Occurrence Of Pancreatic Fistula Research Articles

Acinar cells of the pancreas as an independent predictor of the development of postoperative pancreatic fistula: A review

Analysis of data published in the modern literature on the role of the number of functioning acinar cells of the pancreas as a prognostic marker of the development of pancreatic fistula. The search for sources was carried out in the systems Clinicaltrials.gov, PubMed, Medline, NCCN, Scopus, Elibrary. In writing the literature review, 52 sources published from 2004 to 2022 were used. Included are studies reflecting the importance of functioning acinar cells at the edge of pancreatic resection, as well as other factors associated with the development of pancreatic fistula and other post-resection complications. A large number of acinar cells (40%) and a low collagen content (15%) in the edge of pancreatic resection significantly correlates with the development of pancreatic fistula. The content of adipose tissue in the edge of pancreatic resection showed no connection with the development of pancreatic fistula and other complications after surgery. Palpatory assessment of the structure of the pancreatic parenchyma is subjective and can lead to erroneous interpretation and adoption of inadequate tactics of preventive measures. Intraoperative counting of acinuses at the edge of pancreatic resection is easy to use, while not yielding to more complex methods for assessing the risk of post-resection complications and can be recommended as a routine method for predicting the occurrence of pancreatic fistula

Early and Long-Term Morbidity and Mortality Following Pancreaticoduodenectomy for Periampullary Tumors in Elderly Patients.

The growing elderly population is facing an increasing risk of cancers, consequently raising the pancreatic cancer surgery rate. This study aimed to determine whether advanced age is a risk factor for morbidity and mortality following pancreaticoduodenectomy (PD) for periampullary tumors. The present study included 90 patients who underwent PD for periampullary tumors. Patients were divided into two age-related groups, including those aged 60-74 years (n = 60) (Group 1) and those aged ≥75 years (n = 30) (Group 2). Each patient's characteristics, perioperative features, morbidity, and long-term results were evaluated retrospectively. In both univariate and multivariate logistic regression analyses, old age (≥75 years) was not a risk factor for morbidity and hospital mortality. The multivariate analysis demonstrated that male gender (p = 0.008), pancreatic duct diameter (<3 mm) (p < 0.001), and length of hospital stay (p = 0.005) were independent risk factors for pancreatic fistula post-operation and reoperation. Additionally, hospital mortality was significantly associated with reoperation (p = 0.011). The overall median survival was 27 ± 4.1 (18.8-35.1) months. Lymph node positivity (p < 0.001), neural tumor invasion (p = 0.026), and age ≥75 years (p = 0.045) were risk factors affecting the overall survival rate. Moreover, there was no statistically significant difference in terms of PD rates during the Coronavirus disease-19 (COVID-19) period among groups, and PD during this period was not related to the occurrence of pancreatic fistula. PD can be performed effectively in selected elderly patients with tolerable morbidity and mortality rates.

Postoperative Hyperamylasemia (POH) is an Early Predictor of Pancreatic Fistula Occurrence and Severity after Distal Pancreatectomy: Results from a European Multicentric Study.

The aim of this international multicentric study is to characterize postoperative hyperamylasemia (POH) after distal pancreatectomy (DP), with particular focus on its relationship with postoperative pancreatic fistula (POPF) occurrence and severity. The clinical relevance of POH after DP and its relationship with the occurrence and severity of POPF have not been explored yet. All patients undergoing DP for any indication between 2015 and 2021 at three European referral Centers for pancreatic surgery were retrospectively analyzed. Drain fluid amylase (DFA), C-reactive protein (C-RP), and serum amylase were examined from postoperative-day (POD) 1 to 3. Biochemical leak (BL), POPF, POH, and post-pancreatectomy hemorrhage (PPH) were defined and graded according to ISGPS definitions. In total 1192 patients were included. Overall rates of POH and POPF were 18% (n= 210) and 29% (n= 344), respectively. The presence of DFA ≥2000 U/L on POD 1 (OR=2.11, 95% CI 1.68-2.86), C-RP ≥200 mg/L on POD 3 (OR=2.19, 95% CI 1.68-2.86), and POH (OR=1.58, 95% CI 1.14-2.19) were all independent early predictors of POPF (all P< 0.01). The presence of POH almost doubled the rate of POPF (43% vs. 26%, P<0.001), and higher POPF severity presented also higher POH rates (no POPF= 12%; BL= 19%; B POPF= 24%; C POPF= 52%). Among patients developing POPF, patients with POH had higher rates of PPH (22% vs 9%, P= 0.001), sepsis (24% vs 13%; P=0.011), re-operation (21% vs 8%; P< 0.01), and mortality (3% vs 0.3%; P= 0.025). The occurrence of POH is an early predictor of POPF and its severity after DP. The diagnosis of POH might define patients at higher risk for a complicated course, targeting them for prevention / mitigation strategies against pancreas specific complications.

