Pancreatoduodenectomy In Patients Research Articles

Does preoperative acute pancreatitis inevitably delay pancreatoduodenectomy in patients with periampullary tumors?

Does preoperative acute pancreatitis inevitably delay pancreatoduodenectomy in patients with periampullary tumors?

Postoperative acute pancreatitis after pancreatic resection in patients with pancreatic ductal adenocarcinoma.

Postoperative pancreatic fistula (POPF) is one of the major critical complications after pancreatic resection. Recently, postoperative acute pancreatitis (POAP), a new concept for a pancreatic-specific complication following pancreatic resection, has been advocated, and its association with POPF has been reported. The present study examined the clinical features of POAP and identified the associations of POAP with POPF and other postoperative morbidities in pancreatic ductal adenocarcinoma (PDAC) patients undergoing pancreatic resection. A total of 312 consecutive patients who underwent pancreatic resection for PDAC at our institution from 2013 to 2019 were enrolled in this study. POAP was defined as an elevated serum amylase level above the upper limit normal on postoperative day (POD) 0 or 1, based on Connor's definition. The severity of POPF was assessed by the International Study Group on Pancreatic Surgery definition. A total of 184 patients (58.9%) had POAP. POAP occurred in 58.5% of subtotal stomach-preserving pancreatoduodenectomy patients and 60% of distal pancreatectomy combined with splenectomy patients. The presence of POAP was significantly associated with the development of clinically relevant POPF, higher rates of severe morbidity, and a prolonged hospital stay after pancreatic resection. A multivariate analysis showed that the presence of POAP and elevated C-reactive protein levels on POD 3 were independent predictors of clinically relevant POPF after subtotal stomach-preserving pancreatoduodenectomy. POAP is associated with the development of POPF, higher rates of severe morbidity, and a prolonged hospital stay after pancreatic resection and is an independent risk factor for clinically relevant POPF after pancreatoduodenectomy. POAP represents an important indicator for planning treatment strategies to prevent serious complications, including POPF.

Patterns of mortality after pancreatoduodenectomy: A root cause, day-to-day analysis

BackgroundMortality is consistently reported as an outcome metric in pancreatic surgery. Given its heterogeneity, better characterization of it might provide crucial insights for clinical practice. This study aimed to analyze the timeline and sequence of events that lead to death after pancreatoduodenectomy to identify possible distinct pathways of mortality. MethodsAll consecutive pancreatoduodenectomy cases from 2010 to 2020 were retrospectively analyzed. A day-to-day appraisal of the postoperative course of each fatality was performed and visualized graphically. The graphical analysis allowed for pattern identification. The respective predictors were explored through logistic regression. ResultsOut of 2065 pancreatoduodenectomy patients, in-hospital mortality was 3.1%. With graphical analysis, 3 patterns were identified. Pattern A deaths (71.4%, n = 45) occurred after a median of 43 days (14–260), following pancreas-specific complications such as postoperative pancreatic fistula, postpancreatectomy hemorrhage, and delayed gastric emptying. Pattern B deaths (15.9%, n = 10) occurred after a median of 18 days (1–55), succeeding a critical status in the early postoperative course, mainly related to elevated surgical complexity. Patients with pattern C (12.7%) died after a median of 8 days, mostly for unknown cause after an uneventful postoperative course. The predictors of each pattern were distinctive. ConclusionMortality after pancreatoduodenectomy occurs through 3 distinct pathways. This knowledge could spawn an additional endpoint of value to clinicians and hospitals, delivering a supplementary tool for comparison between centers and diversified patient populations, and it might facilitate the identification of the best targets for improvement. Further studies are needed to validate this tripartite reclassification.

IS THE ANATOMICAL SEQUENCE OF GASTRIC AND BILIARY ANASTOMOSIS IN THE PANCREATODUODENECTOMY RECONSTRUCTION THE CAUSE OF AN INCREASE IN THE INCIDENCE OF CHOLANGITIS? A TECHNICAL VARIANT PRESENTATION AND INITIAL RESULTS.

