Pancreatic Fistula Grade Research Articles

Surgeon vs Pathologist for Prediction of Pancreatic Fistula: Results from the Randomized Multicenter RECOPANC Study

Surgically assessed pancreatic texture has been identified as the strongest predictor of postoperative pancreatic fistula. However, texture is a subjective parameter with no proven reliability or validity. Therefore, a more objective parameter is needed. In this study, we evaluated the fibrosis level at the pancreatic neck resection margin and correlated fibrosis and all clinico-pathologic parameters collected over the course of the Pancreatogastrostomy vs Pancreatojejunostomy for RECOnstruction (RECOPANC) study. The RECOPANC trial was a multicenter randomized prospective trial of patients undergoing pancreatoduodenectomy. There were 261 hematoxylin and eosin-stained slides allocated for histopathologic analyses. Pancreatic fibrosis was scored from 0 to III (no fibrosis up to severe fibrosis) by 2 blinded independent pathologists. All variables possibly associated with POPF were entered into a generalized linear model for multivariable analysis. The fibrosis grade and pancreatic texture were scored in all 261 patients. In POPF B/C (postoperative pancreatic fistula grade B or C) patients, 71% had a soft pancreas, and fibrosis grades were distributed as follows: 48% with score 0, 28% with score I, 20% with score II, and 7% with score III, respectively. Fibrosis grading showed substantial inter-rater reliability (kappa= 0.74) and correlated positively with hard pancreatic texture (p < 0.05). In univariable analysis, area under the curve (AUC) for POPF B/C prediction was higher for fibrosis grade than for pancreatic texture (0.71 vs 0.59). In multivariate analysis, the following predictors were selected: sex, surgeon volume, pancreatic texture, and fibrosis grade. However, the addition of pancreatic texture only led to an incremental improvement (AUC 0.794 vs 0.819). Histologically evaluated pancreatic fibrosis is an easily applicable and highly reproducible POPF predictor and superior to surgically evaluated pancreatic texture. Future studies might use fibrosis grade for risk stratification in pancreatoduodenectomy.

The prognostic value of external vs internal pancreatic duct stents after pancreaticoduodenectomy in patients with FRS\u2009\u2265\u20094: a retrospective cohort study

BackgroundThe prognostic value of external vs internal pancreatic duct stents after pancreaticoduodenectomy remains controversial. This study aimed to evaluate the benefits of external and internal stents using the Fistula Risk Score system with regard to the incidence of clinically relevant postoperative pancreatic fistula.MethodsA total of 382 patients who underwent pancreaticoduodenectomy with duct to mucosa pancreaticojejunostomy were retrospectively enrolled from January 2015 to October 2019. The receiver operating characteristic curve was performed for subgroup analysis of the patients at different levels of risk for pancreatic fistula.ResultsThere were no significant differences in terms of pancreatic fistula or other postoperative complications. According to the receiver operating characteristic curve threshold of 3.5, 172 patients with a Fistula Risk Score ≥ 4 and 210 patients with a Fistula Risk Score < 4 were divided into separate groups. The number of valid cases was insufficient to support the subsequent research in patients with a Fistula Risk Score < 4. In patients with a Fistula Risk Score ≥ 4, the use of an external pancreatic duct stent was significantly more effective than the use of an internal stent, especially with regard to the risk for pancreatic fistula (Grade C) (P = 0.039), at ameliorating the incidence of clinically relevant postoperative pancreatic fistula (P = 0.019). Additionally, the incidence of lymphatic leakage was significantly higher in the external stent group compared with the internal stent group (P = 0.040).ConclusionsCompared with internal stents, the use of an external stent could reduce the incidence of clinically relevant postoperative pancreatic fistula in patients with a Fistula Risk Score ≥ 4. More large-scale prospective clinical trials are warranted to further clarify our results.