Prediction of pancreatic fstula after pancreatoduodenectomy using machine learning

Objective: to analyze the results of pancreatoduodenectomy (PD) and identify predictive risk factors for postoperative pancreatic fistula (PF) using machine learning (ML) technology.Material and Methods. A nonrandomized study of treatment outcomes in 128 patients, who underwent PD for periampullary carcinoma between 2018 and 2023, was conducted. To predict PF, the ML models based on the multilayer perceptron and binary logistic regression (BLR) in SPSS Statistics v.26, were used. The Receiver Operator Characteristics (ROC) analysis was used to assess the accuracy of the models. To compare ROC curves, the DeLong test was used.Results. Clinically significant PF occurred in 19 (14.8 %) patients (grade B according to ISGPS 2016 – in 16 (12.5 %), grade C – in 3 (2.3 %)). The data of 90 (70.3 %) patients were used to train the neural network, and 38 (29.7 %) were used to test the predictive model. In multivariate analysis, the predictors of PF were a comorbidity level above 7 points on the age-adjusted Charlson scale, a diameter of the main pancreatic duct less than 3 mm, and a soft pancreatic consistency. The diagnostic accuracy of the ML model estimated using the area under the ROC curve was 0.939 ± 0.027 (95 % CI: 0.859–0.998, sensitivity: 84.2 %, specificity; 96.3 %). The predictive model, which was developed using BLR, demonstrated lower accuracy: 0.918±0.039 (95 % CI: 0.842–0.994, sensitivity: 78.9 %, specificity: 94.5 %) (p=0.02).Conclusion. The use of machine learning technologies makes it possible to increase the probability of a correct prediction of the occurrence of pancreatic fistula after pancreatoduodenectomy.

The Role of C-reactive Protein and Procalcitonin in Predicting the Occurrence of Pancreatic Fistula in Patients who Underwent Laparoscopic Pancreaticoduodenectomy: a Retrospective Study.

The occurrence of postoperative pancreatic fistula following laparoscopic pancreaticoduodenectomy (LPD) is a significant concern, yet there is currently a lack of consensus on reliable predictive methods for this complication. Therefore, the aim of this study was to assess the clinical significance of C-reactive protein (CRP) and procalcitonin (PCT) values and their reliability in early predicting the development of clinically relevant pancreatic fistula (CRPF) following LPD.A retrospective analysis was conducted using data from 120 patients who had LPD between September 2019 and December 2021. Preoperative assessment data, standard patients' demographic and clinicopathological characteristics, intra- and postoperative evaluation, as well as postoperative laboratory values on postoperative days (PODs) 1, 3, and 7, including white blood cells (WBCs), CRP, and PCT, were prospectively recorded on a dedicated database. Two clinicians separately collected and cross-checked all of the data.Among 120 patients [77 men (64%), 43 women (36%], CRPF occurred in 15 patients (11 grade B and 4 grade C fistulas). The incidence rate of CRPF was 12.3%. A comparison of the median values of WBCs, PCT, and CRP across the two groups revealed that the CRPF group had higher values on most PODs than the non-CRPF group. Receiver operating characteristic (ROC) analysis was used to calculate the area under the curve (AUC) and cutoff values. It was discovered that POD 3 has the most accurate and significant values for WBCs, CRP, and PCT. According to the ROC plots, the AUC for WBCs was 0.842, whereas the AUC for PCT was 0.909. As for CRP, the AUC was 0.941 (95% CI 0.899-0.983, p<0.01) with a cutoff value of 203.45, indicating a sensitivity of 93.3% and specificity of 91.4%.Both CRP and PCT can be used to predict the early onset of CRPF following LPD, with CRP being slightly superior on POD 3.