ABSTRACT - BACKGROUND:Several methods have been proposed for the reconstruction of digestive transit after pancreatoduodenectomy. Biliary anastomosis positioned before gastric anastomosis helps reduce postoperative reflux and cholangitis.AIMS: The objective of this study was to present the anatomical sequence of gastric and biliary continuity after pancreatoduodenectomy in patients with pancreatic tumor and to evaluate the short- and long-term results in an initial series of cases.METHODS: Two techniques were used: one with Roux-en-Y reconstruction and pancreaticojejunostomy and the other with a single jejunal loop and pancreatogastroanastomosis. In both the cases, the gastric anastomosis was placed performed before the biliary one. An analysis of demographic data, Wirsung’s duct and common bile duct dilatation, the use of percutaneous drainage, and postoperative complications was carried out.RESULTS: A total of seven patients (four men and three women), with a mean age of 62 years, underwent surgery. All cases had Wirsung’s duct and common bile duct dilatation. A percutaneous external biliary drainage was performed in four patients. There were three postoperative complications: one related to delayed gastric emptying and two related to wound infections. During a median follow-up of 12 months, no episode of cholangitis was recorded.CONCLUSIONS: Elevated percentages of cholangitis are reported in different reconstructions after pancreatoduodenectomy, and it is difficult to conclude reflux as the main etiology. The proposed gastric and biliary reconstructions show conforming results, facilitating posterior endoscopic access. Late follow-up and large number of cases may help assess whether the etiology of postoperative cholangitis is reflux or other factors unrelated to the order of the anastomoses.

Minimally Invasive Pancreatoduodenectomy in Patients with Abnormal Vascular Anatomy: Surgical Techniques and Clinical Outcomes

Introduction: Minimally Invasive Pancreatoduodenectomy(MIPD) is a complex procedure where abnormal vascular anatomy(AVA), compared to normal vascular anatomy(NVA), can add to the surgical difficulty and risks. In particular, right or common hepatic artery (RHA and CHA, respectively) anomalies can be a source of serious problems. Hence preoperative planning and intraoperative care are paramount. Herein we present a video showing MIPD in case of AVA, discuss our protocol and surgical techniques, and compare results in patients with AVA involving the HA versus NVA. Methods: Data of patients undergoing MIPD(2015-2020) were analysed. Preoperative CT-angiography was performed in all patients. A SMA-first approach was performed in all patients with AVA while a hybrid left/anterior/posterior approach was adopted in NVA. The bile duct was divided at last in NVA patients, while biliary division was performed earlier in patients with AVA or with tumours adherent to the SMV/PV, thus allowing a cranio-caudal and caudo-cranial dissection. Results: among 83 patients, 25 showed AVA: 10 had a LHA from the LGA and 15(18%) had a replaced RHA(n=11)/CHA(n=4). These latter were compared with 68 with NVA. Operative time, blood loos and conversion rates were similar in both groups. Postoperative outcomes were similar, except for significantly lower rates of PPH in AVA patients. Moreover there was no difference in the rates of positive resection margins and number of harvested nodes (table 1). Conclusions: preoperative identification of AVA, SMA-first approach, early biliary division, and cranio-caudal-cranial approach can mitigate the added anatomical challenge, thus ensuring a safe and sound oncological MIPD.

Does Preoperative Acute Pancreatitis Inevitably Delay Pancreatoduodenectomy in Patients with Periampullary Tumors? An Experience in a High-Volume Center

Introduction: Preoperative acute pancreatitis (PAP) in patients with periampullary tumor can cause technical difficulties when performing pancreatoduodenectomy (PD) and may delay the timing of PD. Perioperative risks and optimal timing of subsequent PD remain unclear. Thus, the purpose of this study was to investigate the impact of PAP on surgical outcomes of periampullary tumors and determine the optimal timing of PD.