When arterial resection is justified in pancreatic cancer? results of 38 pancreatic resections with resection of truly involved celiac and/or common hepatic artery

Background:1.It is believed that arterial involvement in pancreatic cancer (PC) is a sign of so far advanced disease that pancreatic resection(PR) is meaningless;2.Distal pancreatectomy(DP) with celiac artery resection(DPCAR) is justified option for locally advanced PC Aim: Assessment of the rates of morbidity, mortality, true pathological artery involvement and R0- resections, overall and disease-free survival after PRs with celiac (CA) and/or common hepatic artery (CHA) resections(AR). Patients and methods: Patients with pancreatic ductal adenocarcinoma (n33) and neuroendocrine cancer(n5) underwent 38 PRs with AR without preoperative occlusion of CHA, 36 without arterial reconstructions(2009-2019). Age 54-76y. ECOG-0-1. Adjuvant chemotherapy,n19, neoadjuvant,n11 with better tendency. IOUS and vascular fluorescence (ICG) were there main methods for assessment of liver and stomach ischemia. Results: The rate of pathological CA/CHA involvement - 100%. Overall rate of R0-resections 87%, for PDAC 85%, vein resections during DPCAR -12(35%). Morbidity: 18 (47%), pancreatic fistula Grade B/C -14(41%), mortality- 2 (5,3%), median OS- 24 months, median DFS -18 months, overall 5-y survival -41%, actual 5-y survival - 13%. No liver and bowel ischemia, gastric ischemia - 15% (1 perfor ation). All the relapses were distant. Conclusion: Neoadjuvant treatment and R0-resection with acceptable morbidity and mortality rates justifies arterial resections for PDAC.

Outcomes after distal pancreatectomy with celiac axis resection for pancreatic cancer: a single center retrospective study

Introduction: As distal pancreatectomy with celiac axis resection (DP-CAR) is the only possible cure for pancreatic body and tail cancer with celiac axis involvement, we performed this study to show the post-operative outcomes of DP-CAR. Method: 48 patients with pancreatic body and tail cancer with celiac axis involvement who underwent DP-CAR in Asan medical center between January 2008 and December 2018 were included in the study. We retrospectively reviewed the patient's preoperative, operative and postoperative data. Primary outcome was major morbidity and 90-day mortality, and secondary outcome was overall survival. Results: Major morbidity occurred in 9 patients (18.8%). 13 patients (27.1%) had pancreatic fistula grade B or C according to ISGPS guideline. There was 1 case (2.1%) of 90-day mortality after operation. Kaplan-Meier estimated median overall survival was 25.0 months. Conclusions: DP-CAR is a good treatment option for cure in pancreatic body and tail cancer with celiac axis involvement without significant morbidity and mortality.

Pancreatic Stump Reinforcement with Falciform Ligament during Laparoscopic Distal Pancreatectomy

Purpose: Pancreatic fistula (PF) is the most common and dangerous complication after distal pancreatectomy (DP). The most effective technique of pancreatic stump closure still unclear. Here, we aimed to compare the efficiency of implementation of falciformed ligament (FL) pancreatic stump closure techniques for preventing PF during laparoscopic DP. Methods: All patients between November 2014 and February 2021 who had laparoscopic DP with pancreatic stump covered with FL or no FL covered was retrieved. Their intra- and postoperative outcomes (Operative time, blood loss, length of hospital stay, postoperative complication according to Clavien-Dindo) were compared. Results: A total of 118 patients were included. Group A - 23 patients with pancreatic stump peirnforcement with FL and group B 95 patients without pancreatic stump reinforcement with FL. Median operative time was 260 (165-510) and 247,5 (range 155-535)min, in group A and B, respectively. and median blood loss was 100 (range 5 - 1000) and 100(range 20-300)ml, in group A and B, respectively. Postoperative stay 8(5-40) days and 9,5(6-38) days (P = 0.590) in group A and B, respectively. Postoperative pancreatic fistula (PPF) grade B occurred in 30% (n7) vs 27%(n26), (P > 0.005) and grade C occurred in 0% vs 3%(n3) P = 0.005, in group A and B, respectively. Conclusion: Pancreatic stump reinforcement with falciformed ligament during laparoscopic distal pancreatectomy is safe and feasible procedure. Prospective multi-centric trials are needed for further evaluation of the technique.

