novel technique of pancreaticojejunostomy (PJ) for RPD. Method: The demographics and perioperative outcomes of a consecutive series of RPD patients who underwent single-layer continuous suture (SCS) for PJ between September 2018 and November 2018 were analyzed. Result: Thirty patients (19 men and 11 women; mean age, 55.0 years) were included in the study. Twenty patients had a soft pancreas, and 15 patients had a small main pancreatic duct (MPD) (<3 mm). The mean operative time was 234.1 minutes, the mean duration of PJ was 14.9 min, and the median estimated blood loss was 100.0 mL (interquartile range, 50-150 mL). No patients required conversion to laparotomy or a blood transfusion. Postoperative major morbidities (Clavien ≥C) occurred in 3 patients (10%), and all recovered after conservative treatment. The overall incidence of postoperative pancreatic fistula was 30% and included 7 cases (23.2%) of Grade A, 2 cases (6.7%) of Grade B, and no case of Grade C pancreatic fistula. The mean postoperative hospital stay was 12.3 days. No 90-day readmission mortality or 90-day mortality was observed. Neither pancreatic texture nor MPD size affected the perioperative outcomes. Conclusion: SCS is a safe and feasible PJ technique for RPD. SCS is easy to perform and is associated with favorable clinical outcomes, regardless of the pancreatic duct size and texture.

Chen’s continuous suture technique for invaginated pancreaticojejunostomy following pancreaticoduodenectomy with no grade B/C POPF and zero motality in 644 patients with soft pancrease and small pancreatic duct

Introduction: Internationally, postoperative pancreatic fistula (POPF) remains a leading cause of morbidity and mortality after pancreaticoduodenectomy (PD). In order to reduce the POPF incidence, a number of technical modifications for pancreato-enteric anastomosis after PD has been proposed. In 1995, we established a new suture technique for end-to-end or end-to-side invaginated pancreaticojejunostomy (PJ) following PD, and the preliminary results were quite encouraging. This study aims to review this new surgical approach, the Chen’s continuous suture technique for invaginated PJ, to evaluate the effectiveness of this approach in reducing the incidence of POPF. Method: To evaluate this new approach, 1852 patients from 8 medical center in China receiving the Chen’s continuous suture technique after a open PD from Jan. 2016 to Jan. 2019 were reviewed. Among them, 644 (34.8%) patients were with soft pancrease and small duct (small than 3 mm in diameter) and were included in this study. The postoperative morbidity and mortality including the POPE incidence were analyzed. Result: The postoperative morbidity was 27% (174/644) and mortality was 0% (0/644). The POPF rate was 8.8% (57/644) for Grade A, and no Grade B and Grade C POPF occurred. Conclusion: Chen’s continuous suture technique is a simple method and provides excellent outcomes in lowering POPF incidence following PD in the patients with the soft pancrease and a small pancreatic duct.

Is there any different risk factor for clinical relevant pancreatic fistula according to the stump closure method following left-sided pancreatectomy?

Backgrounds/AimsConsistency on risk factors for postoperative pancreatic fistula (POPF) after left-sided pancreatectomy (LP) according to the stump closure methods has not been revealed. Appropriate surgical stump closure method after LP is still in debate. This study investigates risk factors for POPF according to the closure methods in LP.MethodsA total of 49 consecutive patients underwent LP with a stapler closure (ST) or hand-sewn closure (HS) between June 2001 and September 2016. The risk factors of pancreatic fistulas were investigated in 49 LPs according to stump closure methods, HS (n=19), and ST (n=30).ResultsThere was no significant difference in the incidence of overall POPF (HS 42.1% vs. ST 50.0%) and clinical relevant POPF (CR-POPF) (HS 5.3% vs. ST 6.7%) between two groups. In the ST group, the pancreas was significantly thick in patients with CR-POPF (27 mm vs. 17 mm) and the tumor was also larger (58 mm vs. 27 mm). In the HS group, the operation time was longer in CR-POPF group (515 min vs 292 min). In univariate analysis, wider diameter of the pancreatic duct (27 mm vs 16 mm) was associated with POPF in the HS group. There was no meaningful risk factor for POPF in the ST group.ConclusionsIncidence of overall POPF between the ST and HS group were clinically insignificant in this study. The thickness of the pancreas and the tumor diameter are factors significantly associated with CR-POPF in the ST group. Long operation time was the only factor associated with CR-POPF in the HS group.