Efficacy of Opioid Spinal Analgesia for Postoperative Pain Management after Pancreatoduodenectomy

Background: Efficacy of opioid spinal analgesia for pain management after pancreatoduodenectomy remains understudied and lacks comparison to thoracic epidural analgesia (TEA). Methods: Pancreatoduodenectomy patients who underwent TEA or opioid spinal for postoperative pain management between May 2015 and June 2020 were included in this observational cohort study. Primary outcome was patient-reported daily pain scores. Secondary outcomes included postoperative morphine milligram equivalents (MMEs) and length of stay (LOS). Multivariable linear regression models were constructed to compare risk-adjusted outcomes between groups. Results: 180 patients were included: 56 (31%) TEA and 124 (69%) spinal. Compared to TEA patients, spinal patients were older (67.0 vs. 64.6, p = 0.045), had a greater body mass index (26.5 vs. 24.4, p = 0.02), and were less frequently smokers (19.4% vs. 41.1%, p = 0.002). Spinal, compared to TEA, was associated with lower intraoperative MMEs (0.25 vs. 22.7, p < 0.001) and postoperative daily MMEs (7.9 vs. 10.3, p = 0.03). Adjusted analyses demonstrated spinal patients had significantly lower pain scores on POD0 (3.4 vs. 5.9, p < 0.001) but greater pain scores on POD3 (4.2 vs. 3.2, p = 0.03) (Figure). There was no difference in average pain score across the entire postoperative period (spinal vs. epidural: 4.18 vs. 4.14, p=0.93), daily MMEs (p=0.50), or LOS (p=0.23). Conclusion: There was no overall difference in postoperative pain scores, opioid use, or LOS between TEA or spinal patients after pancreatoduodenectomy. Opioid spinal analgesia should be considered as part of multimodal analgesic regimens for patients undergoing pancreatoduodenectomy.

The Impact of Preoperative Biliary Stenting on Postoperative Pancreatic Fistula Rates

Introduction: Preoperative biliary stenting (PBS) prior to pancreatoduodenectomy (PD) remains controversial and has been associated with bile contamination, microbiome changes and increased risk of postoperative pancreatic fistula (POPF). This study evaluates the impact of PBS on the risk of clinically relevant (CR)-POPF after PD in a national cohort of patients. Methods: Patients with biliary obstruction (total bilirubin >1.2 mg/dl) that underwent elective PD were identified in the American College of Surgeons-NSQIP dataset (2014-2019). A validated modified Fistula Risk Score (FRS) was used to stratify this cohort into two groups (low FRS ≤6, high FRS >6). Within each group, patient factors, PBS use, CR-POPF and postoperative outcomes were analyzed. Multivariate regression model was used to assess factors associated with CR-POPF. Results: Out of 3864 patients that underwent PD, 3109 (80%) received PBS, 1579 (41%) had a high-FRS and 2285 (59%) had a low-FRS. The rate of CR-POPF was 15%, 24.5%, and 8.5% for the entire cohort, high-FRS and low-FRS groups, respectively. The rate of CR-POPF was similar with (15.1%) and without PBS (14.7%) In both low- and high-FRS groups, PBS was not associated with increased risk for CR-POPF (8.3% vs 9.2% and 25% vs 23%). However, in the low-FRS group, PBS was associated with a reduced LOS (OR 0.7, 95% CI=0.51-0.92, p=0.012) and increased infectious complications (OR 1.6, 95% CI=1.19-2.24, p=0.003). Conclusion: In this retrospective study of a national cohort of PD patients, PBS was not associated with an increased risk of CR-POPF in both low- and high-FRS groups.Tabled 1EP02D-062 Table 1. Multivariable Model*VariablesLow FRSHigh FRSOdds RatioCI (95%)P-ValueOdds RatioCI (95%)P-ValueCR-POPFPBS0.9420.652-1.3630.7531.2590.926-1.7120.142Prolonged LOSPBS0.6820.506-0.9190.0120.9160.659-1.2730.601Infectious ComplicationsPBS1.631.186-2.2410.0031.2170.889-1.6650.221*Adjusted for Mortality, CR-POPF, Prolonged (LOS >14 days), Discharge-not-to-home Open table in a new tab *Adjusted for Mortality, CR-POPF, Prolonged (LOS >14 days), Discharge-not-to-home

High-risk Pancreatic Anastomosis vs. Total Pancreatectomy after Pancreatoduodenectomy: Postoperative Outcomes and Quality of Life Analysis