Laparoscopic spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein (Kimura's procedure)

Authors present the case of a laparoscopic spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein (Kimura's procedure). A 26-year old female patient was admitted with a neoplasm of the tail of the pancreas detected by abdominal ultrasound. Pancreatic protocol CT-scan revealed a 7 cm round-shaped tumor in the tail of the pancreas. The CT features of the lesion were suggestive for mucinous cystadenoma. Spleen-preserving laparoscopic distal pancreatectomy is considered as the first choice procedure for benign lesions located at the body or tail of the pancreas and is performed very frequently worldwide. The advantages of preservation of the spleen are related to the preserved immune function of the organ. The two main surgical techniques that have been proposed and widely adopted for spleen preserving laparoscopic distal pancreatectomy are the Warshaw (splenic vessel ligation) and Kimura (splenic vessel preservation) techniques. The procedure was complicated due to the large size of the lesion and firm adhesions between the vessels and the tumor. Nevertheless the splenic vessels were successfully preserved after clipping all the branches of the splenic vein and artery. No significant bleeding occurred. The estimated blood loss was 50 ml. The operation time was 210 minutes. The postoperative course was complicated by a postoperative pancreatic fistula (POPF) grade B (according to the ISGPF classification), which was managed successfully using interventional percutaneous drainage. Final histopathological examination confirmed mucinous cystadenoma of the tail of the pancreas. The patient was discharged on postoperative day 14 with external drainage tube, which was removed in three weeks after amylase level control in an outpatient clinic. The purpose of the video is to demonstrate our experience in performing Kimura's procedure.

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

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

Approaches and Postoperative Complications of Artery-First Pancreaticoduodenectomy in a Tertiary Care Hospital in Nepal: A Descriptive Cross-sectional Study

Introduction: Superior mesenteric artery first pancreaticoduodenectomy is being increasingly used for pancreatic head and peri-ampullary tumors. The aim of our study was to determine the frequency of various approaches of superior mesenteric artery pancreaticoduodenectomy along with its postoperative complications in a tertiary care center.&#x0D; Methods: This is a descriptive cross-sectional study of patients undergoing superior mesenteric artery first pancreaticoduodenectomy with different approaches conducted at Kathmandu Medical College Teaching Hospital, Sinamangal, Kathmandu, Nepal, from May 2018 to April 2020. Ethical approval was taken from the Institutional Review Committee (reference no: 310520193). The whole sampling method was adopted. Thirty-four patients undergoing a superior mesenteric artery first pancreaticoduodenectomy at our center with different approaches were included in the study. The data analysis was done in the Statistical Package for the Social Sciences version 20.&#x0D; Results: For 34 patients chosen for the study, the male: female ratio was 1.6:1, with a mean age of 53.7 years. The medial uncinate approach was done in the majority of the cases, 26 (76.4%), whereas the inferior infracolic (mesenteric) approach was done in 1 (2.9%) case. Regarding postoperative complications, Clavien Dindo grade 3 and grade 4 were present in 11 (32.3%) patients, pancreatic fistula (Grade B and C) was observed in 6 (17.6%) patients, and mortality occurred in 2 (5.8%). The mean hospital stay was 16±9 days.&#x0D; Conclusions: Superior mesenteric artery first pancreaticoduodenectomy with a different approach can be performed with acceptable morbidity and mortality. Early determination of resectibility is achieved in selected cases.

Spleen-preserving Pancreatectomy (SPP) in Patients Undergoing Pancreatoduodenectomy (PD) with a High Risk of Postoperative Pancreatic Fistula Grade C (POPF-C)

Spleen-preserving Pancreatectomy (SPP) in Patients Undergoing Pancreatoduodenectomy (PD) with a High Risk of Postoperative Pancreatic Fistula Grade C (POPF-C)

Evaluation of an enhanced recovery after surgery protocol for pancreaticoduodenectomy in a tertiary referral hospital: a retrospective cohort study

