Pancreatic Gland Texture Research Articles

Differential Performance of Machine Learning Models in Prediction of Procedure-Specific Outcomes

BackgroundProcedure-specific complications can have devastating consequences. Machine learning–based tools have the potential to outperform traditional statistical modeling in predicting their risk and guiding decision-making. We sought to develop and compare deep neural network (NN) models, a type of machine learning, to logistic regression (LR) for predicting anastomotic leak after colectomy, bile leak after hepatectomy, and pancreatic fistula after pancreaticoduodenectomy (PD). MethodsThe colectomy, hepatectomy, and PD National Surgical Quality Improvement Program (NSQIP) databases were analyzed. Each dataset was split into training, validation, and testing sets in a 60/20/20 ratio, with fivefold cross-validation. Models were created using NN and LR for each outcome. Models were evaluated primarily with area under the receiver operating characteristic curve (AUROC). ResultsA total of 197,488 patients were included for colectomy, 25,403 for hepatectomy, and 23,333 for PD. For anastomotic leak, AUROC for NN was 0.676 (95% 0.666–0.687), compared with 0.633 (95% CI 0.620–0.647) for LR. For bile leak, AUROC for NN was 0.750 (95% CI 0.739–0.761), compared with 0.722 (95% CI 0.698–0.746) for LR. For pancreatic fistula, AUROC for NN was 0.746 (95% CI 0.733–0.760), compared with 0.713 (95% CI 0.703–0.723) for LR. Variables related to intra-operative information, such as surgical approach, biliary reconstruction, and pancreatic gland texture were highly important for model predictions. DiscussionMachine learning showed a marginal advantage over traditional statistical techniques in predicting procedure-specific outcomes. However, models that included intra-operative information performed better than those that did not, suggesting that NSQIP procedure-targeted datasets may be strengthened by including relevant intra-operative information.

The image-based preoperative fistula risk score (preFRS) predicts postoperative pancreatic fistula in patients undergoing pancreatic head resection

Clinically relevant postoperative pancreatic fistula (CR-POPF) is a common severe surgical complication after pancreatic surgery. Current risk stratification systems mostly rely on intraoperatively assessed factors like manually determined gland texture or blood loss. We developed a preoperatively available image-based risk score predicting CR-POPF as a complication of pancreatic head resection. Frequency of CR-POPF and occurrence of salvage completion pancreatectomy during the hospital stay were associated with an intraoperative surgical (sFRS) and image-based preoperative CT-based (rFRS) fistula risk score, both considering pancreatic gland texture, pancreatic duct diameter and pathology, in 195 patients undergoing pancreatic head resection. Based on its association with fistula-related outcome, radiologically estimated pancreatic remnant volume was included in a preoperative (preFRS) score for POPF risk stratification. Intraoperatively assessed pancreatic duct diameter (p < 0.001), gland texture (p < 0.001) and high-risk pathology (p < 0.001) as well as radiographically determined pancreatic duct diameter (p < 0.001), gland texture (p < 0.001), high-risk pathology (p = 0.001), and estimated pancreatic remnant volume (p < 0.001) correlated with the risk of CR-POPF development. PreFRS predicted the risk of CR-POPF development (AUC = 0.83) and correlated with the risk of rescue completion pancreatectomy. In summary, preFRS facilitates preoperative POPF risk stratification in patients undergoing pancreatic head resection, enabling individualized therapeutic approaches and optimized perioperative management.

External validation of four Pancreatic Fistula Risk Score models in the Deep South US: Do racial disparities affect pancreatic fistula prediction?

BackgroundFistula Risk Score (FRS) models often lack adequate discrimination for clinically relevant postoperative pancreatic fistula (CR-POPF) on external validation. We tested four FRS models in the Deep South United States and sought to determine if CR-POPF discrimination was affected by racial disparities. MethodsA single-institution retrospective cohort study of patients who underwent pancreatoduodenectomies between 2013 and 2019 was performed. FRS discrimination for CR-POPF was assessed using ROC curves for both the entire patient population, and for Black vs White patients. ResultsThe Alternative FRS maintains adequate CR-POPF discrimination when considering the patient population as a whole, but inadequately predicts CR-POPF when applied to the Black patient population. The Sun-FRS provides adequate CR-POPF discrimination for Black patients when considering risk grade. Only soft pancreatic gland texture and small duct size were significantly associated with CR-POPF in this patient population. DiscussionInstitutions should assess their preferred FRS model to determine if it provides adequate CR-POPF discrimination among a racially diverse patient population. Further studies are needed to determine how racial disparities influence CR-POPF prediction to better guide postoperative management.