Postoperative Acute Pancreatitis Following Pancreaticoduodenectomy: A Determinant of Fistula Potentially Driven by the Intraoperative Fluid Management.

The aim of the study is to characterize postoperative acute pancreatitis (POAP). A standardized definition of POAP after pancreaticoduodenectomy (PD) has been recently proposed, but specific studies are lacking. The patients were extracted from the prospective database of The Pancreas Institute of Verona. POAP was defined as an elevation of the serum pancreatic amylase levels above the upper limit of normal (52 U/L) on postoperative day (POD) 0 or 1. The endpoints included defining the incidence and predictors of POAP and investigating the association of POAP with postoperative pancreatic fistula (POPF). The study population consisted of 292 patients who underwent PD. The POAP and POPF rates were 55.8% and 22.3%, respectively. POAP was an independent predictor of POPF (OR 3.8), with a 92% sensitivity and 53.7% specificity (AUC 0.79). Preoperative exocrine insufficiency (OR 0.39), neoadjuvant therapy (OR 0.29) additional resection of the pancreatic stump margin (OR 0.25), soft pancreatic texture (OR 4.38), and Main Pancreatic Duct (MPD) diameter ≤3 mm (OR 2.86) were independent predictors of POAP. In high-risk patients, an intraoperative fluid administration of ≤3 ml/kg/h was associated with an increased incidence of POAP (24.6 vs. 0%, P = 0.04) and POPF (27.6 vs. 11.4%, P = 0.05). This study represents the first clinical application of the only available definition of POAP as a specific complication of pancreatic surgery. POAP is associated with an increased occurrence of POPF and overall morbidity and could potentially be avoided through a specific intraoperative fluid regimen in high-risk pancreas.

External versus internal pancreatic duct stenting in duct-to-mucosa pancreaicojejunostomy after pancreaticoduodenectomy: a prospective randomized study

Background: A pancreatic duct stent is often placed across the pancreaticojejunostomy after pancreaticoduodenectomy to decrease the incidence rate of postoperative pancreatic fistula. However, there are few reports in the literatures compared between external and internal pancreatic duct stents. Methods: We conducted a prospective randomized study with 30 patients who underwent pancreaticoduodenectomy and we compared the effects of using external stent versus internal stent in pancreaticojejunostomy on postoperative course, particularly on incidence of postoperative pancreatic fistula. Results: The incidence rate of pancreatic fistula according to the International Study Group on Pancreatic Fistula criteria was significantly higher in external stent group (external, 26.7%; vs internal, 13.3%). In subgroup analysis of patients with soft pancreas, we found similar rates of pancreatic fistula in the two studied groups. The incidence of overall morbidity was similar between both groups while mortality was higher in external stent group. The mean postoperative hospital stay was not significantly different between the two studied groups. Conclusions: Both external stent and internal pancreatic duct stents were safely used for pancreaticojejunostomy. Internal stent had less incidence of postoperative pancreatic fistula and simplifies postoperative management and it might be a better option than external stent in pancreaticojejunostomy after pancreaticoduodenectomy.

The modified duct-to-mucosa pancreaticojejunostomy for small pancreatic duct during pancreaticoduodenectomy

Purpose: Postoperative pancreatic fistulas(POPFs) due to anastomotic leak are closely related to significant morbidity and mortality following pancreaticoduodenectomy(PD).The aim of this study is to introduce modification of the conventional duct-to-mucosa (DM) pancreaticojenunostomy(PJ) and the improved outcomes of this modified PJ technique for small main pancreatic duct. Methods: The modified DM anastomosis is characterized that matching internal stent was inserted into the pancreatic duct remnant and secured with suture at the opening of the pancreatic duct to enhance sealing, prior to the anastomosis. From January 2012 to October 2017, 102 patients underwent PD for small main pancreatic duct (≤ 3mm). In total, 33 cases received conventional DM pancreaticojejunal anastomosis and 69 cases received modified DM pancreaticojejunal anastomosis. Results: The postoperative stay time, diet resumption time and timing of drain removal in the modified DM group were lower than those in conventional DM group. The overall incidence of POPFs was not significantly different between two groups. But, the clinical POPFs (grade B/C) in the modified DM group occurred less frequently than those in the conventional DM group. (4.3 % vs. 24.2 %, p=0.002). Moreover, neither grade C POPF nor in-hospital mortality occurred in the modified DM group. In addition, multivariate analysis showed a significant difference between both groups on significant POPFs (OR 0.211, 95% CI 0.09 to 0.51, P=0.001). Conclusion: The modified DM anastomosis technique in our study is a safer anastomotic method than the traditional DM pancreaticojejunostomy technique. This new technique could effectively reduce the incidence of POPF.