Introduction: Outcomes of high-risk pancreatoduodenectomy (HR-PD) and TP have never been compared. We sought to evaluate total pancreatectomy (TP) as an alternative to pancreatoduodenectomy (PD) in patients at high-risk for postoperative pancreatic fistula (POPF). Methods: All patients who underwent PD or TP between July 2017 and December 2019 were identified. HR-PD was defined according to the alternative Fistula Risk Score. Postoperative outcomes (primary endpoint), pancreatic insufficiency and quality of life after 12 months of follow-up (QoL) were compared between HR-PD or planned PD intraoperatively converted to TP (C-TP). Results: A total of 566 patients underwent PD and 136 underwent TP during the study period. One hundred one (18%) PD patients underwent HR-PD, while 86 (63%) TP patients underwent C-TP. Postoperatively, the patients in the C-TP group exhibited lower rates of post-pancreatectomy hemorrhage (15% vs 28%), delayed gastric emptying (16% vs 34%), sepsis (10% vs 31%), and Clavien-Dindo ≥3 morbidity (19% vs 31%) and had shorter median lengths of hospital stay (10 vs 21 days) (all p< 0.05). The rate of POPF in the HR-PD group was 39%. Mortality was comparable between the two groups (3% vs 4%). Although general, cancer- and pancreas-specific QoL were comparable between the HR-PD and C-TP groups, endocrine and exocrine insufficiency occurred in all the C-TP patients, compared to only 13% and 63% of the HR-PD patients respectively, and C-TP patients had worse diabetes-specific QoL. Conclusions: C-TP may be considered rather than HR-PD only in few selected cases and after adequate counselling.Tabled 1CharacteristicsTotal, No. (%) (N= 187)HR-PD= 101C-TP= 86P-valuePostoperativePOPF, No. (%)39 (39)Abscess, No. (%)39 (21)28 (28)11 (13)0.01PPH, No. (%)41 (22)28 (28)13 (15)0.03DGE, No. (%)48 (26)34 (34)14 (16)<0.01Sepsis, No. (%)40 (21)31 (31)9 (10)<0.01LOS, median (range), days16 (5-289)21 (6-289)10 (5-62)<0.01Clavien-Dindo ≥3, No (%)47 (25)31 (31)16 (19)0.05Mortality, No. (%)7 (4)4 (4)3 (3)0.6 Open table in a new tab

Does Preoperative Acute Pancreatitis Inevitably Delay Pancreatoduodenectomy in Patients with Periampullary Tumors?

Simple SummaryAcute pancreatitis can occur preoperatively in patients with periampullary tumors and cause technical difficulties in performing pancreatoduodenectomy. The aim of this retrospective study was to investigate how preoperative acute pancreatitis would affect postoperative outcomes and to identify the optimal timing of surgery. There were more patients with operation failure (only exploration or unintended total pancreatectomy) in patients with pancreatitis, but no difference was found in rates of other complications. Moreover, when stratified by the timing of surgery, the surgical outcomes did not differ between the patients with and without pancreatitis. The results imply that in terms of surgical complications, pancreatoduodenectomy could be safely performed in patients with preoperative pancreatitis. Further research is necessary to identify safe conditions and proper timing of surgery for patients with preoperative pancreatitis.Preoperative acute pancreatitis (PAP) in patients with periampullary tumor can cause technical difficulties when performing pancreatoduodenectomy (PD) but perioperative risks of PAP remain unclear. The purpose of this study was to investigate the impact of PAP on surgical outcomes and determine the optimal timing of PD. Patients undergoing surgery for periampullary tumors between 2009 and 2018 were included. Simple random sampling (1:4) was performed to compare outcomes between the PAP group and the control group. Operative failure was defined as exploration-only or unwanted total pancreatectomy. The rate of operative failure was higher in the PAP group than in the control group (6.6% vs. 0%, p < 0.001). There was no significant difference in postoperative outcomes including complications or in-hospital mortality between the two groups. Surgical outcomes were compared after dividing PAP groups by intervals (2, 3, or 4 weeks) between the onset of PAP and surgery, and there were no differences between the groups. In conclusion, in spite of the increased risk of operation failure, PD could be performed in PAP patients at comparable rates of postoperative complications. Further study is needed to select patients with PAP in proper conditions for performing PD.