Pancreaticogastrostomy versus Pancreaticojejunostomy and the Proposal of a New Postoperative Pancreatic Fistula Risk Score.

Despite the substantial decrease in mortality rates following a pancreaticoduodenectomy to less than 5%, morbidity rates remain significant, reaching even 73%. Postoperative pancreatic fistula is one of the most frequent major complications and is significantly associated with other complications, including patient death. Currently, there is no consensus regarding the ideal type of pancreatic anastomosis, as the question of the choice between a pancreaticogastrostomy and pancreaticojejunostomy is still open. Furthermore, worldwide implementation of an ideal pancreatic fistula risk prediction score is missing. Our study found several significant predictive factors for the postoperative occurrence of fistulas, such as the soft consistency of the pancreas, non-dilated Wirsung duct, important intraoperative blood loss, other perioperative complications, preoperative patient hypoalbuminemia, and patient weight loss. Our study also revealed that for patients who exhibit fistula risk factors, pancreaticogastrostomy demonstrates a significantly lower pancreatic fistula rate than pancreaticojejunostomy. The occurrence of pancreatic fistulas has been significantly associated with the development of other postoperative major complications, and patient death. As the current pancreatic fistula risk scores proposed by various authors have not been consensually validated, we propose a simple, easy-to-use, and sensitive score for the risk prediction of postoperative pancreatic fistula occurrence based on important predictors from statistical analyses that have also been found to be significant by most of the reported studies. The new pancreatic fistula risk score proposed by us could be extremely useful for improved therapeutic management of cephalic pancreaticoduodenectomy patients.

How to implement minimally invasive duodenum-preserving total pancreatic head resection for patients with pancreatic head lesions: A retrospective study.

Laparoscopic duodenum-preserving pancreatic head resection (LDPPHR) has been widely reported. However, due to the challenges involved in performing total pancreatic head resection during operation, there are few studies reporting it. Between November 2016 and October 2022, we performed laparoscopic duodenum-preserving total pancreatic head resection (LDPPHRt) on 64 patients in the Department of Hepatobiliary Surgery, the Second Hospital of Hebei Medical University. Perioperative data of the patients such as age, gender, body mass index, operation time, blood loss, and postoperative hospital stay were collected and analyzed. This study included 40 women and 24 men aged 41.4 ± 15.7 years. All patients completed the surgery, and none of the patients underwent laparotomy. The average operation time was 275 (255, 310) min. The average postoperative hospital stay was 12 (10, 16) days. The rate of occurrence of pancreatic fistula was 10.9% (7/64), and that of the biliary fistula was 9.4% (6/64). One of the patients underwent cholangiojejunostomy 3 months after the operation due to painless jaundice and bile duct dilatation. By dissecting the space between the pancreatic head and duodenum, the posterior pancreatic duodenal arterial arch and the surface vascular network of the common bile duct (CBD) can be preserved. This ensures the success of LDPPHRt and avoids postoperative complications in the absence of intraoperative image guidance.

Extending Quality Improvement for Pancreatoduodenectomy Within the High-Volume Setting: The Experience Factor.

