Incidence Of Postoperative Pancreatic Fistula Research Articles

Epidural analgesia in the perioperative period and mean arterial pressure as risk factors for postoperative complications after pancreaticoduodenectomy

Objective. To study the influence of epidural analgesia and mean arterial pressure as risk factors for the development of postoperative pancreatic fistula, delayed evacuation of gastric contents and postpancreatic bleeding after pancreaticoduodenectomy. Materials and Methods. The retrospective study included 234 patients who underwent pancreaticoduodenectomy at the National Research Center of Surgery and Transplantation named after O. O. Shalimov from January 2022 to November 2023. The surgical intervention included a standard pancreaticoduodenectomy according to the modified Child's technique. The objective was to evaluate the optimal approach to anesthesia and blood pressure management to minimize the risk of postoperative complications. Data were collected on the type of anesthesia (general anesthesia or a combination of general anesthesia and epidural analgesia), mean arterial pressure, use of vasopressors, and the incidence of postoperative complications. The analysis was performed using logistic–binomial regression to assess the risk of complications depending on the level of blood pressure and the use of epidural analgesia. Results. The combined use of epidural analgesia and general anesthesia was associated with a decrease in the incidence of clinically significant postoperative pancreatic fistula, delayed evacuation of gastric contents, and other complications. Epidural analgesia, although associated with an increased risk of hemodynamic instability, contributed to better pain control and a reduction in the incidence of postoperative complications. A decrease in mean arterial pressure by each 1 mm Hg increases the risk of postoperative pancreatic fistula by 15.8%, which confirms the importance of maintaining an adequate level of pressure to ensure optimal tissue perfusion. Despite the hypothesis of a possible negative effect of vasopressors, their use did not show a statistically significant association with the incidence of postoperative pancreatic fistula. Thus, further studies are needed to clarify the optimal parameters of patient management after pancreaticoduodenectomy.

The safety and efficacy of stapler method for transection of the pancreatic parenchyma during pancreatoduodenectomy (STRAP-PD trial): study protocol for a randomized control trial.

Pancreaticoduodenectomy is a highly difficult and invasive type of gastrointestinal surgery. Prevention of postoperative pancreatic fistula is important, and this may be possible by the stapler method. STRAP-PD is a single center randomized controlled trial. We compare a method of transecting the pancreatic parenchyma in pancreaticoduodenectomy using a surgical stapler device with a conventional transecting method using energy devices (e.g., scalpel, ultrasonic coagulator and incision devices). Patients with soft pancreas who are scheduled to undergo pancreaticoduodenectomy are randomized to arm A (conventional method) or arm B (stapler method). We aim to examine the safety and usefulness of dissection by the automatic suture device, with attention to the rate of pancreatic fistula ISGPF grade B or C and to postoperative complications. This is a single-center randomized study, which began in September 2023 at Wakayama Medical University Hospital. Pancreatic parenchymal transection is typically performed either by direct incision using a scalpel or by employing energy devices such as ultrasonic coagulating cutting devices during pancreaticoduodenectomy. In a prospective pilot study, we conducted pancreatic parenchymal transection in 20 consecutive normal pancreatic cases during pancreaticoduodenectomy, observing postoperative pancreatic fistula grade B in one case (5%). Traditional methods involving scalpel incision or the use of ultrasonic coagulating cutting devices have been historically favored but perceived as technically challenging, and they have been reliant upon the surgeon's skill. Notably, relatively high incidences of postoperative pancreatic fistula among patients with soft pancreas have also been observed. Our proposed stapler method may therefore be a useful method responsible for reducing the development of pancreatic fistula. This method would be as part of minimally-invasive surgery for pancreaticoduodenectomy. It uses an endoscopic linear stapler to cut the pancreatic parenchyma, so it is likely to be more convenient than conventional methods and can be used universally. TRIALREGISTRATION: University Hospital Medical Information Network Clinical Trials Registry,UMIN000052089. the Registration Date on 1st September 2023.