Outcomes comparison of Pancreato-Gastrostomy and Isolated Jejunal Loop Pancreato-Jejunostomy following Pancreato-Duodenectomy in patients with soft pancreas and at moderate-high risk for POPF: a retrospective multicenter experience-based analysis.

Following pancreatoduodenectomy (PD), the modality of pancreato-enteric continuity restoration may impact on postoperative pancreatic fistula (POPF) risk. The aim of this study is to compare, among patients with soft pancreas and at moderate/high risk for POPF, the outcomes of PD with Pancreato-Gastrostomy (PG), versus Isolated Jejunal Loop Pancreato-Jejunostomy (IJL-PJ). 193 patients with a Callery Fistula Risk Score (C-FRS) ≥ 3 operated at 3 HPB Units, two performing PG and one IJL-PJ as their preferred anastomotic technique following PD (2009-2019) were included in this study (PG = 123, IJL-PJ = 70). Primary outcomes were POPF, clinically relevant (cr-)postoperative pancreatic hemorrhage (cr-PPH), delayed gastric emptying (cr-DGE), and postoperative major complications and mortality. POPF, cr-PPH, and cr-DGE occurred in 21.8%, 17.6%, and 11.4% of patients, and did not differ significantly between PG (26%, 19.5%, and 10.6%, respectively) and IJL-PJ (17.1%, 14.3%, and 12.9%, respectively; all p > 0.05) patients. Major (Dindo ≥ 3) complication and mortality rates were 26.4% and 3.3%, respectively, and did not differ significantly between PG (29.3% and 3.8%) and IJL-PJ (21.4% and 2.9) patients (p > 0.05). A faster surgical drain and nasogastric tube removal matched a significantly shorter hospitalization among IJL-PJ patients (median LOS: 18days versus 25days among PG patients, p < 0.001). In conclusion, IJL-PJ and PG, when performed by surgeons specialized with the concerned anastomotic technique in patients with soft pancreas and moderate/high risk for POPF, have similar results in terms of perioperative mortality and postoperative complications both overall and specific for PD.

Early biliary complications after pancreatoduodenectomy

This study aimed to review latest investigations concerning early biliary complications following major pancreatic surgery. 127 original articles in English language were found via PubMed literature search using key words over the last 5 years. After application of exclusion criteria (full-text in English not available, duplicating paper, age of paper over 5 years) a total of 29 articles were included in this study. Herein we review epidemiology and classification of early biliary complications after pancreatoduodenectomy, current views on pathogenesis, prophylaxis, diagnostics and treatment of early biliary complications. In early postoperative course of pancreatoduodenectomy patients may develop transient jaundice, cholangitis, early biliary strictures and post-procedural bile leak. Frequency of these conditions range from 3 to 24% and depends on epidemiological features of population, statistics and combined conditions. A number of patient- and surgery-dependent risk factors have been described. Modern interventional radiology offers a wide range of procedures for diagnostics and treatment of early biliary complications after pancreatoduodenectomy which showed to be safe and effective when endoscopic manipulations are contraindicated due to high risk. Well-timed diagnosis and treatment allow to avoid severe early biliary complications, re-interventions and reoperations which provides a good prognosis and lowers medical and financial burden.