Is sutureless pancreaticogastrostomy more effective than single-layer duct-to-mucosa pancreaticojejunostomy in pancreaticoduodenectomy?

Introduction: The present study aimed to assess the safety of pancreatic anastomosis after pancreaticoduodenectomy (PD) and to compare the results of sutureless pancreatogastrostomy (PG) with those of single-layer duct-to-mucosa pancreatojejunostomy (PJ) after PD in patients with malignant disease of the pancreatic head and of the periampullary region. Methods: The study included 173 consecutive patients undergoing PD from May 2009 to December 2015 at a single surgical center. Single-layer duct-to-mucosa PJ was performed in 52 patients and sutureless PG in the remaining 123. The primary endpoint was the safety of the procedures, which was assessed as the occurrence of complications during hospitalization. Postoperative pancreatic fistula (POPF) was classified as grade A, B, or C according to the International Study Group of Pancreatic Fistula classification. Results: We found that the incidence of POPF was 11.52%. With regard to POPF, the present study showed no significant difference in the two groups (p=0.043). The incidence of Grade C POPF was significantly higher in the PJ group than in the PG group (p=0.001), which was been reflected in the form of a higher rate of postoperative hemorrhage (p=0.001), intra-abdominal abscess (p=0.012), and septic shock (p=0.012) events in the PJ group. Conclusions: The evaluation of short-term outcomes demonstrates that suturelessPG is a feasible and safe technique, associated with lower life-threatening complications than single-layer duct-to-mucosa PJ. If longterm functional outcomes confirm similar results, sutureless PG could become a valid alternative for pancreatic anastomosis after PD in patients with soft pancreas and high morbidity.

Effect of antibiotic choice on the development of postoperative pancreatic fistula: a NSQIP study

Choice of antibiotic surgical site infection for pancreatic surgery is variable, with no consensus on their optimal choice of prophylactic antibiotics. We aim to assess the influence of antibiotic choice on the development of postoperative pancreatic fistula (POPF). The American College of Surgeons - National Surgical Quality Improvement Program Pancreatectomy Targeted Participant Use Data File 2016 was queried to identify patients who underwent distal pancreatectomy (DP) or pancreatoduodenectomy (PD). The incidence of POPF was compared by genre of antibiotic given: 1st generation cephalosporin (Abx1) vs 2nd or 3rd generation cephalosporin or broad spectrum antibiotics (Abx2). A total of 1762 (32.5%) and 3659 (67.5%) patients underwent DP and PD, respectively. Abx1 was given intraoperatively as prophylaxis to 2060 (38%) patients. The rate of fistula formation was 18.4% (n=995). The rate of fistula formation was significantly different by the extent of antibiotic coverage; 19.9% (n=409) and 17.4% (n=586) for the Abx1 and Abx2 groups (P=0.026), respectively. The choice of antibiotic did not significantly change the rate of fistula formation in patients who underwent DP (P>0.05). However, a significant change was noted in PD patients; 20.2% (n=253) and 17.2% (n=414), P=0.023, for Abx1 and Abx2, respectively. The choice of antibiotic coverage did not change the severity of fistulae (P=0.77) for either DP or PD. Prophylactic antibiotic choice affects the rate of fistula formation following PD but not DP. Further prospective studies assessing the specific bacteria and its role in fistula formation is warranted, and indeed underway in the ACS-AHPBA trial.