Purpose: The implementation of an enhanced recovery after surgery (ERAS) protocol results in accelerated perioperative recovery, reduced length of hospital stay (LOS) and in-hospital costs. The primary endpoint of this study is to evaluate the different targets of the ERAS protocol separately. The secondary endpoints are the 30-day reoperation rate, readmission rate and mortality. Method: This single centre retrospective analysis reviews the data of 154 patients who underwent a pancreaticoduodenectomy between August 2016 and December 2019. As per ERAS protocol, the epidural analgesia was stopped on postoperative day (POD)2, the nasogastric tube (NGT) removed on POD3 and regular food tolerated by POD5. Drains were removed on POD2, POD3 and the soft drain along the pancreatic anastomosis between POD3-10. Results: Epidural analgesia was discontinued on POD2 in 26 patients (17.7%), the NGT removed on POD3 in 74 patients (49.0%), and regular food started by POD5 in 52 patients (34.9%). The lateral drain was removed in 81 patients (52.9%) on POD2, the medial drain in 39 patients (26.2%) at POD3, the soft drain in 95 patients (61.7%) between POD3 and POD10. Nine patients (5.8%) had post-pancreatectomy haemorrhage (PPH), 14 (9.1%) had a postoperative pancreatic fistula grade B or C (POPF), 5 (3.3%) had a bile leakage, and 44 (28.6%) experienced delayed gastric emptying (DGE). The 30-day readmission rate was 8.4%, the reoperation rate was 10.4%, and the in-hospital mortality 1.3%. Conclusion: Efficient implementation requires strict follow-up of all included ERAS elements, but should not be restricted to low-risk patients. Delayed gastric emptying and POPF are predictors for a prolonged LOS. Length of hospital stay is influenced by multiple factors and therefore not a good parameter to evaluate implementation of an ERAS protocol.

Blind resection is forbidden in cases of pancreatic insulinoma

Introduction: Insulinoma is one of the most frequent functional pancreatic neuroendocrine tumors (pNETs). Despite the progress of diagnostic technology and techniques there are cases of mistaken tactics in the detection and localization of tumors. Material and Methods: There were 196 patients with pNETs surgically treated in our department from January 2007 to December 2020. All patients underwent abdominal CT and MRI. In complicated cases we used arterial calcium stimulation with hepatic venous sampling (ASVS). There were 7 cases of tactical intraoperative errors. Most of these patients (4 cases) had undergone surgery in other regional clinics and hospitals. The other three had previously been treated in our center. Most of these cases (6) were female with a median age of 43,6. Results: In all cases during final surgery intraoperative ultrasound and frozen sections were performed. Re-resection of the distal pancreas was performed in three cases. When the tumors' localisation was in the pancreatic head a pancreatic head resection (2 cases) or tumor enucleation (1 case) was performed. Postoperative complications included postpancreatectomy hemorrhage – 1, severe postoperative pancreatitis – 1, postoperative pancreatic fistula grade B/C – 2. There was one lethal outcome. The long-term survival results for the other patients have been uneventful. Conclusion: Blind resection of the pancreatic insulinoma is forbidden even in cases of “hidden” insulinoma. All available preoperative diagnostics, including ASVS, must be performed before the surgery. Intraoperative ultrasound and frozen section with confirmation of the neuroendocrine origin of the lesion must be routinely performed.

Single-center Experience with Wirsungostomy (WS) as Treatment of Postoperative Pancreatic Fistula Grade C (POPF-C) after Pancreatoduodenectomy (PD)

Single-center Experience with Wirsungostomy (WS) as Treatment of Postoperative Pancreatic Fistula Grade C (POPF-C) after Pancreatoduodenectomy (PD)

Methods of Preventing of Postoperative Complications in Patients after Pancreaticoduodenectomy

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

The prognostic value of Presepsin for postoperative complications following pancreatic resection: A prospective study.