Abstracts of the Annual Congress 2021 23‐24 September 2021, virtual conference

COVID-19 has led to a reduction in beds for elective surgery requiring postoperative level 2 or 3 care such as those undergoing pancreatoduodenectomy (PD) [1]. A post-anaesthetic care unit (PACU) has been established to deliver level 2 care for up to 23 h in order to reduce the requirement for critical care services. The aim of this study is to identify factors associated with successful discharge from PACU to the ward after PD surgery. Methods We conducted a single-centre retrospective observational study that utilised a prospectively maintained database of patients undergoing PD from December 2019 to January 2020. Data regarding duration of postoperative respiratory, cardiovascular and renal support requirements, epidural status and comorbidity details were obtained. These were compared between PD alone, PD with vein resection, PD and visceral resection and PD with arterial resection. Patients were categorised as 'suitable for PACU' if they met all of the pre-specified criteria: (1) inotropic support for ≥ 20 h, (2) no respiratory support and (3) no renal support. Binomial logistic regression was used to determine the suitability for PACU using gender, age, body mass index (BMI), Charlson Comorbidity Index (CCI), epidural status, Surgical Outcome Risk Score (SORT) and length of operation as independent variables of interest. Results There were 175 patients, of which 86 (49%) were categorised as 'suitable for PACU' after PD. Suitability for PACU was more likely with shorter operating times (p < 0.001), but less likely for male patients (p = 0.003) and with epidural analgesia (p = 0.002). PD with venous resection patients had a longer period of postoperative inotropy compared with those without venous resection. Discussion The high incidence of patients requiring organ support beyond 23 h suggests that PACU admission for PD patients will require a modification of current practice. It may not be appropriate to admit PD with venous resection to PACU. Epidural analgesia may not be appropriate for patients going to PACU, but further investigations are required to determine optimal analgesic solutions [2].

Current Trends of types of pancreatoduodenectomy focusing on the role of robot assisted pancreatoduodenectomy

Pancreatoduodenectomy (PD) is the most challenging abdominal surgery. In spite of the popularization of laparoscopic procedures for most GI surgery, laparoscopic PD is not so widely spread. Recently, robotic PD has gained popularity due to many merits. So we investigated current trends of types of PD and the clinical role of robotic surgery. Between 2015 and 2020, a total of 1,263 PD was performed. 929 patients underwent open PD, and 334 underwent robotic PD. Demographics and surgical outcomes were analyzed according to the time period, and propensity score-matched (PSM) analysis was performed to evaluate complications and oncologic outcomes. Patients undergoing robotic PD were younger (63.7 vs. 65.2 years, p = 0.035); however, no significant difference was observed in sex (p = 0.152) and BMI (p = 0.742). Robotic PD patients were more likely to have the benign disease (30.2%) than those who received open surgery (13.7%). Robot PD has gradually increased from 6.3% to 71.6%. Operation time was longer in the robot group (338.8 vs. 296.5 minutes, p < 0.001); however, estimated blood loss did not significantly differ (473.5 vs. 429.2 mL, p = 0.335). Overall complication (18.6% vs. 17.9%, p = 0.843) and CR-POPF rates (9.9% vs. 8.4%, p = 0.478) were similar. The hospital stay was shorter in robot PD (10.9 days) than open PD (15.3 days). After PSM analysis, no significant difference of morbidity and survival outcome in cancer patients was observed. The number of robot PD has markedly increased in a relatively short time showing comparable morbidity/mortality and oncologic outcome. Considering better recovery and cosmetic outcomes, robot PD has become one of standard surgical methods in pancreatic surgery.

Robotic Resection and Reconstruction of the Superior Mesenteric Vein Without Graft During Pancreatoduodenectomy (with Video)

BackgroundPancreatoduodenectomy is the procedure of choice for tumors in the head of the pancreas. Invasion of major vessels is a relative contraindication for minimally invasive approach. We present a video of a robotic resection and reconstruction of the superior mesenteric vein (SMV) without the use of a graft during pancreatoduodenectomy. MethodsA 56-year-old female with ductal adenocarcinoma is referred for treatment. CT scan and endoscopic ultrasound showed a 3-cm tumor in the pancreatic head with contact with SMV. The multidisciplinary team decided for upfront surgery. Robotic superior mesenteric artery first approach was used to release the head of the pancreas, so the whole surgical specimen is only attached by the tumor invasion of the SM. After the partial resection of the SMV, its extension precluded lateral suture and a transverse anastomosis was necessary to minimize the risk of narrowing of the SMV. After completion of the venous anastomosis, reconstruction of the alimentary tract was done as usual. ResultsOperative time was 430 min. Time of clamping was 30 min and the time for the SMV suture is 23 min. Estimated blood loss was 370 mL. Pathology confirmed a T3N1 ductal adenocarcinoma with free margins. The patient was discharged on the 7th postoperative day. ConclusionsRobotic resection and reconstruction of the SMV is safe and feasible without graft during pancreatoduodenectomy in patients with invasion but not encasing of the portal vein or SMV. The proposed technique should be used in cases where the invasion requires extended resection that precludes simple lateral suture.