To analyze the association of a surgeon's experience with postoperative outcomes of pancreatoduodenectomies (PDs) when stratified by Fistula Risk Score (FRS). Centralization is now well-established for pancreatic surgery. Nevertheless, the benefits of individual surgeon's experience in high-volume settings remain undefined. Pancreatoduodenectomies performed by 82 surgeons across 18 international specialty institutions (median: 140 PD/year) were analyzed. Surgeon cumulative PD volume was linked with postoperative outcomes through multivariable models, adjusted for patient/operative characteristics and the FRS. Then, surgeon experience was also stratified by the 10, previously defined, most clinically impactful scenarios for clinically relevant pancreatic fistula (CR-POPF) development. Of 8189 PDs, 18.7% suffered severe complications (Accordion≥3), 4.8% were reoperated upon and 2.2% expired. Although the most experienced surgeons (top-quartile; >525 career PDs) more often operated on riskier cases, their experience was significantly associated with declines in CR-POPF ( P <0.001), severe complications ( P =0.008), reoperations ( P <0.001), and length of stay (LOS) ( P <0.001)-accentuated even more in the most impactful FRS scenarios (2830 patients). Risk-adjusted models indicate male sex, increasing age, ASA class, and FRS, but not surgeon experience, as being associated with severe complications, failure-to-rescue, and mortality. Instead, upper-echelon experience demonstrates significant reductions in CR-POPF (OR 0.66), reoperations (OR 0.64), and LOS (OR 0.65) in moderate-to-high fistula risk circumstances (FRS≥3, 68% of cases). At specialty institutions, major morbidity, mortality, and failure-to-rescue are primarily associated with baseline patient characteristics, while cumulative surgical experience impacts pancreatic fistula occurrence and its attendant effects for most higher-risk pancreatoduodenectomies. These data also suggest an extended proficiency curve exists for this operation.

Clinical relevance of post-pancreatectomy acute pancreatitis and impact on occurrence of pancreatic fistula: Serum hyperamylasemia and pancreatitis do not predict clinically relevant pancreatic leak

Clinical relevance of post-pancreatectomy acute pancreatitis and impact on occurrence of pancreatic fistula: Serum hyperamylasemia and pancreatitis do not predict clinically relevant pancreatic leak

ALTERNATIVE FISTULA RISK SCORE AND FIRST POSTOPERATIVE DAY DRAIN FLUID AMYLASE AS PREDICTORS OF PANCREATIC FISTULA AFTER PANCREATICODUODENECTOMY.

The high morbidity and mortality rates of pancreaticoduodenectomy are mainly associated with pancreaticojejunal anastomosis, the most fragile and susceptible to complications such as clinically relevant postoperative pancreatic fistula. The alternative fistula risk score and the first postoperative day drain fluid amylase are predictors of the occurrence of clinically relevant postoperative pancreatic fistula. No consensus has been reached on which of the scores is a better predictor; moreover, their combined predictive power remains unclear. To the best of our knowledge, this association had not yet been studied. This study assessed the predictive effect of alternative fistula risk score and/or drain fluid amylase on clinically relevant postoperative pancreatic fistula in a retrospective cohort of 58 patients following pancreaticoduodenectomy. The Shapiro-Wilk and Mann-Whitney tests were applied for assessing the distribution of the samples and for comparing the medians, respectively. The receiver operating characteristics curve and the confusion matrix were used to analyze the predictive models. The alternative fistula risk score values were not statistically different between patients in the clinically relevant postoperative pancreatic fistula and non- clinically relevant postoperative pancreatic fistula groups (Mann-Whitney U test 59.5, p=0.12). The drain fluid amylase values were statistically different between clinically relevant postoperative pancreatic fistula and non- clinically relevant postoperative pancreatic fistula groups (Mann-Whitney U test 27, p=0.004). The alternative fistula risk score and drain fluid amylase were independently less predictive for clinically relevant postoperative pancreatic fistula, compared to combined alternative fistula risk score + drain fluid amylase. The combined model involving alternative fistula risk score >20% + drain fluid amylase=5,000 U/L was the most effective predictor of clinically relevant postoperative pancreatic fistula occurrence following pancreaticoduodenectomy.