Drain fluid amylase on post-operative day 5 as pronostic factor of grade B–C pancreatic fistula after distal pancreatectomy

Background: Post-operative pancreatic fistula (POPF) is one of the most feared complications after distal pancreatectomy (DP) and associates an increased morbidity and mortality. Aim: To analyze the incidence and risk factors of POPFs in our series and stratify the risk factors for grade B/C POPFs after DP. Methods: We performed a single-center retrospective study which analyzes patients who underwent DP between 2010 and 2017. We recollected demographic, surgical, post-operative and histological data. Drain fluid amylase was examined on postoperative day 3, 5 and 7, following our protocol. POPFs were classified according to the International Study Group of Pancreatic Fistula definitions. We performed a descriptive analysis and multivariate logistic regression to determine the prognostic factors of POPF Results: A total of 92 patients underwent DP. Laparoscopic approach was performed in 39 (42%) patients, with a conversion rate of 22%. In 85% of the cases we used endostapler and in 24% we performed manual suture of the pancreatic stump. Sealant was placed on the resection surface in 60% of the cases. POPF was diagnosed in 26% of the patients, of whom 19% were grade B-C. None of the variables analyzed were significantly associated with POPF, but the drain fluid amylase >1000 U/L on post-operative day 5, was associated with grade B-C POPFs [OR 20, p = 0.028 (CI 1.301–287)]. Conclusion: In our series, no overall POPF predictive factors were found after DP. However, an elevated drain fluid amylase on post-operative day 5 can predict a worst outcome and should influence our therapeutic strategy.

Major postoperative complications after pancreaticoduodenectomy and its associated factors – A retrospective analysis

Introduction: There are two major complications following Pancreaticoduodenectomy (PD); postoperative pancreatic fistula (POPF) and delayed gastric emptying (DGE). The aim of this study is to identify the risk factors associated with both complications, as well as perioperative fluids administration. Methodology: We conducted a retrospective observational study in 243 patients who underwent elective PD between the period of January 2011 until June 2016 and analysed using univariate and multivariate models. There were 60 patients with POPF and 2 patients with DGE. Result: After univariate analysis, weight, BMI, WBC at day 3, post op INR derangement, CRP, surgical site infections (SSI), intraabdominal collections, total fluid volume given postoperatively and fluid balance in 24 hours duration were significantly associated with higher incidence of POPF (p < 0.05). Univariate analysis for the DGE showed only signs of infection (p = 0.021) and intra-abdominal collections (p = 0.033) were significantly associated with higher incidence of DGE. In multivariate analysis, postoperative INR derangement OR 2.376 (p = 0.048), intra-abdominal collection OR 9.842 (p < 0.001), SSI OR 3.736 (p = 0.003) and postoperative fluid balance (24 hours) OR 1.001 (p < 0.001), were identified as independent significant risk factors for POPF; and SSI OR 2.415 (p = 0.009) was the only independent significant risk factor for DGE. Conclusion: Sepsis have higher association in developing both POPF and DGE. Where as BMI and postoperative fluid balance is associated with increased risk of developing POPF.

Afferent Loop Decompression Technique is Associated with a Reduction in Pancreatic Fistula Following Pancreaticoduodenectomy.

Postoperative pancreatic fistula (POPF) is a major complication and main cause of mortality after pancreaticoduodenectomy (PD). Afferent loop decompression technique (ALDT) has theoretical feasibility to reduce the rate of POPF. The aim of this study is to determine whether ALDT is a protective factor for POPF. A total of 492 consecutive patients who underwent PD between January 2012 and December 2014 were identified from a prospective database. All data were extracted and events were judged based on medical records. Propensity score matching was conducted to balance several variables. Univariate and multivariate analyses were performed, respectively, to investigate the independent risk factors for pancreatic fistula. ALDT required a nasogastric tube with multiple side holes to be placed deep into the afferent jejunal limb. The rationale for this technique was to prevent pancreatic fistula by decreasing intraluminal pressure in the afferent jejunal loop by placement of the nasogastric tube and the application of continuous low-pressure suction after surgery. The total rate of POPF for the entire cohort was 30.7%, and ISGPS grade-A/B/C POPF rates were 18.1, 10.6 and 2.0%, respectively. In-hospital mortality was 1.6%. Among the 331 patients who received ALDT, 89 developed pancreatic leakage (26.9 vs. 38.5% for non-ALDT; P = 0.009) and eight developed biliary leakage (2.4 vs. 6.2% for non-ALDT; P = 0.035). Apart from ALDT, decreased preoperative ALT, soft pancreas, long operative time and tumour presence in the lower common bile duct (as opposed to the pancreas) were identified as other independent risk factors for POPF following multivariate logistic regression analysis. ALDT may reduce the incidence of POPF after PD.