Postoperative day 1 combination of serum C-reactive protein and drain amylase values predicts risks of clinically relevant pancreatic fistula. The “90-1000” score

BackgroundSeveral scoring systems predict risks of clinically relevant postoperative pancreatic fistula after pancreatectomy, but none have emerged as the gold standard. This study aimed to evaluate the accuracy of postoperative day 1 drain amylase and serum C-reactive protein levels in predicting clinically relevant postoperative pancreatic fistula compared with intraoperative pancreatic characteristics. MethodsPatients who underwent pancreatectomy between 2017 and 2019 were included prospectively. Cutoff values were determined using receiver operating characteristic curves, and a score combining postoperative day 1 drain amylase and serum C-reactive protein was tested in a multivariate logistic regression model to evaluate clinically relevant postoperative pancreatic fistula risk. ResultsA total of 274 pancreatic resections (182 pancreaticoduodenectomies and 92 distal pancreatectomies) were included. The pancreatic gland texture was “soft” in 47.8% (n = 131), and 55.8% (n = 153) had a small size main pancreatic duct (≤3 mm). Clinically relevant postoperative pancreatic fistula occurred in 58 patients (21.2%). Drain amylase ≥1,000 UI/L and serum C-reactive protein ≥90 mg/L were identified as the optimal cutoffs to predict clinically relevant postoperative pancreatic fistula. On multivariate analysis these cutoffs were independent predictors of clinically relevant postoperative pancreatic fistula after both pancreaticoduodenectomies (drain amylase: P < .001, serum C-reactive protein: P = .006) and distal pancreatectomies (drain amylase: P = .009, serum C-reactive protein: P = .001). The postoperative day 1 “90-1000” model, a 2-value score relying on these cutoffs, significantly (P < .001) outperformed intraoperative pancreatic parenchymal characteristics in predicting clinically relevant postoperative pancreatic fistula after both pancreaticoduodenectomies and distal pancreatectomies. A postoperative day 1 “90-1000” score = 0 had a negative predictive value of 97% and 94%, respectively, after pancreaticoduodenectomy and distal pancreatectomies. ConclusionA combined score relying on postoperative day 1 values of drain amylase and serum C-reactive protein levels was accurate in predicting risks of clinically relevant postoperative pancreatic fistula after pancreatectomy.

Intra-pancreatic distal cholangiocarcinoma and pancreatic ductal adenocarcinoma: a common short and long-term prognosis?

The aim of the study was to compare histological features, postoperative outcomes, and long-term prognostic factors after pancreaticoduodenectomy for distal cholangiocarcinoma and pancreatic ductal adenocarcinoma. From 2005 to 2017, 188 pancreaticoduodenectomies (pancreatic ductal adenocarcinoma n = 151, distal cholangiocarcinoma n = 37) were included. Postoperative outcomes were compared after matching on pancreatic gland texture and main pancreatic duct size. Matching according to tumor size, lymph node invasion and resection margin was used to compare overall and disease-free survival. Distal cholangiocarcinoma patients had more often "soft" pancreatic gland (P = 0.002) and small size main pancreatic duct (P = 0.001). Pancreatic ductal adenocarcinoma patients had larger tumors (P = 0.009), and higher lymph node ratio (P = 0.017). Severe morbidity (P = 0.023) and clinically relevant pancreatic fistula (P = 0.018) were higher in distal cholangiocarcinoma patients. After matching on gland texture and main pancreatic duct diameter, clinically relevant postoperative pancreatic fistula was still more frequent in distal cholangiocarcinoma patients (P = 0.007). Tumor size > 20mm was predictive of impaired overall survival (P = 0.024) and disease-free survival (P = 0.003), tumor differentiation (P = 0.027) was predictive of impaired overall survival. Survival outcomes for distal cholangiocarcinoma and pancreatic ductal cholangiocarcinoma were similar after matching patients according to tumor size, lymph node invasion and resection margin. Long-term outcomes after pancreaticoduodenectomy for distal cholangiocarcinoma and pancreatic ductal adenocarcinoma patients are similar. Postoperative course is more complicated after pancreaticoduodenectomy for distal cholangiocarcinoma than pancreatic ductal adenocarcinoma. After pancreaticoduodenectomy, patients with distal cholangiocarcinoma and pancreatic ductal adenocarcinoma have similar long-term oncological outcomes.