Postoperative Hyperamylasemia Is an Early Predictor of Pancreatic Fistula Occurrence and Severity after Distal Pancreatectomy: Results from an European Multicentric Study

Postoperative Hyperamylasemia Is an Early Predictor of Pancreatic Fistula Occurrence and Severity after Distal Pancreatectomy: Results from an European Multicentric Study

The methods of prophylaxis of the pancreatic fistula occurrence after pancreato–duodenectomy

Objective. To elaborate the measures system, which permit to reduce the occurrence of pancreatic fistula and other severe complications after performance of pancreato–duodenectomy.&#x0D; Materials and methods. There were analyzed the results of treatment of 327 patients, in whom pancreato–duodenectomy was performed. In accordance to the scheme proposed, using the elaborated scale of risk for the postoperative pancreatic fistula occurrence with estimation of sarcopenia presence and application of certain prophylactic measures 98 patients were operated in period from November 2018 to December 2020 yr. (the main group). Into the control group 229 patients were included, operated on in the clinic from January 2015 to October 2018 yr. without estimation of risk for the pancreatic fistula occurrence and presence of sarcopenia. The method of pancreato–jejunoanastomosis formation was selected by operating surgeon.&#x0D; Results. Postoperative complications have occurred in 94 (41.0%) patients of the control group and in 28 (28.6%) patients of the main group (c 2 = 4.56, p=0.03). Clinically significant postoperative pancreatic fistula of B Degree have occurred in 9 (9.2%) patients of the main group, what was statistically significantly lower, than in the control group, in which postoperative pancreatic fistula of B or C Degree have occurred in 64 (27.9%) patients (c 2 = 11.6, p=0.0007). Lethality was 2.2% in the control group and 1.02% – in the main one.&#x0D; Conclusion. Introduction of the measures system elaborated have permitted to lower the postoperative pancreatic fistula rate statistically significantly from 27.9 to 9.2%, and of other postoperative complications – from 41.0 to 28.6% and lethality from 2.2 to 1.02%.

Impact of pancreatic fat infiltration on postoperative pancreatic fistula occurrence in patients undergoing invagination pancreaticojejunostomy

BackgroundNo studies to date have determined the impact of pancreatic fat infiltration on postoperative pancreatic fistula (POPF) occurrence in patients undergoing invagination pancreaticojejunostomy (IV-PJ). MethodsThe medical records of patients with a soft pancreas who underwent pancreatoduodenectomy followed by IV-PJ were reviewed . The pancreatic fat ratio on computed tomography (CT) images (I-PFR) was determined using preoperative CT and verified by histologic examination. The relationship between the I-PFR and POPF occurrence was determined. Patients were classified into 2 groups based on I-PFR value (fatty and non-fatty pancreas). Postoperative outcomes were compared between the two groups, and specifically among patients who developed POPF. ResultsOf 221 patients, POPF occurred in 67 (30.3%). I-PFR was positively correlated with histologic-calculated fat ratio (ρ = 0.517, p < 0.001). This index was shown to be an independent predictor of POPF. Based on an I-PFR cut-off value of 3.2%, 92 patients were classified in the fatty pancreas group. Subgroup analysis of the patients who developed POPF showed that incidence of abscess formation and hemorrhage tended to be higher in patients with fatty pancreas than in those with non-fatty pancreas. ConclusionsPancreatic fat infiltration is highly associated with POPF and possibly causes subsequent serious complications in patients undergoing IV-PJ.

Effect of the Use of Reinforced Stapling on the Occurrence of Pancreatic Fistula After Distal Pancreatectomy: Results of the REPLAY (REinforcement of the Pancreas in distaL pAncreatectomY) Multicenter Randomized Clinical Trial.