Increased incidence of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) in patients with distal bile duct cancer and ampullary cancer vs. adenocarcinoma of the pancreas

Denial of climate change may exacerbate the problem by impeding pro-environmental behavior and policy. An online survey of 219 US citizens assessed tolerance of ambiguity, political orientation, and beliefs about climate change. Results indicated that low tolerance of ambiguity predicted beliefs that: 1) climate change is not a problem; 2) is not the result of human activity, and; 3) cannot be corrected through individual behavior. Analyses also supported that these relationships were mediated by conservative political orientation. The link between conservative politics and refusal to accept climate science may reflect a proximate relationship; personality characteristics, like tolerance of ambiguity, may ultimately be responsible for drawing people to both political and environmental ideologies.

Efficacy and safety comparison of nabpaclitaxel plus s-1 and gemcitabine plus s-1 as first-line chemotherapy for metastatic pancreatic cancer

Although the mortality and morbidity of pancreaticoduodenectomy (PD) have improved significantly over the past years, the concerns for elderly patients undergoing PD are still present. Furthermore, the frequency of PD is increasing because of the increasing proportion of elderly patients and the increasing incidence of periampullary tumors. This study aimed to analyze the outcomes of PD in elderly patients.We studied all patients who had undergone PD in our center between January 1995 and February 2015. The patients were divided into three groups based on age: group I (patients aged >60 years), group II (those aged 60 to 69 years) and group III (those aged ≥70 years). The primary outcome was the rate of total postoperative complications. Secondary endpoint included total operative time, hospital mortality, length of postoperative hospital stay, delayed gastric emptying, re-exploration, and survival rate.A total of 828 patients who had undergone PD for resection of periampullary tumor were included in this study. There were 579 (69.9%) patients in group I, 201 (24.3%) in group II, and 48 (5.8%) in group III. The overall incidence of complications was higher in elderly patients (25.9% in group I, 36.8% in group II, and 37.5% in group III; P=0.006). There were more patients complicated with delayed gastric emptying in group II compared with the other two groups. There was no significant difference in the incidence of postoperative pancreatic fistula, biliary leakage, pancreatitis, pulmonary complications and hospital mortality.PD can be performed safely in selected elderly patients. Advanced age alone should not be a contraindication for PD. The outcome of elderly patients who have undergone PD is similar to that of younger patients, and the increased rate of complications is due to the presence of associated comorbidities.

Randomized clinical trial of the effect of a fibrin sealant patch on pancreatic fistula formation after pancreatoduodenectomy.

BackgroundThe potential for a fibrin sealant patch to reduce the risk of postoperative pancreatic fistula (POPF) remains uncertain. The aim of this study was to evaluate whether a fibrin sealant patch is able to reduce POPF in patients undergoing pancreatoduodenectomy with pancreatojejunostomy.MethodsIn this multicentre trial, patients undergoing pancreatoduodenectomy were randomized to receive either a fibrin patch (patch group) or no patch (control group), and stratified by gland texture, pancreatic duct size and neoadjuvant treatment. The primary endpoint was POPF. Secondary endpoints included complications, drain‐related factors and duration of hospital stay. Risk factors for POPF were identified by logistic regression analysis.ResultsA total of 142 patients were enrolled. Forty‐five of 71 patients (63 per cent) in the patch group and 40 of 71 (56 per cent) in the control group developed biochemical leakage or POPF (P = 0·392). Fistulas were classified as grade B or C in 16 (23 per cent) and ten (14 per cent) patients respectively (P = 0·277). There were no differences in postoperative complications (54 patients in patch group and 50 in control group; P = 0·839), drain amylase concentration (P = 0·494), time until drain removal (mean(s.d.) 11·6(1·0) versus 13·3(1·3) days; P = 0·613), fistula closure (17·6(2·2) versus 16·5(2·1) days; P = 0·740) and duration of hospital stay (22·1(2·2) versus 18·2(0·9) days; P = 0·810) between the two groups. Multivariable logistic regression analysis confirmed that obesity (odds ratio (OR) 5·28, 95 per cent c.i. 1·20 to 23·18; P = 0·027), soft gland texture (OR 9·86, 3·41 to 28·54; P < 0·001) and a small duct (OR 5·50, 1·84 to 16·44; P = 0·002) were significant risk factors for POPF. A patch did not reduce the incidence of POPF in patients at higher risk.ConclusionThe use of a fibrin sealant patch did not reduce the occurrence of POPF and complications after pancreatoduodenectomy with pancreatojejunostomy. Registration number: 2013‐000639‐29 (EudraCT register).