Alternative fistula risk score is a better predictor of ideal outcome in patients undergoing minimally invasive pancreaticoduodenectomy

Background: The benefit of minimally-invasive (MIPD) versus open pancreaticoduodenectomy (OPD) to patients is controversial. The major driver of morbidity and mortality after pancreaticoduodenectomy is postoperative pancreatic-fistula (POPF). The alternative-fistula risk score (aFRS) is a validated prognostic tool that predicts patients' risk of POPF using three variables (pancreatic duct size, gland texture, and patient BMI). We hypothesized that patients who are not at high risk for POPF benefit most from MIPD. Methods: Patients undergoing pancreaticoduodenectomy were prospectively followed for 40 months. Perioperative and pathologic covariates and outcomes were compared. Patients were categorized as either aFRS-high risk (POPF-risk >20%) or aFRS-low/intermediate-risk (POPF-risk ≤20%). The ideal-outcome (IO) was defined as shown in Figure-1. Multivariable logistic regression was used to test for independent-associations with IO. Results: Out of 312 patients, 212 (83.7%) underwent OPD and 51 (16.4%) underwent MIPD. MIPD patients had significantly longer overall operative time (462.8 minvs.378.5 min,p< 0.001), reduced intraoperative blood loss (280.5 mlvs.436.0 ml,p=0.001), and a decreased rate of 90-day readmission (15.7%vs.30.7%,p=0.030) . MIPD patients were significantly more likely to be aFRS-high risk (56.9%vs.40.2%,p=0.028). IO was significantly more frequent in aFRS-low/intermediate-risk patients undergoing MIPD compared to aFRS-low/intermediate-risk patients undergoing OPD, aFRS-high risk patients undergoing either MIPD or OPD (40.9%vs15.4%v6.9% vs14.3%,p=0.007). In multivariate analysis, MIPD in aFRS-low/intermediate-risk patients was independently-associated with an increased likelihood of IO (OR= 4.09, p=0.012). Conclusions: Patients who are not at high-risk for POPF are most likely to benefit from MIPD. The aFRS could be a useful tool to aid the surgeon experience and expertise in selecting patients for MIPD.

Does bacterobilia influence pancreatic fistula after pancreaticoduodenectomy independently of fistula risk score?

Introduction: Post-operative pancreatic fistulae(POPF) remain a major complication following pancreaticoduodenectomy. Risk factors for development of POPF include pancreatic duct diameter and gland texture, body mass index(BMI) and intraoperative blood loss. However, emerging evidence suggests that bacteria in the biliary tree, secondary to biliary intervention or obstruction-related bacterial overgrowth, may predispose to POPF. Methods: Consecutive patients undergoing pancreaticoduodenectomy at a single tertiary Hospital between 2012 and 2020 were included for analysis. Data were derived from prospectively-maintained databases and case notes review. Patients were excluded from analysis if data were incomplete. Bile sampling was performed intraoperatively. A validated Fistula Risk Score was calculated from patient BMI and pre-/intra-operative pancreatic duct diameter. The International Study Group of Pancreatic Fistula(ISGPS) definition and classification of POPF was used. Results: A total of 176 patients were included for analysis. Bacterobilia was present in 126(72%) patients; 95(86%) stented and 28(45%) non-stented patients. Significantly higher rates of clinically-relevant (ISGPS B/C) POPF were seen in the bacterobilia group(25% vs. 12%; p=0.02) and there was a trend towards higher overall POPF(38% bacterobilia vs. 28% sterile; p=0.20), and SSI(25% vs. 16%; p= 0.2) rates in bacterobilia patients. There was no difference in median LOS(15 days bacterobilia vs. 14 days sterile) or mortality(2% bacterobilia vs. 2% sterile). The most frequently cultured organisms were Enterococcus spp.(27%; Faecalis 10% and Faecium 7%), Escherichia coli(37%), Streptococcus(34%) and Klebsiella(12%). Conclusions: The presence of bacterobilia is significantly associated with the development of clinically relevant POPF. Methods for reducing the presence of bacterobilia, such as the development of fast-track pancreaticoduodenectomy pathways and the avoidance of biliary stenting, should be considered.

Microbiome Patterns in Matched Bile, Duodenal, Pancreatic Tumor Tissue, Drainage, and Stool Samples: Association with Preoperative Stenting and Postoperative Pancreatic Fistula Development.