Impact of Surgical Technique on Reducing the Incidence of Postoperative Pancreatic Fistula: A Systematic Review and Meta-Analysis

<i>Background</i>: Postoperative pancreatic fistula (POPF), a complication frequently encountered following pancreaticoduodenectomy. Pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) are the most frequently utilized reconstructive strategies with different anastomosis techniques. This study was conducted to evaluate the optimal surgical technique to prevent POPF. <i>Methods</i>: The study was conducted using PRISMA guidelines with PROSPERO registration No. CRD42023494393. Patients undergoing pancreaticoduodenectomy includes the use of PJ or PG with different anastomoses techniques and developed POPF were included. We conducted a systematic literature review from January 2019 to December 2023 using a comprehensive search strategy, through Web of Science, ProQuest, Science Direct, PubMed, and Google Scholar databases. Meta-analysis was utilized to analyze the outcomes. The risk of bias was assessed using the Newcastle-Ottawa scale. <i>Results</i>: Eighteen studies with 3343 patients who underwent various anastomoses (including the Modified DuVal, Heidelberg PJ, and Blumgart methods) were included. Postoperative pancreatic fistula (POPF) occurred in 27% of patients. Techniques such as modified Heidelberg, Peng, shark mouth PJ, and Kiguchi PJ were associated with lower POPF rates, whereas modified and classical Blumgart techniques exhibited higher rates. While mortality rates varied among surgical techniques, overall mortality was low. <i>Conclusions</i>: Data from this study can be used to shape future studies and direct physicians to develop strategies to reduce the risk of POPF and thereby reduce morbidity and mortality, leading to improved patient outcomes. Furthermore, this data can inform clinical decision-making and guide the development of evidence-based practice guidelines to optimize surgical outcomes.

Powered stapler and polyglycolic acid sheet for pancreatic fistula after distal pancreatectomy

BackgroundAlthough distal pancreatectomy (DP) is crucial for the treatment of pancreatic diseases, it often leads to postoperative pancreatic fistula (POPF), a complication with significant management challenges and health effects. Despite the use of various techniques, including suturing methods, staplers, and biodegradable materials, the optimal strategy to reduce POPF remains unclear. This study investigated the combined use of powered staplers and polyglycolic acid (PGA) sheets to mitigate POPF. MethodsThis study retrospectively analyzed the data of 165 patients who underwent DP at Sapporo Medical University Hospital between January 2013 and August 2023. This study compared the incidence of clinically relevant POPF (CR-POPF) between patients treated without (group O, n = 50) and with powered staplers and PGA sheets (group P, n = 115). In addition, the surgical techniques, patient demographics, and postoperative outcomes were examined. ResultsThis study found no significant difference in the overall incidence of POPF between the groups. However, group P had a significantly lower incidence of CR-POPF than group O (20.9% vs 40.0%, respectively; P = .011). Multivariate analysis demonstrated that male sex (odds ratio [OR], 2.81; 95% CI, 1.26–6.26; P = .012) and pancreatic thickness of more than 14 mm (OR, 2.85; 95% CI, 1.17–6.95; P = .021) were independent risk factors for CR-POPF. The use of powered staplers and PGA sheets (OR, 0.38; 95% CI, 0.17–0.85; P = .017) was associated with reduced CR-POPF risk. ConclusionThe combined use of powered staplers and PGA sheets can significantly decrease the incidence of CR-POPF in patients with DP.

Stent A pancreaticojejunostomy after pancreatoduodenectomy: Is it always necessary?