BackgroundPresepsin is involved in binding lipopolysaccharides and previous studies have confirmed its value as a marker for early diagnosis and prediction of severity in sepsis. Comparable studies assessing the predictive potential regarding postoperative complications and mortality following pancreatic resection are lacking.MethodsThis prospective study included 70 patients undergoing pancreatic resection from December 2017 until May 2019. Presepsin was measured preoperatively, on postoperative day 1, 3 and 8 (POD1/3/8) and correlated with the clinical course and mortality.ResultsSevere complications (Clavien-Dindo ≥3a) occurred in 28 patients (40%), postoperative pancreatic fistula (POPF) grade B/C occurred in 20 patients (28.6%), infectious complications in 28 (40%), and four patients (5.7%) died during hospital stay. Presepsin levels at any timepoint did not correlate with further development of postoperative complications or in-hospital mortality whereas CRP levels on postoperative day (POD) 3 were significantly associated with clinically relevant POPF (AUC 0.664, 95%CI 0.528–0.800; p = 0.033). Preoperative Presepsin levels as well as Presepsin on POD1 were significantly elevated in patients with malignant compared to benign underlying disease (299pg/ml vs. 174pg/ml and 693.5pg/ml vs. 294pg/ml; p = 0.009 and 0.013, respectively).ConclusionIn our cohort, Presepsin was not eligible to predict the postoperative course following pancreatic resection. However, Presepsin levels were significantly elevated in patients with malignant disease, this finding warrants further investigation.

Evaluation of an enhanced recovery program for outcome improvement after pancreaticoduodenectomy: A retrospective cohort study

BackgroundThe introduction of the Enhanced Recovery After Surgery (ERAS) protocol after pancreaticoduodenectomy (PD) has led to a reduction in hospital stay (LOS) without compromising surgical outcome. The primary endpoint of this study is to evaluate the adherence to postoperative targets of the ERAS protocol, and to describe short-term surgical outcomes. The secondary endpoints are 30-day readmission rate, reoperation rate and mortality. Materials and methodsThis single centre retrospective analysis reviews all data of patients who underwent a PD in our tertiary referral hospital between August 2016 and December 2019. A total of 170 patients were operated of whom 154 patients were enrolled in the ERAS protocol. As per ERAS protocol, epidural analgesia was stopped on postoperative day (POD) 2, nasogastric tube (NGT) removed on POD3, regular food tolerated by POD5. Drains were removed on POD2 and POD3, the soft drain along the pancreatic anastomosis between POD3-10. ResultsEpidural analgesia was removed on POD2 in 26 patients (17.7%), NGT removed on POD3 in 74 patients (49.0%), regular food tolerated by POD5 in 52 patients (34.9%). The lateral drain was removed in 81 patients (52.9%) on POD2, the medial drain in 39 patients (26.2%) on POD3, the soft drain in 95 patients (61.7%) between POD3 and 10. Nine patients (5.8%) had post-pancreatectomy haemorrhage (PPH), 14 (9.1%) postoperative pancreatic fistula grade B or C (POPF), 5 (3.3%) bile leakage, and 44 (28.6%) delayed gastric emptying (DGE). The 30-day readmission rate was 8.4%, reoperation rate 10.4%, and the in-hospital mortality 1.3%. ConclusionsThe adherence to targets of the ERAS protocol was found to be rather low. Biliary leakage, POPF, DGE, and PPH all led to an adapted ERAS protocol with prolonged LOS. Most complications were detected along the ERAS pathway, indicating that also patients at high risk for complications can be safely included in the ERAS protocol.

Duodenopancreatectomía cefálica y tutorización externa del conducto de Wirsung. Resultados de una serie de 80 casos consecutivos

IntroductionThere is controversy regarding the ideal pancreaticojejunostomy technique after pancreaticoduodenectomy. Many authors consider the external Wirsung stenting technique to be associated with a low incidence of fistula, morbidity and mortality. We analyse our experience with this technique. Patients and methodsA retrospective analysis of the morbidity and mortality of a series of 80 consecutive patients who had been treated surgically over a 6.5-year period for pancreatic head or periampullary tumors, performing pancreaticoduodenectomy and pancreaticojejunostomy with external Wirsung duct stenting. ResultsMean patient age was 68.3 ± 9 years, and the resectability rate was 78%. The texture of the pancreas was soft in 51.2% of patients and hard in 48.8%. Pylorus-preserving resection was performed in 43.8%. Adenocarcinoma was the most frequent tumor (68.8%), and R0 was confirmed in 70% of patients. Biochemical fistula was observed in 11.2%, pancreatic fistula grade B in 12.5% and C in 2.5%, whereas the abdominal reoperation rate was 10%. Median postoperative hospital stay was 16 days, and postoperative and 90-day mortality was 2.5%. Delayed gastric emptying was observed in 36.3% of patients, de novo diabetes in 12.5%, and exocrine insufficiency in 3. Patient survival rates after 1, 3 and 5 years were 80.2, 53.6 and 19.2%, respectively. ConclusionsAlthough our low rates of postoperative complications and mortality using external Wirsung duct stenting coincides with other more numerous recent series, it is necessary to perform a comparative analysis with other techniques, including more cases, to choose the best reconstruction technique after pancreaticoduodenectomy.