Postoperative complications after pancreatic surgery are still a significant problem in clinical practice. The aim of this study was to characterize and compare the microbiomes of different body compartments (bile duct, duodenal mucosa, pancreatic tumor lesion, postoperative drainage fluid, and stool samples; preoperative and postoperative) in patients undergoing pancreatic surgery for suspected pancreatic cancer, and their association with relevant clinical factors (stent placement, pancreatic fistula, and gland texture). For this, solid (duodenal mucosa, pancreatic tumor tissue, stool) and liquid (bile, drainage fluid) biopsy samples of 10 patients were analyzed using 16s rRNA gene next-generation sequencing. Our analysis revealed: (i) a distinct microbiome in the different compartments, (ii) markedly higher abundance of Enterococcus in patients undergoing preoperative stent placement in the common bile duct, (iii) significant differences in the beta diversity between patients who developed a postoperative pancreatic fistula (POPF B/C), (iv) patients with POPF B/C were more likely to have bacteria belonging to the genus Enterococcus, and (v) differences in microbiome composition with regard to the pancreatic gland texture. The structure of the microbiome is distinctive in different compartments, and can be associated with the development of a postoperative pancreatic fistula.

Development of a Novel Pancreatoduodenectomy-Specific Risk Calculator: an Analysis of 10,000 Patients

BackgroundPancreatoduodenectomy (PD) is often performed in frail patients and is associated with significant morbidity. The five-factor modified frailty index (mFI-5) has been utilized to predict adverse postoperative outcomes, but has not been tested in PD. We aimed to develop risk tools to generate and predict 30-day outcomes after PD and compare their performance with the mFI-5. Risk tools were then used to generate a PD-specific calculator. MethodsElective PDs from the 2014–2016 ACS NSQIP® Procedure Targeted Pancreatectomy PUFs were identified. Multivariable logistic regression models were constructed to predict postoperative mortality, any complication, serious complication, clinically relevant postoperative pancreatic fistula (CR-POPF), and discharge not-to-home. Predictive accuracy was evaluated through repeated stratified tenfold cross-validation and compared to the mFI-5. ResultsNine thousand eight hundred sixty-seven PDs were captured. Nine risk factors were retained: sex, age, BMI, DM, HTN, ASA classification, pancreatic duct size, gland texture, and adenocarcinoma. Cross-validated C-indices ranged from 0.49 to 0.61 for the mFI-5 and 0.63 to 0.75 for our risk models. The best-performing model was for discharge not-to-home (C = 0.75), and the model delivering the largest increase in predictive accuracy was for CR-POPF (CmFI-5/Model = 0.49/0.70). A user-friendly risk calculator was created predicting the five outcomes of interest. ConclusionWe have created a PD-specific risk calculator that outperforms the mFI-5. This calculator may serve as a useful adjunct in shared decision-making for patients and surgeons.

A retrospective study comparing external and internal without stent pancreatic drainage after pancreatic operation

Abstract Background : Postoperative pancreatic fistula (POPF) is one of the most common complications and the leading cause of morbidity and mortality after pancreatic operation with pancreatojejunostomy (PJ). Many strategies have been used to prevent the incidence of POPF, among which drainage of pancreatic juice is effective. There are two types of drainage methods used in clinical practice; however, the method with a superior effect remains unknown. This study compared the effect of external and internal drainage without stent (in other words, no drainage, only PJ by duct-to-mucosa) on the incidence of clinically relevant POPF (CR-POPF) to provide evidence to select a better drainage scheme in clinical practice. Methods Overall, 520 patients undergoing pancreatic operation, including PJ were included in this single-centre study and were divided into two groups according to drainage methods. We compared the incidence of CR-POPF between the two groups and performed stratified analysis according to the Fistula Risk Score (FRS) and pancreatic gland texture. Factors such as gender, age, Body Mass Index (BMI), operative procedure, and drainage methods were included in univariable and multivariable analyses. Results The incidence rate of CR-POPF between two groups was significantly different (23.3% vs 13.6%, P Conclusions Compared with internal drainage without stent or only simple PJ by duct-to-mucosa, the external drainage method was associated with a higher incidence of CR-POPF. However, this conclusion needs to be further confirmed in large samples.