The establishment of a postoperative pancreatic fistula (POPF) is considered the most common and, concomitantly, the most serious complication associated with pancreaticoduodenectomy (PD). The search for either technical modifications of the operative technique or pharmaceutical interventions that could possibly aid in decreasing the incidence of this often-devastating complication appears justified. The stenting of the pancreatic duct, with the use of either internal or external stents, has been evaluated in this direction. In theory, it is an approach that could eliminate many pathophysiological factors responsible for the occurrence of a POPF. The purpose of the present study was to review the current data regarding the role of pancreatic duct stenting on the incidence of POPF, after PD, by using PubMed and Reference Citation Analysis. In general, previous studies seem to highlight the superiority of external stents over their internal counterparts in regard to the incidence of POPF; this is at the cost, however, of increased morbidity associated mainly with the stent removal. Certainly, the use of an internal stent is a less invasive approach with acceptable results and is definitely deprived of the drawbacks arising through the complete diversion of pancreatic juice from the gastrointestinal tract. Bearing in mind the scarcity of high-quality data on the subject, an approach of reserving stent placement for the high-risk for POPF patients and individualizing the selection between the use of an internal or an external stent according to the distinct characteristics of each individual case scenario appears appropriate.

Prevention of Postoperative Pancreatic Fistula: Systematic Review and Meta-Analysis

Background: After pancreatic surgery, the development of postoperative pancreatic fistula (POPF) is a serious concern. POPF involves the leakage of pancreatic fluids from the surgical site, which can lead to complications and even death. Preventing POPF is essential for enhancing patient recovery and lessening the impact on healthcare resources. This systematic review and meta-analysis evaluated medical methods and surgical techniques to prevent POPF. Methods: This study was registered under the International Prospective Register of Systematic Reviews (PROSPERO) with the registration number CRD42024500938. An electronic search was conducted through the PubMed, Google Scholar, Web of Science, and ScienceDirect databases for all relevant articles published in English from 2018 to 2023. The following search terms were used: ((Whipple procedure OR Pancreaticojejunal OR Pancreaticogastrostomy) AND (Prevention of postoperative pancreatic fistula) AND (Prevention OR Octreotide OR Sealant agent OR Stent OR Postoperative drain)). Results: Of 260 papers, 28 articles extracted through the database search were considered suitable for the systematic review. The included studies investigated a variety of surgical approaches for pancreatic resection. Pancreaticoduodenectomy (PD) was the most prevalent intervention. The incidence rates for POPF varied widely across the studies, ranging from as low as 11.6% to as high as 100%. The incidence rate of clinically relevant POPF (CR-POPF) ranged from 11.7% to 33.3%. The length of postoperative hospital stays also varied significantly. Discussion: Postoperative pancreatic fistula (POPF) affects 13–41% of patients post-pancreatic surgery. Despite its high incidence, mortality rates are low. Postoperative hospital stay varies, with higher rates in older patients and overweight individuals. Advancements in surgical techniques and perioperative management have reduced mortality rates to <5%. Conclusions: This study provides insights into the outcomes of pancreatectomy, including the incidence of POPF, postoperative hospital stays, and mortality rate. The findings suggest that the incidence of POPF is similar to that suggested in the literature and is influenced by various factors.

SP4.7 - Intraoperative pancreas consistency and evidence of pancreatitis during pancreatoduodenectomy, and the incidence of postoperative pancreatic fistula

Abstract Background Soft/normal pancreas consistency is a known risk factor for postoperative pancreatic fistula (POPF) in patients who undergo pancreatoduodenectomy (PD) for malignancy. A hard pancreas is considered less technically challenging to work with and generally allows the formation of a more robust pancreatic anastomosis. This study aimed to investigate the impact of pancreas consistency and intra-operative pancreatitis on the incidence of POPF in PD patients. Methods Data was extracted from the Recurrence After Whipple’s (RAW) study, a multicentre retrospective cohort study of outcomes following PD performed for malignancy (29 centres in 8 countries, n=1484). Patients with operation notes which documented a subjective assessment of pancreas tissue consistency and whether there was intra-operative evidence of pancreatitis were included. The incidence of POPF and clinically relevant POPF (CR-POPF) was calculated and comparisons were made using the chi-squared test. The 2016 International Study Group of Pancreatic Fistula definitions were used. Results Of the 40.6% patients included, 41.5% had a soft/normal pancreas and 58.2% had a firm/hard pancreas. Both POPF (OR: 5.2, 95% CI: 3.3-8.3) and CR-POPF (OR: 4.7, 95% CI: 2.5-8.9) were significantly more common in the former (both p<0.0001). A soft/normal pancreas was most common in patients with cholangiocarcinoma and least common in those with pancreatic cancer (56.4% vs 33.4%). 32.6% had their intra-operative pancreatitis status documented. Of these, 22.8% had evidence of pancreatitis and 77.2% did not. POPF (11.8% vs 16.1%, p=0.3) and CR-POPF (8.2% vs 9.4%, p=0.7) rates were similar in these groups. Conclusion In our multicentre study of PD outcomes, POPF and CR-POPF were significantly more common in those with a soft/normal pancreas. This may have implications for postoperative management planning.

