Postoperative Pancreatic Fistula Rate Research Articles

Laparoscopic and Open Distal Pancreatectomy—An Initial Single-Institution Experience with a Propensity Score Matching Analysis

Laparoscopic distal pancreatectomy is a minimally invasive approach for the surgical treatment of neoplasms in the distal pancreas. This study aimed to compare this approach to the open procedure. A retrospective analysis of a prospectively maintained database of 400 pancreatectomies was performed. The laparoscopic distal pancreatectomy group (LDP) was compared to the open distal pancreatectomy group (ODP). A propensity score matching analysis (PSM) was performed. From 2016 to 2023, 108 distal pancreatectomies were carried out, 19 (17.6%) laparoscopically and 89 (82.4%) openly. The conversion rate was 13.6%. The severe morbidity rates were 28.1% in the ODP group, 47.4% in the LDP group, and 15.8% in the ODP-PSM group. The difference between the latter two was statistically significant (p = 0.034) due to the high rate of Clavien–Dindo grade 3a complications (42.1% versus 10.5%, p = 0.042) in the LDP group. The 90-day mortality rates were 3.3% in the ODP group and 5.3% in the other two groups. The LDP group had a shorter duration of intravenous narcotic analgesia (5 versus 7 days, p = 0.041). There was no difference in the R0 resection or postoperative pancreatic fistula rates. Our attention should be drawn to preventing postoperative complications because the oncological outcomes are already comparable with those of the open procedure, and postoperative pain management is promising.

Efficacy of Neoadjuvant Radiotherapy After Chemotherapy and the Optimal Interval from Radiotherapy to Surgery for Borderline Resectable and Resectable Pancreatic Cancer.

Benefits of neoadjuvant treatment for pancreatic cancer with major vessel invasion has been demonstrated through randomized controlled trials; however, the optimal neoadjuvant treatment strategy remains controversial, especially for radiotherapy. Therefore, we aimed to evaluate the efficacy and safety of neoadjuvant radiotherapy followed by chemotherapy and the optimal time interval to undergo surgery after radiotherapy in (borderline) resectable pancreatic cancer. Between 2013 and 2022, patients with (borderline) resectable pancreatic cancer with vessel contact who received 5-fluorouracil with leucovorin, oxaliplatin, and irinotecan or gemcitabine and nanoparticle albumin-bound paclitaxel as initial treatment following surgery were included. Patients who received radiotherapy after chemotherapy and those who did not were matched using 1:1 nearest-neighbor propensity scores. Propensity scores were measured using the tumor size at initial image, duration of neoadjuvant chemotherapy, and responsiveness to neoadjuvant chemotherapy. Of 212 patients, 166 patients were retrieved for the matched cohort. Patients who received radiotherapy had significantly better postoperative survival, local control, and R0 resection rates than those who did not. Furthermore, patients who underwent surgery within 4 weeks after completing radiotherapy had lower intraoperative blood loss and a clinically relevant postoperative pancreatic fistula rate than those who underwent surgery after more than 4 weeks. In patients with (borderline) resectable pancreatic cancer with vessel contact who were scheduled for curative-intent surgery after neoadjuvant chemotherapy, additional radiotherapy was associated with better postoperative survival and local control. Furthermore, our findings suggested that scheduling surgery within 4 weeks following radiation therapy might enhance the perioperative outcomes.

Adaptation of antibiotics and antifungal strategy to preoperative biliary drainage to improve postoperative outcomes after pancreatic head resection.

Biliary contamination significantly correlates with major comorbidities during pancreatic head resection. Recently, a piperacillin-tazobactam prophylaxis demonstrated a lower rate of infectious complications (IC) and postoperative pancreatic fistula (POPF) in this population. However, bacterial contamination is rare in patients without a preoperative biliary drainage (PBD) and probably could not benefit from this antibiotic. Furthermore, little is known about the role of biliary fungal contamination. All retrospective cases undergoing pancreatic head resection with intraoperative biliary sample were included. Postoperative outcomes of patients with a piperacillin-tazobactam-based treatment were compared to cases in which a narrow-spectrum antibiotic was administrated, stratified according to the use of a PBD. The same analysis was repeated for antifungal treatment administration. Among the 205 cases included, PBD was necessary in 127 patients (62%). Broad-spectrum treatment was associated with fewer overall and clinically relevant POPF (p=0.001 and p=0.004), overall morbidity (p=0.044), and overall IC (p=0.018), but only in the PBD group. Similarly, antifungal treatment was significantly associated with some specific IC only in the PBD group. At multivariable analysis, antifungal therapy in the whole cohort (p=0.029) and the use of a piperacillin-tazobactam (p=0.007) treatment in patients with a PBD were independently associated with a reduced risk of a clinically relevant POPF. A broad-spectrum antibiotic therapy reduces overall morbidity after pancreatic head resection, but only in cases with a history of PBD. Furthermore, the use of an antifungal prophylaxis or therapy should be further investigated in these patients because it may reduce the risk of some IC.

Middle segment preserving pancreatectomy versus total pancreatectomy: a comparative analysis of short- and long-term outcomes.