Comparison of three fistula risk scores after pancreatoduodenectomy: A single-institution retrospective study

Postoperative pancreatic fistula (POPF) after pancreatoduodenectomy greatly influences patients' postoperative course. Several evaluation methods have been used to assess the risk of clinically relevant POPF (CR-POPF) after pancreatoduodenectomy namely, the original, alternative, and updated alternative fistula risk scores (o-FRS, a-FRS, and ua-FRS, respectively). We enrolled 106/179 patients who underwent pancreatoduodenectomy in our institution between April 2013 and Mar 2018. CR-POPF was defined as grade B and C POPF according to the 2016 definitions of the International Study Group on Pancreatic Surgery. Pancreatic gland texture was the only significant risk factor for CR-POPF (p=0.007). The CR-POPF incidence increased significantly according to the risk groups defined by both o-FRS (p=0.004) and a-FRS (p=0.004). The area under the curve for o-FRS, a-FRS, and ua-FRS was 0.693, 0.693, and 0.671, respectively. o-FRS, a-FRS, and ua-FRS were almost equally useful for risk evaluation for CR-POPF after pancreatoduodenectomy. Further studies, especially for preoperative objective evaluation of pancreatic gland texture, are needed for more useful and accurate risk evaluation.

A propensity score analysis of over 12,000 pancreaticojejunal anastomoses after pancreaticoduodenectomy: does technique impact the clinically relevant fistula rate?

BackgroundClinically relevant postoperative pancreatic fistula (CR-POPF) remains a major cause of morbidity in patients undergoing pancreatic surgery. Controversy exists as to whether there is any difference in CR-POPF with a Duct-to-Mucosa (DTM) versus an Invagination (IG) pancreaticojejunostomy (PJ). MethodsDemographic, perioperative, intraoperative, and postoperative data were captured from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) 2014–2017 databases. Potential confounders were included in a logistic regression and a propensity score model. The primary outcome was CR-POPF. ResultsA total of 12,361 pancreaticojejunal anastomoses were performed with 11,168 patients undergoing DTM (90%) and 1193 undergoing IG (10%) after pancreaticoduodenectomy. Amongst all patients, there was no significant difference in CR-POPF between DTM and IG on multivariate (OR = 0.95, p = 0.64) or propensity score analysis (OR = 0.99, p = 0.93). After stratification by pancreatic gland texture and duct size, there was a decrease in CR-POPF with DTM amongst patients with duct size greater than 6 mm on multivariate analysis (OR = 0.35, p = 0.009) and propensity score analysis (OR = 0.40, p = 0.018). There were no significant differences in any other strata. ConclusionDTM or IG technique are not associated with CR-POPF for patients with average size pancreatic ducts; however, DTM is preferable in patients with large pancreatic duct diameter (>6 mm).

The impact of perioperative inotropes on the incidence of pancreatic leak following pancreaticoduodenectomy.

Backgrounds/AimsPancreatic leak and fistula formation following pancreatic resection is a dreaded complication associated with significant morbidity and mortality. The perioperative use of inotropes has been implicated in anastomotic dehiscence in other types of gastrointestinal surgery but their impact in pancreatic surgery remains unclear and a potentially modifiable risk factor for pancreatic leak. This study aims to assess the impact of perioperative inotrope infusion on the incidence of pancreatic leak following pancreaticoduodenectomy.MethodsRetrospective data analysis of all patients undergoing pancreaticoduodenectomy at a tertiary HPB institute. Multivariate analysis and regression models assessed the impact of inotrope use against other known risk factors such as pancreatic duct size and gland texture. Pancreatic fistulae were graded as per ISGPF as Grade A (biochemical leak), Grade B and Grade C fistula.ResultsOne-hundred and twenty-three (123) patients were included. A total of 52 patients (42%) developed a leak (29 grade A, 15 grade B, and 8 Grade C). In the fistula group, 28 patients (55%) received perioperative inotropes compared to 26 (35%) in the no fistula group. On univariate analysis, patients receiving inotropes (p=0.04) and patients with a soft pancreatic texture (p=0.003) had a statistically higher incidence of developing a pancreatic fistula of any grade. On multivariate analysis, only inotrope use was associated with an increased risk of developing a pancreatic fistula of any grade (OR 2.46, p=0.026), independent of pancreatic texture and pancreatic duct size.ConclusionsPerioperative inotrope use is associated with an increase incidence of pancreatic leak following pancreaticoduodenectomy and should therefore be used judiciously.