Pancreatic fistula after gastrectomy. Retrospective single-center analysis

Objective: to determine the frequency and risk factors for postoperative pancreatic fistula (POPF) after gastrectomy. Material and Methods. From January 1, 2018 to October 31, 2023, 198 patients with stage I–III gastric cancer underwent gastrectomy with D2 lymphadenectomy at a Regional Oncological Dispensary. The characteristics of the studied patients were assessed according to a unified protocol. Statistically significant factors influencing the development of POPF were identified. Results. The incidence of POPF was 18.7 % (37/198). It was found that not all pancreatic fistulas were accompanied by acute pancreatitis. Among the patients with POPF, 5 had associated acute pancreatitis: 2 with mild, and 3 with moderate severity; no severe acute pancreatitis was observed. The statistically significant indicator for the occurrence of POPF was the neutrophil-lymphocyte index (p=0.033), in the absence of other infectious phenomena. In addition, the following significant factors were identified: lymphadenopathy of regional lymph nodes (p=0.037), tumor stage (T criterion) (p=0.002), splenectomy (p<0.001), and resection of the pancreas (p<0.001). Conclusion. The frequency of postoperative pancreatic fistulas after gastrectomy was 18.7 %. Statistically significant factors for the development of POPF include resection of the pancreas, splenectomy, lymph node status, tumor size, and depth of invasion. An additional indicator for the development of POPF is an increase in the neutrophil-lymphocyte index 1 day after surgery.

Characteristics and outcomes of minimally invasive surgery for congenital biliary dilatation in children aged

We evaluated the minimally invasive surgery for congenital biliary dilatation (CBD) in adults and children and analyzed the surgical outcomes, especially in children aged <6 years. Characteristics and surgical outcomes of patients with CBD who underwent minimally invasive surgery at our hospital between 2013 and 2023 were retrospectively reviewed. Overall, 129 patients (89 children aged <6 years, 9 children aged between 6 and 18 years, and 21 adults) were included in this study. Children exhibited more protein plug presence and abnormal biochemical data than adults. Incidence of postoperative pancreatic fistulas was highest in the adult group (3.4%, 11%, and 33%, respectively, p < .01). In children aged <6 years, postoperative bile leakage and pancreatic fistulas occurred in 9.0% and 3.4% of patients, respectively. Multivariate logistic regression analysis revealed that the Todani IVA was associated with a decrease in postoperative bile leakage (odds ratio: -1.7; 95% confidence interval: (-3.3)-(-0.22), p = .03). Adults with CBD required prolonged operative times and had more short-term complications than children with CBD. In children aged <6 years, minimally invasive surgery for CBD can be safely performed; however, a small diameter of the bile duct may be associated with bile leakage.

A comparison of pancreatojejunostomy using the modified Blumgart anastomosis with or without a four-needle three-loop suture device and continuous sutures for duct-to-mucosa anastomosis in robotic pancreaticoduodenectomy.