The aim of the study was to evaluate the impact of the use of a reinforced stapler (RS) during distal pancreatectomy (DP) on postoperative outcomes. DP remains associated with significant postoperative morbidity owing to pancreatic fistula (PF). To date, there is no consensus on the management of the pancreatic stump. The use of an RS potentially represents a simple way to decrease the rate of PF. The REPLAY study (NCT03030170) is a prospective, multicenter, randomized study. Patients who underwent DP were randomized (1:1 ratio) in 2 groups for the use of a standard stapler (SS) or an RS to close remnant pancreatic parenchyma. The primary endpoint was the rate of overall PF. Secondary endpoints included severity of PF, length of hospital stay, overall morbidity, and rate of readmission for a PF within 90 days. Participants were blinded to the procedure actually carried out. A total of 199 were analyzed (SS, n=99; RS, n=100). One patient who did not undergo surgery was excluded. Baseline characteristics were comparable in both groups. The rate of overall PF was higher in RS group (SS: 67.7%, RS: 83%, P =0.0121), but the rate of clinically relevant PF was similar (SS: 11.1%, RS: 14%, P =0.5387). Mean length of total hospital stay, readmission for PF, postoperative morbidity, and mortality at 90 days were similar. The results of this randomized clinical trial did not favor the use of RS during DP to reduce the rate of PF.

The usefulness of preoperative exocrine function evaluated by the 13C-trioctanoin breath test as a significant physiological predictor of pancreatic fistula after pancreaticoduodenectomy

BackgroundThe association between pancreatic fistula (PF) after pancreaticoduodenectomy (PD) and preoperative exocrine function is yet to be elucidated. This study aimed to evaluate the association between the preoperative results of the 13C-trioctanoin breath test and the occurrence of PF, showing the clinical relevance of the breath test in predicting PF.MethodA total of 80 patients who underwent 13C-trioctanoin breath tests prior to PD from 2006 to 2018 were included in this study. Univariate and multivariate analyses were conducted to reveal the preoperative predictors of PF, showing the association between 13C-trioctanoin absorption and PF incidence.ResultsAmong 80 patients (age, 68.0 ± 11.9 years, 46 males and 34 females; 30 pancreatic ductal adenocarcinoma [PDAC]/50 non-PDAC patients), the incidence of PF was 12.5% (10/80). Logistic regression analysis results revealed that the frequency of PF increased significantly as the 13C-trioctanoin breath test value (Aa% dose/h) increased (odd’s ratio: 1.082, 95% confidence interval: 1.007–1.162, p = 0.032). Moreover, the optimal cutoff value of the preoperative fat absorption level to predict PF was 38.0 (sensitivity, 90%; specificity, 74%; area under the curve, 0.78; p = 0.005). Indeed, the incidence of PF was extremely higher in patients whose breath test value was greater than 38.0 (33%, 9/27) compared with that in patients with values less than 38.0 (1.8%, 1/53).ConclusionsFavorable preoperative fat absorption evaluated using the 13C-trioctanoin breath test is a feasible and objective predictor of PF after PD.

Utility of fistula risk score in assessing the risk of postoperative pancreatic fistula occurrence and other significant complications after different types of pancreatic neuroendocrine tumor resections.

This study was performed to evaluate the utility of the fistula risk score (FRS) and its components in predicting the occurrence of postoperative pancreatic fistula and other significant postoperative complications after resections of pancreatic neuroendocrine tumors. Retrospective analysis of 131 patients operated on for pancreatic neuroendocrine tumors between 2015 and 2021 was performed. The correlation of the FRS scale with the occurrence of postoperative pancreatic fistulas and postoperative complications according to the Clavien-Dindo classification was analyzed; only in 109 cases of distal resections and pancreatoduodenectomies (PD). Soft pancreatic texture and intraoperative blood loss of >700 mL are risk factors for clinically significant pancreatic fistula (P = 0.001 and P = 0.001, respectively) and significant postoperative complications (P = 0.016 and P = 0.001, respectively). Wirsung duct diameter (WDD) was associated only with the occurrence of postoperative pancreatic fistula (P = 0.013). FRS scale is associated with the occurrence of pancreatic fistulas and clinically significant postoperative complications in cases of distal resections and PDs (P < 0.001 and P = 0.005, respectively). Postoperative complications are correlated with the occurrence of fistula type B or C (P < 0.001). Soft pancreatic texture, intraoperative blood loss of >700 mL, and a WDD of ≤3 mm are risk factors for clinically significant postoperative pancreatic fistula. FRS may be applied not only in PDs but also in distal pancreatectomies. Unfortunately, it is not used in total pancreatic resections and enucleations since FRS takes into account the WDD.