Postoperative Pancreatic Fistula Following Pancreaticoduodenectomy—Stratification of Patient Risk

BackgroundPostoperative pancreatic fistula (POPF) remains a major cause of morbidity following pancreaticoduodenectomy (PD). We sought to develop and validate a risk score system that utilized preoperative computed tomography (CT) measurements, laboratory values, and intraoperative pancreatic texture to estimate risk of developing POPF after PD. MethodsPatients who underwent PD between 2014 and 2017 were identified. Pre- and intraoperative risk factors associated with POPF were identified. Three separate risk models were developed and assessed using multivariable analyses and receiver operating curves. ResultsAmong the 150 patients who underwent a PD, mean age was 64 years and the majority of the patients were male (59.3%, n = 89). Overall, the incidence of BL/POPF following PD was 22%. On multivariable analysis, factors associated with POPF included preoperative total serum protein < 6 g/dL (OR 3.35, 95% CI 1.04–10.34, p = 0.04), radiologic pancreatic duct diameter (OR 0.72, 95% CI 0.53–0.97, p = 0.03), intraoperative pancreatic gland texture estimated by surgeon (OR 0.17, 95% CI 0.05–0.62, p = 0.006), as well as intraoperative pancreatic duct diameter measured by surgeon (OR 0.77, 95% CI 0.61–0.98, p = 0.030). Each risk factor was assigned a weighted score (CT pancreatic duct diameter < 5 mm: 8 points; soft pancreatic gland texture: 5 points; total serum protein < 6 g/dL: 3 points; CT visceral abdominal fat ≥ 230 cm2: 2 points). Patients scoring 4–5 were at low risk of POPF, while patients with a score of 6–18 had a high risk for POPF. The Harrell’s c-index for the scoring system was 0.71 (standard error [SD] 0.094) for the training set and 0.67 (SD 0.034) for the test set (with n = 1000 bootstrapping resamples). ConclusionA simple risk score for POPF that utilized preoperative radiologic and clinical variables combined with specific intra-operative factors was able to stratify patients relative to POPF risk with good discriminatory ability.

What is the Incidence of Malignancy in Resected Intraductal Papillary Mucinous Neoplasms? An Analysis of Over 100 US Institutions in a Single Year.

A subset of intraductal papillary mucinous neoplasms (IPMNs) will progress to invasive adenocarcinoma, however identifying invasive from non-invasive disease preoperatively remains challenging. The rate of malignancy in resected IPMNs in the US remains unclear. We aimed to determine the rate of malignancy and factors associated with high-risk pathology in resected IPMNs. The most recent annual cohort of patients undergoing pancreatectomy included in the American College of Surgeons National Surgical Quality Improvement Program were assessed, and contributions of demographics, preoperative laboratory values, and outcome data to level of IPMN dysplasia were analyzed. The main outcomes were incidence of invasive carcinoma or high-grade dysplasia. Of 5025 pancreatectomies in 1year, 478 patients underwent pancreatectomy for IPMN. Invasive carcinoma/high-grade dysplasia was identified in 23% of resected lesions, and there was no difference in patient characteristics or type of resection performed in patients with invasive versus non-invasive pathology. Patients with invasive IPMNs presented significantly more often with high liver function tests, >10% weight loss, clinical jaundice and stent placement, and were more likely to undergo an open operation (p=0.03). There were no differences in perioperative outcomes. Adjusted logistic regression identified an association between invasive disease and non-soft pancreatic gland texture (odds ratio 0.19, 95% confidence interval 0.05-0.68, p<0.01). Approximately 10% of all pancreatectomies in the US are for IPMNs. In these patients, treated after the revised international consensus guidelines, only 23% of IPMNs contained invasive or high-grade histology. Resections carried similar morbidity regardless of pathology. Improved biomarkers are needed to aid in surgical selection.

C-Reactive Protein on Postoperative Day 1 Is a Reliable Predictor of Pancreas-Specific Complications After Pancreaticoduodenectomy