Despite descriptions of different pancreatojejunostomy procedures using robotic pancreaticoduodenectomy (RPD), a standardized procedure has not yet been established. No prior report has described pancreatojejunostomy by RPD combined with modified Blumgart anastomosis with continuous suturing for duct-to-mucosa anastomosis. This study investigated this surgical technique and evaluated the short-term outcomes of the simplified pancreatojejunostomy procedure. Between December 2021 and March 2024, 36 patients underwent pancreatojejunostomy using modified Blumgart anastomosis with continuous suturing for duct-to-mucosa anastomosis using RPD. Patients were divided into an early group (n = 15), without the use of the new four-needle three-loop suture device during the modified Blumgart anastomosis and a late group (n = 21) that did use this device. The late group had a significantly shorter pancreatojejunostomy duration (60min vs. 49min, p = 0.004) than the early group. Both groups showed equivalent postoperative outcomes; however, the late group exhibited a trend toward a lower rate of postoperative pancreatic fistula grade ≥ B (26.7% vs. 4.8%, p = 0.138). Pancreatojejunostomy using modified Blumgart anastomosis with a four-needle three-loop suture device and continuous suture for duct-to-mucosa anastomosis in patients undergoing RPD is simple and effective. This new suturing device may further reduce the incidence of postoperative pancreatic fistulas.

Postoperative Pancreatic Fistula Following Duct To Mucosa Pancreaticojejunostomy After 100 Consecutive Whipple’s Surgery

Background: Postoperative pancreatic fistula (POPF) remains a concerning complication following pancreaticojejunostomy (PJ). Its incidence can be as high as 20%, with identified risk factors including soft gland texture, small main pancreatic duct (MPD) diameter, pancreatic pathology, and significant intraoperative blood loss. Our primary objective is to determine the incidence of POPF and assess its associated risk factors by consistently applying a uniform surgical technique and utilizing uniform suturing materials. Methods: Our study included patients who underwent PJ following pancreaticoduodenectomy at our center using a consistent duct-to-mucosa technique and the same suturing material, PDS 5-0. Data from 100 consecutive patients were collected and entered into the Statistical Package for the Social Sciences (SPSS 26) for analysis of postoperative pancreatic fistula (POPF). Results: Among the 100 patients, the incidence of clinically relevant POPF was 5%. Factors such as gland texture and main pancreatic duct (MPD) diameter did not demonstrate any statistically significant correlation with POPF, however the frequency of POPF was notably high in cases with an MPD diameter of less than 3 mm. Mortality following clinically relevant POPF was substantial, reaching 4%, and this association was statistically significant (p &lt; 0.001). Conclusion: POPF represents a severe complication associated with statistically significant mortality. Employing a uniform standard duct-to-mucosa anastomotic technique along with consistent use of suturing material is imperative to mitigate bias and minimize the risk of POPF.

Incidence of Pancreatic Leakage in Isolated Biliary Limb Roux-en-Y Reconstruction in Whipple Procedure

Abstract Background Whipple is currently the procedure of choice in the treatment of localized pancreatic cancer. Isolated Roux-en-Y loop pancreaticojejunostomy was proposed as a method of reconstruction following pancreaticoduodenectomy. The idea is to isolate the bile from pancreatic secretions to minimize pancreatic enzyme activation and ultimately pancreatic fistula formation. It was also proposed that if a pancreatic fistula develops, it will be a pure fistula and thereby more benign as opposed to a mixed pancreatic fistula containing bile. Objective To estimate the incidence of pancreatic fistula in patients undergoing isolated Roux-en- Y hepaticojejunostomy reconstruction following pancreaticoduodenectomy. Patients and Methods In this prospective observational study, our aim is to calculate the incidence of post-operative pancreatic fistula in 20 patients that underwent Roux-en-Y isolated biliary limb reconstruction following pancreaticoduodenectomy for the treatment of pancreatic cancer. The study includes patients that underwent this procedure at Ain Shams University Hospitals in the period between January 2021 and July 2022 with a post-operative follow up period of 3 weeks. Patients were diagnosed with pancreatic cancer using MRI or CT scans with some of them also undergoing endoscopic US with biopsy. They were then admitted to one of the two main Ain Shams University Hospitals for pre-operative preparation. Results Our study did no estimate post-operative complications such as delayed gastric emptying and wound infection. Pancreaticoduodenectomy is a major surgery that carries a significant burden in terms of morbidity and mortality. Post-operative pancreatic fistula can be fatal as it can lead to vascular pseudoaneurysms that may fatally rupture. The idea behind using isolated biliary limb roux-en-y reconstruction is to alleviate the morbidity caused by post-operative pancreatic fistula. Conclusion Further comparative studies with a higher number of patients are recommended to assess and compare the value of isolated biliary limb reconstruction when compared to conventional reconstruction.