The impact of obesity and severe obesity on postoperative outcomes after pancreatoduodenectomy

BackgroundThe impact of obesity on postoperative outcomes after pancreatoduodenectomy remains insufficiently studied. MethodsAll pancreatoduodenectomy patients were abstracted from the 2014 to 2018 American College of Surgeons National Surgical Quality Improvement Program data sets and were stratified into the following 3 body mass index categories: non-obese (body mass index 18.5–29.9), class 1/2 obesity (body mass index 30–39.9), and class 3 severe obesity (body mass index ≥ 40). Analyses tested associations between patient factors and four 30-day postoperative outcomes: mortality, composite morbidity, delayed gastric emptying, and postoperative pancreatic fistula. Multivariable logistic regression models tested independent associations between patient factors and these 4 outcome measures. ResultsA total of 16,823 patients were included in the study: 12,234 (72.7%) non-obese, 4,030 (24%) obese, and 559 (3.3%) with severe obesity. Bivariable analyses demonstrated significant associations between obesity, severe obesity, and greater proportions of numerous preoperative comorbidities as well as a greater likelihood of postoperative complications, including postoperative pancreatic fistula, delayed gastric emptying, composite morbidity, and mortality (all P ≤ .001). After adjusting for significant covariates, obesity was independently associated with postoperative pancreatic fistula (odds ratio 1.49, 95% confidence interval: 1.33–1.67, P < .001), delayed gastric emptying (odds ratio 1.16, 95% confidence interval: 1.05–1.28, P = .004), composite morbidity (odds ratio 1.28, 95% confidence interval: 1.18–1.38, P < .001), and mortality (odds ratio 1.79, 95% confidence interval: 1.36–2.36, P < .001). ConclusionObesity and severe obesity are significantly associated with worse short-term outcomes after pancreatoduodenectomy. Preoperative considerations, such as weight management strategies during individualized treatment planning, could improve outcomes in this population.

Continuous suture is a risk factor for benign hepaticojejunostomy stenosis after pancreatoduodenectomy in patients with a non-dilated bile duct.

It is unclear whether hepaticojejunostomy with a continuous suture is suitable for patients with a non-dilated bile duct. Medical records of patients who underwent pancreatoduodenectomy between 2003 and 2013 were retrospectively reviewed, focusing on the incidence of benign anastomotic stenosis and its relationship with suture method (continuous vs interrupted) and common hepatic duct size. Among 336 patients, 172 had a non-dilated (<8mm) duct, and the remaining 164 had a dilated duct. Benign stenosis occurred in 12.2% (21/172) in the former, but in only 0.6% (1/164) in the latter (p<0.001; median follow-up period, 43.5 months). Thus, further analysis was conducted in the 172 patients with a non-dilated duct, among whom 116 received a continuous suture and 56 received an interrupted suture. The cumulative incidence of benign anastomotic stenosis was significantly higher in patients who received a continuous suture vs those who received an interrupted suture (15.6% vs 1.8%, respectively, at 3 years; p=0.006). Multivariable analysis identified continuous suture, male gender, and cholangitis (within 3 months after surgery) as independent risk factors for benign stenosis. In this observational study, the use of a continuous suture was associated with benign anastomotic stricture in patients with a non-dilated hepatic duct.

A simple preoperative stratification tool predicting the risk of postoperative pancreatic fistula after pancreatoduodenectomy

BackgroundPostoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) can be associated with severe postoperative morbidity. This study aims to develop a preoperative POPF risk calculator that can be easily implemented in clinical routine. MethodsPatients undergoing PD were identified from a prospectively-maintained database. A total of 11 preoperative baseline and CT-based radiological parameters were used in a binominal logistic regression model. Parameters remaining predictive for grade B/C POPF were entered into the risk calculator and diagnostic accuracy measures and ROC curves were calculated for a training and a test patient cohort. The risk calculator was transformed into a simple nomogram. ResultsA total of 242 patients undergoing PD in the period from 2012 to 2018 were included. CT-imaging-based maximum main pancreatic duct (MPD) diameter (p = 0.047), CT-imaging-based pancreatic gland diameter at the anticipated resection margin (p = 0.002) and gender (p = 0.058) were the parameters most predictive for grade B/C POPF. Based on these parameters, a risk calculator was developed to identify patients at high risk of developing grade B/C POPF. In a training cohort of PD patients this risk calculator was associated with an AUC of 0.808 (95%CI 0.726–0.874) and an AUC of 0.756 (95%CI 0.669-0-830) in the independent test cohort. A nomogram applicable as a visual risk scale for quick assessment of POPF grade B/C risk was developed. ConclusionThe preoperative POPF risk calculator provides a simple tool to stratify patients planned for PD according to the risk of developing postoperative grade B/C POPF. The nomogram visual risk scale can be easily integrated into clinical routine and may be a valuable model to select patients for POPF-preventive therapy or as a stratification tool for clinical trials.

Importance of Intestinal Environment and Cellular Plasticity of Islets in the Development of Postpancreatectomy Diabetes.

To elucidate the pathogenesis of postpancreatectomy diabetes mellitus (PPDM). Forty-eight patients without diabetes undergoing either pancreatoduodenectomy (PD) (n = 20) or distal pancreatectomy (DP) (n = 28) were included. A 75-g oral glucose tolerance test was performed every 6 months. Microbiome composition and short-chain fatty acids (SCFAs) in feces were examined before and 6 months after surgery. The association of histological characteristics of the resected pancreas with PPDM was examined. During follow-up (median 3.19 years), 2 of 20 PD patients and 16 of 28 DP patients developed PPDM. Proteobacteria relative abundance, plasma glucagon-like peptide 1 (GLP-1), and fecal butyrate levels increased only after PD. Postsurgical butyrate levels were correlated with postsurgical GLP-1 levels. With no significant difference in the volume of the resected pancreas between the surgical procedures, both β-cell and α-cell areas in the resected pancreas were significantly higher in DP patients than in PD patients. In DP patients, the progressors to diabetes showed preexisting insulin resistance compared with nonprogressors, and both increased α- and β-cell areas were predictors of PPDM. Furthermore, in DP patients, α-cell and β-cell areas were associated with ALDH1A3 expression in islets. We postulate that a greater removal of β-cells contributes to the development of PPDM after DP. Islet expansion along with preexisting insulin resistance is associated with high cellular plasticity, which may predict the development of PPDM after DP. In contrast, PD is associated with alterations of gut microbiome and increases in SCFA production and GLP-1 secretion, possibly protecting against PPDM development.

Limited resection vs. pancreaticoduodenectomy for primary duodenal adenocarcinoma: a systematic review and meta-analysis.

It is well known that surgery is the mainstay treatment for duodenal adenocarcinoma. However, the optimal extent of surgery is still under debate. We aimed to systematically review and perform a meta-analysis of limited resection (LR) and pancreatoduodenectomy for patients with duodenal adenocarcinoma. A systematic electronic database search of the literature was performed using PubMed and the Cochrane Library. All studies comparing LR and pancreatoduodenectomy for patients with duodenal adenocarcinoma were selected. Long-term overall survival was considered as the primary outcome, and perioperative morbidity and mortality as the secondary outcomes. Fifteen studies with a total of 3166 patients were analyzed; 995 and 1498 patients were treated with limited resection and pancreatoduodenectomy, respectively. Eight and 7 studies scored a low and intermediate risk of publication bias, respectively. The LR group had a more favorable result than the pancreatoduodenectomy group in overall morbidity (odd ratio [OR]: 0.33, 95% confidence interval [CI] 0.17-0.65) and postoperative pancreatic fistula (OR: 0.13, 95% CI 0.04-0.43). Mortality (OR: 0.96, 95% CI 0.70-1.33) and overall survival (OR: 0.61, 95% CI 0.33-1.13) were not significantly different between the two groups, although comparison of the two groups stratified by prognostic factors, such as T categories, was not possible due to a lack of detailed data. LR showed long-term outcomes equivalent to those of pancreatoduodenectomy, while the perioperative morbidity rates were lower. LR could be an option for selected duodenal adenocarcinoma patients with appropriate location or depth of invasion, although further studies are required.