BackgroundPostoperative pancreatic fistula and pancreas-specific complications have a significant influence on patient management and outcomes after pancreatoduodenectomy. The aim of the study was to assess the value of serum C-reactive protein on the postoperative day 1 as early predictor of pancreatic fistula and pancreas-specific complications. MethodsBetween 2013 and 2016, 110 patients underwent pancreaticoduodenectomy. Clinical, biological, intraoperative, and pathological characteristics were prospectively recorded. Pancreatic fistula was graded according to the International Study Group on Pancreatic Fistula classification. A composite endpoint was defined as pancreas-specific complications including pancreatic fistula, intra-abdominal abscess, postoperative hemorrhage, and bile leak. The diagnostic accuracy of serum C-reactive protein on postoperative day 1 in predicting adverse postoperative outcomes was assessed by ROC curve analysis. ResultsSix patients (5%) died and 87 (79%) experienced postoperative complications (pancreatic-specific complications: n = 58 (53%); pancreatic fistula: n = 48 (44%)). A soft pancreatic gland texture, a main pancreatic duct diameter < 3 mm and serum C-reactive protein ≥ 100 mg/L on postoperative day 1 were independent predictors of pancreas-specific complications (p < 0.01) and pancreatic fistula (p < 0.01). ROC analysis showed that serum C-reactive protein ≥ 100 mg/L on postoperative day 1 was a significant predictor of pancreatic fistula (AUC: 0.70; 95%CI: 0.60–0.79, p < 0.01) and pancreas-specific complications (AUC: 0.72; 95%CI: 0.62–0.82, p < 0.01). ROC analysis showed that serum C-reactive protein ≥ 50 mg/L at discharge was a significant predictor of 90-day hospital readmission (AUC: 0.70; 95%CI: 0.60–0.79, p < 0.01). ConclusionsC-reactive protein levels reliably predict risks of pancreatic fistula, pancreas-specific complications, and hospital readmission, and should be inserted in risk-stratified management algorithms after pancreaticoduodenectomy.

Comparison of different feeding regimes after pancreatoduodenectomy - a retrospective cohort analysis

BackgroundDelayed gastric emptying (DGE) is the most frequent pancreatic specific complication (PSC) after pancreaticoduodenectomy (PD). Several gastric decompression systems exist to manage DGE. Patients with a pancreatic tumor require prolonged nutrition; however, controversies exist concerning nutrition protocol after PD. The aim of the study was to assess the safety and efficacy of nasogastric (NG), gastrostomy (GT), and gastrojejunostomy (GJ) tubes with different feeding systems on postoperative courses.MethodsBetween January 2013 and March 2016, 86 patients underwent PD with pancreaticogastrostomy. Patients were divided into three groups: GJ group with enteral nutrition (EN, n = 12, 14%), NG (n = 31, 36%) and GT groups (n = 43, 50%), both with total parenteral nutrition (TPN).ResultsPatients in the GJ (n = 9, 75%) and GT (n = 18, 42%) groups had an American Society of Anesthesiologists (ASA) score of 3 more often than those in the NG group (n = 5, 16%, p ≤ 0.01). Multivariate analysis identified the GT tube with TPN as an independent risk factor of severe morbidity (p = 0.02) and DGE (p < 0.01). An ASA score of 3, jaundice, common pancreatic duct size ≤3 mm and soft pancreatic gland texture (p < 0.05) were found as independent risk factors of PSCs. Use of a GJ tube with EN, GT tube with TPN, jaundice, and PSCs were identified as independent risk factors for greater postoperative length of hospital stay (p < 0.01). Mean global hospitalization cost did not differ between groups.ConclusionGT tube insertion with TPN was associated with increased severe postoperative morbidity and DGE and should not be recommended. EN through a GJ tube after PD is feasible but does not have clear advantages on postoperative courses compared to an NG tube.

Minimally invasive pancreatoduodenectomy: laparoscopic or robotic?

Objective: Laparoscopic and robotic surgery are novel approaches to pancreatoduodenectomy (PD). Reported series of minimally invasive PD are small or not adequately controlled. The aim of this analysis is to report outcomes following laparoscopic and robotic pancreatoduodenectomy compared with the open procedure in a large, multi-center cohort. Methods: The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) Participant Use File 2014 was queried to identify patients having undergone minimally invasive (MI) pancreatoduodenectomy (163/3092, 5.2%). MI-PD included laparoscopic and robotic approaches as well as converted cases. Patients with a hybrid approach, vascular resections, and other major concomitant organ resection were excluded. Propensity scoring was used to match cohorts of patients having undergone and open, laparoscopic, and robotic PD. Results: The median age was 65, and 56% were men. Fifteen percent of patients were pretreated with neoadjuvant therapy, 51% had pancreatic adenocarcinoma. Patient cohorts were similar with respect to patient demographics, comorbidities, neoadjuvant therapy, and pancreatic gland texture and duct size. Operative time was longer in patients having undergone MI-PD. Post-operative outcomes are shown in the table. Conclusion: Laparoscopic and robotic approaches to pancreatoduodenectomy are safe and can be performed with comparable morbidity and mortality but take longer to perform. A robotic approach may reduce the need for conversion to open surgery compared to traditional laparoscopy.Tabled 1Conversion to open (%)Operative time (min)Overall morbidity (%)CR-POPF (%)DGE (%)Percutaneous drain (%)30-day mortality (n, %)Length of stay (days)Open (n =530)–353.0*27.914.716.011.59, 1.710.7Laparoscopic (n =81)32.7†436.827.119.626.0†13.92, 2.511.0Robotic (n =77)12.5421.626.018.111.810.51, 1.310.9*P<0.01 vs Lap/Robotic.†P<0.05 vs RoboticCR-POPF: clinically relevant-postoperative pancreatic fistula; DGE: Delayed gastric emptying. Open table in a new tab *P<0.01 vs Lap/Robotic. †P<0.05 vs Robotic CR-POPF: clinically relevant-postoperative pancreatic fistula; DGE: Delayed gastric emptying.