Omental Flap Technique in Pancreaticojejunostomy: Does it Prevent Pancreatic Fistula Development after Pancreaticoduodenectomy?

The aim of our study was to investigate the clinical results of omental flap application during pancreaticojejunostomy (PJ) anastomosis in pancreatoduodenectomy (PD) surgeries. The data of patients who underwent pancreaticoduodenectomy in our hospital were evaluated retrospectively. The patients were divided into two groups; patients with an omental flap (Group 1) and those without an omental flap (Group 2). The demographic and other characteristics of the groups and the incidence of postoperative pancreatic fistula (POPF) development were compared. One hundred patients were included (39 females, 61 males) Group 1 consisted of 20 patients with omental flaps and Group 2 consisted of 80 patients without omental flaps. While no clinically significant (Grade B and C) leaks were observed in Group 1, both biochemical and clinically significant leak rates were lower in Group 1 compared to 4 patients (5%) in Group 2. There was no statistically significant difference compared with Group 2 (p > 0.05). Although not statistically significant in this study, postoperative complication rates and the incidence of POPF tended to decrease in patients who underwent omental flaps.

Is duct-to-mucosa pancreaticojejunostomy necessary after pancreaticoduodenectomy: A meta-analysis of randomized controlled trials

The incidence of postoperative pancreatic fistula is influenced by the effectiveness of the pancreaticojejunostomy, and the most suitable pancreaticojejunostomy for pancreaticoduodenectomy remains uncertain. Since grade A postoperative pancreatic fistula is no longer considered a true fistula, the purpose of this meta-analysis was to compare the effectiveness of duct-to-mucosa anastomosis and invagination anastomosis in reducing the incidence of grade B/C postoperative pancreatic fistula. The meta-analysis was conducted using software Review Manager 5.3, and the fixed-effect model was employed for pooled statistic calculations. The Cochrane Collaboration Risk of Bias Tool was utilized for quality assessment. Ten randomized controlled trials from Embase, Web of Science, MEDLINE, and the Cochrane Library (1990.01–2022.10) including 1471 patients, met the inclusion criteria. This meta-analysis has been registered on PROSPERO with the registration number CRD42023491673. The incidence of grade B/C fistula was significantly lower in the invagination group (7.7 %) compared to the duct-to-mucosa group (12.8 %, mostly Cattell manner)(RR = 1.65, 95%CI: 1.14–2.39, P = 0.008; heterogeneity: P = 0.008, I2 = 68 %),heterogeneity among the results was addressed through sensitivity analysis. In patients with a soft pancreas, the incidence of grade B/C fistula was significantly lower in those who underwent invagination anastomosis (10 %) compared to those who underwent duct-to-mucosa anastomosis (41.9 %)(RR = 4.19, 95%CI: 1.33–13.25, P = 0.01).No significant differences were observed in terms of the occurrence of grade B/C fistula in firm pancreas, postoperative mortality, other major postoperative complications, anastomosis time, and postoperative bile leak. Therefore, we concluded that invagination anastomosis is significantly superior to duct-to-mucosa anastomosis in reducing the incidence of grade B/C fistula, especially in patients with a soft pancreas.

Middle-segment preserving pancreatectomy: a literature review and case report.