Application of a novel embeddedness-like pancreaticojejunostomy anastomosis technique used in pancreaticoduodenectomy.

Optimized pancreaticojejunostomy anastomosis was used to investigate the effects on the incidence rate of postoperative complications in pancreaticoduodenectomy. The data of 250 patients who underwent pancreaticoduodenectomy between August 2011 and December 2015 were analyzed; all surgery was performed by a single team. The first 100 surgeries were performed using traditional pancreaticojejunostomy anastomosis, whereas the next 150 patients underwent novel pancreaticojejunostomy anastomosis (the experimental group). General information, disease status and the occurrence rate of postoperative complications [postoperative pancreatic fistula (POPF), biliary leakage, delayed gastric emptying, bleeding and mortality] within 30 days of surgery were observed. In the first group, 56 patients had POPF (56%), the proportion of grades A, B and C was 44% (n=44), 9% (n=9) and 3% (n=3), respectively; in the experimental group, 30 patients had POPF (20%), the proportion of grades A, B and C was 14.67% (n=22), 5.33% (n=8) and 0%, respectively. Furthermore, in the experimental group, none of the patients exhibited postoperative bleeding or succumbed during surgery. The application of the novel embeddedness-like pancreaticojejunostomy anastomosis technique in pancreaticoduodenectomy was safe and effective, and may reduce the incidence of POPF in future.

Two-point measurement of amylase in drainage fluid predicts severe postoperative pancreatic fistula after gastric cancer surgery.

Early identification of patients at risk of postoperative pancreatic fistula (POPF) allows appropriate management after gastrectomy. Although some reports have suggested a correlation between POPF and the concentration of amylase in drained abdominal fluid (D-AMY), this has not been proven to impact sufficiently on clinical decision-making. A sustained high level of D-AMY is often assumed to be due to unsatisfactory drainage or excessive pancreatic leakage. We assessed the clinical utility of measuring D-AMY on postoperative day (POD) 1 and POD3 for prediction of POPF. Starting in April 2014, 801 patients who underwent radical gastrectomy with prophylactic drain placement were consecutively enrolled. We routinely measured D-AMY on POD1 and POD3, and compared the incidence of problematic POPF and clinical factors including D-AMY. We also attempted to clarify whether such two-point D-AMY measurement was clinically useful for patient management after gastrectomy. Fifty-one of the patients (6.4%) developed Clavien-Dindo grade III or worse POPF. Using D-AMY cutoffs of 2218IU/L on POD1 and 555IU/L on POD3, the patients were successfully classified. The highest risk group, in which D-AMY was higher than the cut-off value on both POD1 and POD3, showed a significantly high rate of occurrence (33/105, 31.4%) and high positive likelihood ratio (6.74). Multivariate analysis showed that classification into this highest risk group was an independent risk factor for development of severe POPF (odds ratio 15.2, 95% CI 7.92-29.0). Two-point measurement of D-AMY may be an efficient tool for achieving individualized management of POPF following radical gastrectomy.

Reproducibility of preoperative endoscopic injection of botulinum toxin into the sphincter of Oddi to prevent postoperative pancreatic fistula.

BackgroundA postoperative pancreatic fistula (POPF) is the most common and potentially life-threatening surgical complication in pancreatic surgery. One possible pharmacological treatment could be the endoscopic injection of botulinum toxin (BTX) into the sphincter of Oddi to prevent POPF. Promising data reported a significantly reduced rate of clinically relevant POPF. We analyzed the effect of BTX injection in our patients undergoing distal pancreatectomy (DP).MethodsA retrospective analysis of patients undergoing DP was performed. Patients with preoperative endoscopic injection of BTX into the sphincter of Oddi were included. The end points were postoperative outcomes including POPF. BTX patients were compared with a historical cohort and matched in a 1:1 ratio using a propensity score analysis.ResultsA total of 19 patients were treated with endoscopic injection of BTX before open (n=8) or laparoscopic (n=11) DP. The median age of the patients was 67 years and the mean body mass index was 25.9 kg/m2. In median, the intervention was performed 1 day (range, 0–14 days) before the operation. There were no intervention-related complications. The incidence of POPF was not statistically different between the two groups: a clinically relevant POPF grade (B/C) occurred in 32% (BTX) and 42% (control; p=0.737). Likewise, there were no significant differences in postoperative drain fluid amylase levels, morbidity, and mortality.ConclusionThe present study could not reproduce the published results of a significant lowering of grade B/C POPF. The explanations could be the timing of BTX injection before surgery and the endoscopic technique of BTX injection. However, the conflicting results after BTX injection in two high-volume centers prompt a randomized controlled multicenter trial with trained endoscopists.