1028 - Pancreatic Duct Size and Gland Texture do not Affect Pancreatic Leak Rate after Distal Pancreatectomy

1028 - Pancreatic Duct Size and Gland Texture do not Affect Pancreatic Leak Rate after Distal Pancreatectomy

A Propensity Score–Matched Analysis of Robotic vs Open Pancreatoduodenectomy on Incidence of Pancreatic Fistula

The adoption of robotic pancreatoduodenectomy (RPD) is gaining momentum; however, its impact on major outcomes, including pancreatic fistula, has yet to be adequately compared with open pancreatoduodenectomy (OPD). To demonstrate that use of RPD does not increase the incidence of clinically relevant pancreatic fistula (CR-POPF) compared with OPD. Data were accrued from 2846 patients who underwent pancreatoduodenectomies (OPDs, n = 2661; RPDs, n = 185), performed by 51 surgeons at 17 institutions worldwide (2003-2015). All RPDs were conducted at a high-volume, academic, pancreatic surgery specialty center-in a standardized fashion-by surgeons who had surpassed the RPD learning curve. Propensity score matching was used to minimize bias from nonrandomized treatment assignment. The RPD and OPD cohorts were matched by propensity scores accounting for factors significantly associated with either undergoing robotic surgery or CR-POPF occurrence on logistic regression analysis. These variables included pancreatic gland texture, pancreatic duct diameter, intraoperative blood loss, pathologic findings of disease, and intraoperative drain placement. Use of RPD or OPD. The major outcome of interest was CR-POPF occurrence, which is the most common and morbid complication following pancreatoduodenectomy. The overall cohort was 51.5% male, with a median age of 64 years (interquartile range, 56-72 years). The propensity score-matched cohort comprised 152 RPDs and 152 OPDs; all covariate imbalances were alleviated. After adjusting for potential confounders, undergoing RPD was associated with a reduced risk for CR-POPF incidence (OR, 0.4 [95% CI, 0.2-0.7]; P = .002) relative to OPD. Other predictors of risk-adjusted CR-POPF occurrence included soft pancreatic parenchyma (OR, 4.7 [95% CI, 3.4-6.6]; P < .001), pathologic findings of high-risk disease (OR, 1.4 [95% CI, 1.1-1.9]; P = .01), small pancreatic duct diameter (vs ≥5 mm: 2 mm, OR, 2.1 [95% CI, 1.4-3.1]; P < .001; ≤1 mm, OR, 1.8 [95% CI, 1.0-3.0]; P = .03), elevated intraoperative blood loss (vs ≤400 mL: 401-700 mL, OR, 1.5 [95% CI, 1.1-2.0]; P = .01; >1000 mL, OR, 2.1 [95% CI, 1.4-2.9]; P < .001), omission of intraoperative drain(s) (OR, 0.5 [95% CI, 0.3-0.8]; P = .005), and octreotide prophylaxis (OR, 3.1 [95% CI, 2.3-4.0]; P < .001). Patients undergoing RPD demonstrated similar CR-POPF rates compared with patients in the OPD cohort (6.6% vs 11.2%; P = .23). This relationship held for both grade B (6.6% vs 9.2%; P = .52) and grade C (0% vs 2.0%; P = .25) POPFs. Robotic pancreatoduodenectomy was also noninferior to OPD in terms of the occurrence of any complication (73.7% vs 66.4%; P = .21), severe complications (Accordion grade ≥3, 23.05% vs 23.7%; P > .99), hospital stay (median: 8 vs 8.5 days; P = .31), 30-day readmission (22.4% vs 21.7%; P > .99), and 90-day mortality (3.3% vs 1.3%; P = .38). To our knowledge, this is the first propensity score-matched analysis of robotic vs open pancreatoduodenectomy to date, and it demonstrates that RPD is noninferior to OPD in terms of pancreatic fistula development and other major postoperative outcomes.