Establishment of risk prediction model of postoperative pancreatic fistula after pancreatoduodenectomy: 2016 edition of definition and grading system of pancreatic fistula: a single center experience with 223 cases

ObjectiveTo establish a risk prediction model for pancreatic fistula according to the pancreatic fistula standards of the 2016 edition.MethodsClinical data from 223 patients with PD admitted to Tianjin Third Central Hospital from January 2016 to December 2020 were retrospectively analyzed. Patients were divided into modeling (January 2016 to December 2018) and validation (January 2019 to December 2020) sets according to the time of admission. The risk factors for postoperative pancreatic fistula (POPF) were screened by univariate and multivariate logistic regression analyses, and a risk prediction model for POPF was established in the modeling set. This score was tested in the validation set.ResultsLogistic regression analysis showed that the main pancreatic duct index and CT value were independent risk factors according to the 2016 pancreatic fistula grading standard, based on which a risk prediction model for POPF was established. Receiver operating characteristic curve analysis showed that the area under the curve was 0.775 in the modeling set and 0.848 in the validation set.ConclusionThe main pancreatic duct index and CT value of the pancreas are closely related to the occurrence of pancreatic fistula after PD, and the established risk prediction model for pancreatic fistula has good prediction accuracy.

The effect of high intraoperative blood loss on pancreatic fistula development after pancreatoduodenectomy: An international, multi-institutional propensity score matched analysis

BackgroundThe association between intraoperative estimated blood loss and outcomes after pancreatoduodenectomy has, thus far, been rarely explored. MethodsIn total, 7,706 pancreatoduodenectomies performed at 18 international institutions composing the Pancreas Fistula Study Group were examined (2003–2020). High estimated blood loss (>700 mL) was defined as twice the median. Propensity score matching (1:1 exact-match) was employed to adjust for variables associated with high estimated blood loss and clinically relevant pancreatic fistula occurrence. The study was powered to detect a 33% clinically relevant pancreatic fistula increase in the high estimated blood loss group, with α = 0.05 and β = 0.2. ResultsThe propensity score model included 966 patients with high estimated blood loss and 966 patients with lower estimated blood loss; all covariate imbalantces were solved. Patients with high estimated blood loss patients experienced higher clinically relevant pancreatic fistula rates (19.4 vs 12.6%, odds ratio 1.66; P < .001), as well as higher severe complication rates (27.8 vs 15.6%), transfusions (50.1 vs 14.3%), reoperations (9.2 vs 4.0%), intensive care unit transfers (9.9 vs 4.8%) and 90-day mortality (4.7 vs 2.0%, all P < .001). High estimated blood loss was an independent predictor for clinically relevant pancreatic fistula (odds ratio 1.78, 95% confidence interval 1.37–2.32), as were prophylactic Octreotide administration (odds ratio 1.95, 95% confidence interval 1.46–2.61) and soft pancreatic texture (odds ratio 5.32, 95% confidence interval 3.74–5.57; all P < .001). Moreover, a second model including 1,126 pancreatoduodenectomies was derived including vascular resections as additional confounder (14.0% vascular resections performed in each group). On multivariable regression, high estimated blood loss was confirmed an independent predictor for clinically relevant pancreatic fistula reduction (odds ratio 1.80, 95% confidence interval 1.32–2.44; P < .001), whereas vascular resection was not (odds ratio 0.64, 95% confidence interval 0.34–1.88; P = .156). ConclusionThis study better establishes the relationship between estimated blood loss and outcomes after pancreatoduodenectomy. Despite inherent contributions to blood loss, its minimization is an actionable opportunity for clinically relevant pancreatic fistula reduction and performance optimization in pancreatoduodenectomy. Accordingly, practical insights are offered to achieve this goal.

The impact of minimally invasive surgery on hospital readmissions, emergency department visits and functional recovery after distal pancreatectomy.