Pancreatic resections in patients who refuse blood transfusions. The application of a perioperative protocol for a true bloodless surgery

BackgroundThe refusal of blood transfusions compels surgeons to face ethical and clinical issues. A single-institution experience with a dedicated perioperative blood management protocol was reviewed to assess feasibility and short-term outcomes of true bloodless pancreatic surgery. MethodsThe institutional database was reviewed to identify patients who refused transfusion and were scheduled for elective pancreatic surgery from 2010 through 2018. A protocol to optimize the hemoglobin values by administration of drugs stimulating erythropoiesis was systematically used. ResultsPerioperative outcomes of 32 Jehovah’s Witnesses patients were included. Median age was 67 years (range, 31–77). Nineteen (59.4%) patients were treated with preoperative erythropoietin. Twenty-four (75%) patients underwent pylorus-preserving pancreaticoduodenectomy, 4 (12.5%) distal pancreatectomy (DP) with splenectomy, 3 (9.4%) spleen-preserving DP, and 1 (3.1%) total pancreatectomy. Median estimated blood loss and surgical duration were 400 mL (range, 100–1000) and 470 min (range, 290–595), respectively. Median preoperative hemoglobin was 13.9 g/dL (range, 11.7–15.8) while median postoperative nadir hemoglobin was 10.5 g/dL (range, 7.1–14.1). The most common histological diagnosis (n = 15, 46.9%) was pancreatic ductal adenocarcinoma. Clavien-Dindo grade I-II complications occurred in fourteen (43.8%) patients while one (3.1%) patient had a Clavien-Dindo grade IIIa complication wich was an abdominal collection that required percutaneous drainage. Six (18.8%) patients presented biochemical leak or postoperative pancreatic fistula grade B. Median hospital stay was 16 days (range, 8–54) with no patient requiring transfusion or re-operation and no 90-day mortality. ConclusionsA multidisciplinary approach and specific perioperative management allowed performing pancreatic resections in patients who refused transfusion with good short-term outcomes.

High risk pathogens and risk factors for postoperative pancreatic fistula after pancreatectomy; a retrospective case-controlled study.

Although the rates of surgical site infection are decreasing, surgical site infection after pancreatectomy remains frequent because of postoperative pancreatic fistula. Recent studies suggested a relationship between postoperative pancreatic fistula and pathogens cultured from drainage fluids after pancreatectomy. This study aimed to assess and evaluate high-risk pathogens cultured from postoperative drainage fluids for postoperative pancreatic fistulas or severe postoperative complications after pancreatectomy. We retrospectively enrolled patients who underwent pancreaticoduodenectomy or distal pancreatectomy between 2012 and 2019. We assessed clinical characteristics and microbiological results of drainage cultures of pancreaticoduodenectomy or distal pancreatectomy patients, and we investigated the risk factors for clinically relevant postoperative pancreatic fistulas and Clavien-Dindo status using univariate and multivariate analyses. Finally, we detected high-risk pathogens from drainage cultures and analyzed the correlation between these pathogens and the severity of clinically relevant postoperative pancreatic fistula or Clavien-Dindo status. Four hundred and twenty-nine patients were enrolled: 257 underwent pancreaticoduodenectomy and 172 underwent distal pancreatectomy. Clinically relevant postoperative pancreatic fistulas and Clavien-Dindo status≥III were more frequently seen in pancreaticoduodenectomy patients than in distal pancreatectomy patients, namely grade C postoperative pancreatic fistula, which was observed in 19 pancreaticoduodenectomy patients. The most common pathogen found from drainage cultures was Enterococcus species, followed by Enterobacter species and Candida species. All pathogens were associated with clinically relevant postoperative pancreatic fistulas; however, Candida species was a dominant microorganism of clinically relevant postoperative pancreatic fistulas grade C, Clavien-Dindo status≥IV, and hemorrhage due to pseudoaneurysm. The presence of Candida species in the drainage fluid culture after pancreaticoduodenectomy can be a predictive factor of severe infectious complications, including postoperative pancreatic fistulas; thus, we should regularly collect cultures from drainage fluids and monitor for Candida infection.