Pancreatic fistula and mortality after surgical management of pancreatic trauma: analysis of 81 consecutive patients during 11 years at a Korean trauma center.

PurposePancreatic trauma is infrequent because of its central, deep anatomical position. This contributes to a lack of surgeon experience and many debates exist about its standard care. This study aimed to investigate the postoperative pancreatic fistula (POPF) and mortality of pancreatic trauma after operation.MethodsWe reviewed records in the trauma registry of our institution submitted from January 2006 to December 2016. The grade of pancreatic injury, surgical management, morbidity, mortality, and other clinical variables included in the analyses.ResultsData from a total of 26,072 trauma patients admitted to the Emergency Department were analyzed. Pancreatic trauma was observed in 114 of these patients (0.44%). Laparotomy was performed in 81 patients (2 pan creatico duodenectomies, 2 pancreaticogastrostomies, peripancreatic drainage in 41 patients, distal pancreatectomies in 34 patients, and 9 patients who underwent surgery for damage control). The incidence of POPF was 38.3%. The overall mortality was 8.8% (7 of 81). In multivariate analysis, pancreas injury grade IV (≥4) (adjusted odds ratio [AOR], 4.071; P = 0.029) and preoperative peritonitis signs (AOR, 2.903; P = 0.039) were independent risk factors for POPF. All patients who died had also another major abdominal injury (≥grade 3). Multiorgan failure was a major cause of death (6 of 7, 85.7%). The mortality rate of isolated pancreas injury was 0%.ConclusionThe pancreas injury grade and preoperative peritonitis were significant risk factors of POPF. The mortality rate of isolated pancreatic trauma was very low.

The Effect of Preoperative Biliary and Pancreatic Drainage on Postoperative Pancreatic Fistula: A Retrospective Cohort Study.

Background Surgeons and endoscopists welcome routine preoperative biliary drainage prior to pancreaticoduodenectomy despite evidence that it increases complications. Its effect on postoperative pancreatic fistula is variably reported in literature. Simultaneous biliary and pancreatic drainage is rarely performed for very selected indications and its effects on postoperative pancreatic fistula are largely unknown. Our aim was to analyze the same while eliminating confounding factors. Methods Retrospective single center cohort study of patients who underwent pancreaticoduodenectomy over the past 10 years for carcinoma obstructing the lower common bile duct. Patients who underwent biliary stenting alone, biliary and pancreatic stenting, and no stenting prior to pancreaticoduodenectomy were the three study cohort groups and their records were scrutinized for the incidence of postoperative pancreatic fistula. Results Sixty-two patients underwent biliary stenting alone, 5 patients underwent both biliary and pancreatic stenting, and 237 patients were not stented in the adenocarcinoma group without chronic pancreatitis. The pancreatic fistula rate was similar in the patients who underwent biliary stenting alone when compared with the group which was not stented. (24/62 versus 67/237, odds ratio [OR] =0.619, confidence interval (CI) =0.345–1.112, p = 0.121). However, the patients who underwent both biliary and pancreatic stenting had a significant increase in postoperative pancreatic fistula compared with the not stented ( p = 0.003). By univariate and multivariate analysis using Firth logistic regression, pancreatic texture (OR = 1.205, CI = 0.103–2.476, p = 0.032) and the presence of a biliary and pancreatic stent (OR = 2.695, CI = 0.273–7.617, p = 0.027) were the significant factors affecting pancreatic fistula. Conclusion Preoperative biliary drainage alone has no significant influence on postoperative pancreatic fistula except when combined with pancreatic stenting. We need more such studies from other centers to confirm that the rare event of preoperative biliary and pancreatic stenting has indeed this harmful effect on healing of postoperative pancreatic anastomosis.