A recent RCT showed similar postoperative outcomes and a reduced time to functional recovery in patients undergoing minimally invasive distal pancreatectomy (DP) compared to open approach. However, it reported very-high post-discharge readmission rates, calling for further investigation. The aim of our study was to evaluate the extent to which minimally invasive surgery impacts on postoperative readmissions following DP. Clinical data for patients undergoing DP between 2011 and 2018 were reviewed. Primary outcome was hospital readmission at 90 days after surgery. Secondary outcomes included post-discharge emergency department (ED) visits and time to functional recovery. Regression analyses were performed to evaluate the impact of the laparoscopic approach and other perioperative factors. Overall, 376 consecutive patients underwent DP during the study period. Laparoscopy was successfully performed in 219 (58%) patients. Overall, 62 patients (16.5%) returned to the ED after discharge, 41 (18.7%) of laparoscopically operated patients, and21 (13.4%) of those undergoing open surgery (p = 0.162). Forty-six (12.2%) of them required readmission, 31 (14.2%) after laparoscopic, and 15 (9.6%) after open procedures (p = 0.179). At multivariate regression, a low preoperative physical status (OR 2.3, 95% CI 1.2-4.7; p = 0.017), occurrence of pancreatic fistula (OR 6.8, 95% CI 2.9-15.9; p < 0.001), and post-pancreatectomy hemorrhage (OR 3.9, 95% CI 1.2-13.1; p = 0.025) were significantly associated with 90-day readmission, while laparoscopy had no impact. Median time to reach functional recovery was 5 (IQR 4-6) days. At multivariate analysis, laparoscopy reduced time to functional recovery by 13% (95% CI -19 to -6%; p < 0.001), time to adequate oral intake by 19% (95% CI -27 to -10%; p < 0.001), and time to adequate pain control by 12% (95% CI -18 to -5%; p < 0.001). Hospital readmissions and ED visits following DP were not influenced by the surgical approach. A low preoperative physical status, occurrence of postoperative pancreatic fistula and hemorrhage were significantly associated with post-discharge readmission within 90days.Laparoscopy reducedtimetofunctional recovery.

Diagnostic criteria for a “soft” pancreas and their influence on the occurrence of pancreatic fistula after pancreatoduodenal

Purpose. Identification of the possibilities of contrast enhancement computed tomography in evaluated the number of the acinar structures in the pancreatic parenchyma at the preoperative stage to predict the development pancreatic fistula.Material and methods. In 2016–2019, 196 pancreatoduodenectomy were performed. 86 patients were retrospectively selected. Patients were divided into 2 groups: group 1 included 16 observations with the development of clinically significant pancreatic fistula, in 2 – 70 cases without complications. According to preoperative contrast enhancement computed tomography, structure of the pancreas, pancreatic parenchyma thickness, pancreatic duct diameter, the density of the pancreas in the native phase, relative parenchyma enhancement ratio, washout coefficient, pancreas stump volume were evaluated. According histological, the number of acinar and fat cells in the section of the removed pancreas was evaluated.Results. “Soft” structure of the pancreas (r = 0.374, p = 0.000), pancreatic parenchyma thickness (r = 0.549, p = 0.000), the density of the pancreas in the native phase of the scan (r = 0.568, p = 0.000), the values relative parenchyma enhancement ratio (r = 0.63, p = 0.000), pancreas stump volume (r = 0.508, p = 0.000) positively correlated with clinically significant pancreatic fistula and the number of acinar cells. Pancreatic duct diameter (r = −0.339, p = 0.001) negatively correlated with clinically significant pancreatic fistula and the number of acinar cells. Pancreatic fistula risk is 3.09 times higher with the number of acini more than 72.5%, sensitivity 75%, specificity 75.71%. Pancreatic fistula risk is 1.8 times higher with the density of the pancreas in the native phase over 35.5 HU sensitivity 62%, specificity 65%. Pancreatic fistula risk is 2.76 times higher with values parenchyma accumulation coefficient more than 1, sensitivity 75%, specificity 73%.Conclusions. Contrast enhancement computed tomography allows evaluating acinar index in the preoperative period to pick out the high-risk patient group to development of pancreatic fistula.