Pancreaticoduodenectomy: Outcomes of a complex surgical procedure from a developing country

BackgroundPancreaticoduodenectomy (PD) plays an integral part in the management of pancreatic, periampullary and duodenal cancers, along with a few other pathologies of this region. Despite advances in surgery PD continues to have significant morbidity and noteworthy mortality. The aim of this study is to provide an in-depth report on the patient characteristics, indications and the outcomes of PD) in a tertiary cancer hospital in Pakistan. Materials and methodsThe study population included patients who underwent PD between January 1, 2014 and march 31, 2019, at Shaukat Khanum Memorial Cancer Hospital and Research Center (SKMCH&RC) in Pakistan. The data was retrospectively analyzed from the Hospital Information System (HIS), which is a prospectively maintained patient electronic database of SKMCH&RC. Patient characteristics, procedural details and post-operative outcomes according to internationally accepted definitions were reported. ResultsA total of 161 patients underwent PD at our hospital in the study period at a median age of 53 years, ranging from 19 to 78 years. 62% of the patients were males while 37% were females. Jaundice was the most common presenting symptom (64.6%), followed by abdominal pain (26.7%). PD with pancreaticogastrostomy was performed in 110 patients (68.3%), while pancreaticojejunostomy was performed in the rest of the cohort. Surgical site infection (SSI) was observed in 64 patients (40%). The incidence of Pancreatic Fistula grade C based on the International Study Group on Pancreatic Fistula (ISGPF) definition was 7.45% (n = 12). The 30 days mortality rate was 3.1%. Median survival of the cohort was 21 ±1.13 months and disease-free survival was 16±2.62 months. ConclusionPD can be performed with acceptable morbidity and mortality in a resource constrained country, as long as it is undertaken in a high-volume center. This is in keeping with data published from other well-reputed international centers.

Indications and outcomes of enucleation versus formal pancreatectomy for pancreatic neuroendocrine tumors

BackgroundPancreatoduodenectomy (PD) or distal pancreatectomy (DP) are common procedures for patients with a pancreatic neuroendocrine tumor (pNET). Nevertheless, certain patients may benefit from a pancreas-preserving resection such as enucleation (EN). The aim of this study was to define the indications and differences in long-term outcomes among patients undergoing EN and PD/DP. MethodsPatients undergoing resection of a pNET between 1992 and 2016 were identified. Indications and outcomes were evaluated, and propensity score matching (PSM) analysis was performed to compare long-term outcomes between patients who underwent EN versus PD/DP. ResultsAmong 1034 patients, 143 (13.8%) underwent EN, 304 (29.4%) PD, and 587 (56.8%) DP. Indications for EN were small size (1.5 cm, IQR:1.0–1.9), functional tumors (58.0%) that were mainly insulinomas (51.7%). After PSM (n = 109 per group), incidence of postoperative pancreatic fistula (POPF) grade B/C was higher after EN (24.5%) compared with PD/DP (14.0%) (p = 0.049). Median recurrence-free survival (RFS) was comparable among patients who underwent EN (47 months, 95% CI:23–71) versus PD/DP (37 months, 95% CI: 33–47, p = 0.480). ConclusionComparable long-term outcomes were noted among patients who underwent EN versus PD/DP for pNET. The incidence of clinically significant POPF was higher after EN.