Middle segment-preserving pancreatectomy (MSPP) is a relatively new parenchymal-sparing surgery that has been introduced as an alternative to total pancreatectomy (TP) for multicentric benign and borderline pancreatic diseases. To date, only 36 cases have been reported in English. We reviewed 22 published articles on MSPP and reported an additional case. Our patient was a 49-year-old Japanese man diagnosed with Zollinger-Elison syndrome (ZES) caused by duodenal and pancreatic gastrinoma associated with multiple endocrine neoplasia syndrome type 1. We avoided TP and chose MSPP as the operative technique due to his relatively young age. The patient developed a grade B postoperative pancreatic fistula (POPF), which improved with conservative treatment. He was discharged without further treatment. To date, no tumor has recurred, and pancreatic function seems to be maintained. According to a literature review, the morbidity rate of MSPP is as high as 54%, mainly due to the high incidence of POPF (32%). In contrast, there was no perioperative mortality, and postoperative pancreatic function was comparable to that after conventional pancreatectomy. Despite the high incidence of POPF, MSPP appears to be safe, with low perioperative mortality and good postoperative pancreatic sufficiency.

Evaluation of Patients with Postoperative Pancreatic Fistula After Isolated Splenectomy: A Retrospective Study

Objective: Postoperative pancreatic fistula (POPF) is a potentially life-threatening complication. This complication occurs not only after pancreatic surgery but may also arise after other abdominal procedures. In this study, we aimed to determine the incidence and risk factors of POPF in patients undergoing isolated splenectomy. Methods: Patients who underwent isolated splenectomy were identified. POPF was defined according to the 2016 update of International Study Group of Pancreatic Fistula classification and graded as biochemical leak (BL), grade B fistula, and grade C fistula. Characteristics and perioperative variables were compared between patients who had pancreatic fistula and those who have not. Results: The study cohort consisted of 59 patients with median age 38.9 years, and 50.8% male. The indication was trauma in 18 (30.5%) patients. Twenty (33.9%) patients were operated upon emergently. Thirty-seven (62.7%) splenectomies were performed open. Out of all patients, 14 (23.7%) developed any sort of pancreatic fistula. BL occurred in 11 (18.6%) patients and 3 (5.1%) patients developed a grade B fistula. Comparison of patients with and without BL/POPF demonstrated no significant differences in demographics, surgical indication, operative method, surgical approach, or postoperative outcome. Conclusions: Despite higher incidence of pancreatic leak, the rate of clinically relevant fistula is relatively low. In this study, we did not identify any factors associated with BL/POPF. Thus, further studies are needed on pancreatic fistula after splenectomy.

How I do it. Pancreatojejunostomy: surgical tips to mitigate the severity of postoperative pancreatic fistulas after open or minimally invasive pancreatoduodenectomy.

Pancreatoduodenectomy is the most appropriate technique for the treatment of periampullary tumors. In the past, this procedure was associated with high mortality and morbidity, but with improvements in patient selection, anesthesia, and surgical technique, mortality has decreased to less than 5%. However, morbidity remains increased due to various complications such as delayed gastric emptying, bleeding, abdominal collections, and abscesses, most of which are related to the pancreatojejunostomy leak. Clinically relevant postoperative pancreatic fistula is the most dangerous and is related to other complications including mortality. The incidence of postoperative pancreatic fistula ranges from 5-30%. Various techniques have been developed to reduce the severity of pancreatic fistulas, from the use of an isolated jejunal loop for pancreatojejunostomy to binding and invagination anastomoses. Even total pancreatectomy has been considered to avoid pancreatic fistula, but the late effects of this procedure are unacceptable, especially in relatively young patients. Recent studies on the main techniques of pancreatojejunostomy concluded that duct-to-mucosa anastomosis is advisable, but no technique eliminates the risk of pancreatic fistula. The purpose of this study is to highlight technical details and tips that may reduce the severity of pancreatic fistula after pancreatojejunostomy during open or minimally invasive pancreatoduodenectomy.

Effect of artificial or autologous coverage of the pancreatic remnant or anastomosis on postoperative pancreatic fistulas after partial pancreatectomy: meta-analysis of randomized clinical trials.

Postoperative pancreatic fistulas remain a driver of major complications after partial pancreatectomy. It is unclear whether coverage of the anastomosis or pancreatic remnant can reduce the incidence of postoperative pancreatic fistulas. The aim of this study was to evaluate the effect of autologous or artificial coverage of the pancreatic remnant or anastomosis on outcomes after partial pancreatectomy. A systematic literature search was performed using MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL) up to March 2024. All RCTs analysing a coverage method in patients undergoing partial pancreatoduodenectomy or distal pancreatectomy were included. The primary outcome was postoperative pancreatic fistula development. Subgroup analyses for pancreatoduodenectomy or distal pancreatectomy and artificial or autologous coverage were conducted. A total of 18 RCTs with 2326 patients were included. In the overall analysis, coverage decreased the incidence of postoperative pancreatic fistulas by 29% (OR 0.71, 95% c.i. 0.54 to 0.93, P < 0.01). This decrease was also seen in the 12 RCTs covering the remnant after distal pancreatectomy (OR 0.69, 95% c.i. 0.51 to 0.94, P < 0.02) and the 4 RCTs applying autologous coverage after pancreatoduodenectomy and distal pancreatectomy (OR 0.53, 95% c.i. 0.29 to 0.96, P < 0.04). Other subgroup analyses (artificial coverage or pancreatoduodenectomy) showed no statistically significant differences. The secondary endpoints of mortality, reoperations, and re-interventions were each affected positively by the use of coverage techniques. The certainty of evidence was very low to moderate. The implementation of coverage, whether artificial or autologous, is beneficial after partial pancreatectomy, especially in patients undergoing distal pancreatectomy with autologous coverage.

Updates in the management of postoperative pancreatic fistula.

Postoperative pancreatic fistula (POPF) remains a common and dreaded complication after pancreatic resections and is associated with increased morbidity and mortality. Over the years, several different strategies have been investigated to prevent and mitigate POPF. However, when a POPF occurs, a consensus on the optimal management strategy of grade B and grade C POPF is still lacking, and the current management strategy is often based on local expertise and driven by patient's condition. Nevertheless, whereas the incidence of POPF after pancreatic surgery has remained stable, the overall mortality related to this complication has decreased over the years. This reflects an improvement in the management of this complication, which has become increasingly conservative. The aim of this review is to provide an updated evidence- based overview on the management strategies of POPF for surgeons and physicians in the clinical practice.

Characterization of Pancreatic Fistula after Post-pancreatectomy Acute Pancreatitis.

This study aimed to investigate the clinical significance and risk factors of postoperative pancreatic fistula (POPF) after post-pancreatectomy acute pancreatitis (PPAP) in patients who underwent pancreaticoduodenectomy (PD). PPAP has been recognized as a critical factor in the pathophysiology of POPF after PD. A total of 817 consecutive patients who underwent elective PD between January 2020 and June 2022 were included. PPAP and POPF were defined in accordance with the International Study Group for Pancreatic Surgery (ISGPS) definitions. Multivariate logistic analyses were performed to investigate the risk factors for POPF. Comparisons between PPAP-associated POPF and non-PPAP-associated POPF were made to further characterize this intriguing complication. Overall, 159 (19.5%) patients developed POPF after PD, of which 73 (45.9%) occurred following PPAP, and the remaining 86 (54.1%) had non-PPAP-associated POPF. Patients with PPAP-associated POPF experienced significantly higher morbidity than patients without POPF. Multivariate analyses revealed distinct risk factors for each POPF type. For PPAP-associated POPF, independent risk factors included estimated blood loss >200mL (OR 1.93), MPD ≤3cm (OR 2.88), and soft pancreatic texture (OR 2.01), largely overlapping with FRS (Fistula Risk Score) elements. On the other hand, non-PPAP-associated POPF was associated with age >65 years (OR 1.95), male (OR 2.10), and MPD ≤3cm (OR 2.57). Notably, among patients with PPAP, the incidence of POPF consistently hovered around 50% regardless of the FRS stratification. PPAP-associated POPF presents as a distinct pathophysiology in the development of POPF after PD, potentially opening doors for future prevention strategies targeting the early postoperative period.