Middle-segment preserving pancreatectomy (MSPP) serves as an alternative to total pancreatectomy (TP) for preserving the pancreatic body in multifocal pancreatic neoplasms. Despite the potential benefits of TP, the detailed short- and long-term prognoses remain unclear. We evaluated the feasibility of MSPP by comparing the perioperative outcomes and postoperative endocrine and exocrine functions with those of TP. The study included 10 TP and 7 MSPP patients. Patients with pancreatic ductal adenocarcinoma and invasive intraductal papillary mucinous carcinoma were excluded. MSPP was associated with a high incidence (57.1%) of postoperative pancreatic fistula (POPF); however, there were no cases of post-pancreatectomy hemorrhage or postoperative mortality in any group. The postoperative hospital stay and readmission rates were comparable between the groups. At 1year postoperatively, MSPP reduced the risk of new-onset insulin-dependent diabetes mellitus, maintained good glycemic control with minimal hypoglycemic events, and preserved skeletal muscle, subcutaneous fat, and visceral fat. One patient in the MSPP group with a neuroendocrine tumor had postoperative recurrence in the para-aortic lymph node. Despite the high POPF rate and oncologic limitations, MSPP showed superior long-term outcomes in glycemic control and preservation of body composition. MSPP may be an acceptable treatment option for selected patients.

Impact of soft pancreas on pancreaticoduodenectomy outcomes and the development of the preoperative soft pancreas risk score.

Pancreatic texture is difficult to predict without palpation. Soft pancreatic texture is associated with increased post-operative complications, including postoperative pancreatic fistula (POPF), cardiac, and respiratory complications. We aimed to develop a calculator predicting pancreatic texture using patient factors and to illustrate complications from soft pancreatic texture following pancreaticoduodenectomy. Data was collected from the 2016 to 2021 American College of Surgeons National Surgical Quality Improvement database including 17,706 pancreaticoduodenectomy cases. Patients were categorized into two cohorts based on pancreatic texture (9,686 hard, 8,020 soft). Multivariable modeling assessed the impact of patient factors on complications, mortality, and pancreatic texture. These preoperative factors were integrated into a risk calculator (preoperative soft pancreas risk score [PSPRS]) that predicts pancreatic texture. Patients with a soft pancreas had higher rates of postoperative complications compared to those with a hard pancreas (56.5% vs 42.2%; p < 0.001), particularly a threefold increase in POPF rate, and at least a twofold increase in rates of acute kidney injury, deep organ space infection, septic shock, and prolonged length of stay. Female sex (odds ratio [OR]: 1.14, confidence interval [CI]: 1.06-1.22, p < 0.001) and higher body mass index (OR: 1.12, CI: 1.09-1.16, p < 0.001) were independently associated with a soft pancreas. PSPRS ≥6 correctly identified >40% of patients preoperatively as having a hard pancreas (68.9% specificity). A soft pancreas was independently associated with serious postoperative complications. Our results were integrated into a risk calculator predicting pancreatic texture from preoperative patient factors, potentially enhancing preoperative counseling and surgical decision-making.

Effect of Transpancreatic Mattress Suture With Polyglycolic Acid Sheet in Pancreatic Stump Closure for the Prevention of Postoperative Pancreatic Fistula in Robotic Distal Pancreatectomy.

Pancreatic stump closure in minimally invasive distal pancreatectomy (DP) commonly utilizes staplers due to its simplicity; however, postoperative pancreatic fistula (POPF) remains the most frequent complication. We have developed a novel stump closure technique using a transpancreatic mattress suture with a polyglycolic acid sheet (TP method) under robotic DP. This study aims to evaluate the efficacy of the TP method. This study included 145 cases of pure minimally invasive DP performed between February 2011 and July 2024: 34 robotic (R) and 97 laparoscopic (Lap). Surgical outcomes were compared across 3 groups based on the stump closure method: 18 cases using the TP method (TP group; R: 18), 22 with hand-sewn closure in a fish-mouth manner (FM group; Lap: 22), and 91 with a reinforced stapler (S group; R: 16, Lap: 75). Logistic regression analysis was employed to identify risk factors for POPF. POPF occurred in 20 of 131 cases (grade B: 19, C: 1, 15.3%). The TP group exhibited the lowest POPF rate (TP vs FM vs S: 5.6% vs 27.3% vs 14.3%). Multivariate analysis identified pancreatic thickness ≥12mm as an independent risk factor. For thickness <12mm, no significant differences in POPF rates were observed (TP vs FM vs S: 0% vs 25.0% vs 5.6%). However, for thickness ≥12mm, the TP group had a significantly lower POPF rate compared with the S group (TP vs FM vs S: 7.7% vs 28.6% vs 47.4%). The TP method is superior to stapler closure in preventing POPF, especially in cases with pancreatic thickness of ≥12mm.

Competency, Proficiency, and Mastery: Learning Curves for Robotic Distal Pancreatectomy at 16 International Expert Centers.

The aim of this study was to evaluate the different phases of the learning curve for robotic distal pancreatectomy (RDP) in international expert centers. RDP is an emerging minimally invasive approach; however, only limited, mostly single center data are available on its safe implementation, including the learning curve. Consecutive patients undergoing elective RDP from 16 expert centers across three continents were included to assess the learning curve. Based on the first 100 RDPs at each center, three cutoffs were used to define the learning curve: operative time for competency, major complications (Clavien-Dindo grade ≥III) for proficiency, and textbook outcome for mastery. Clinical outcomes before and after the cutoffs were compared. The learning curve analysis was conducted on 1109 of 2403 RDPs. Competency, proficiency, and mastery, respectively, were reached after 46, 63, and 73 RDP procedures. After competency, operative time decreased from 245 to 235 minutes (P=0.002). Attaining proficiency was reflected by a reduction in the rate of major complications from 20% to 15% (P=0.012), and mastery was associated with a higher proportion of patients with textbook outcome (71% vs. 63%; P=0.028). The postoperative pancreatic fistula rate remained stable along the learning curve, ranging between 18.5% and 21.5%. Previous laparoscopic experience accelerated the learning process by virtue of reduced operative time and an earlier decrease in major complications. Competency, proficiency, and mastery for RDP were reached after 46, 63, and 73 procedures, respectively, at international expert centers. The findings highlight that the learning curves for intraoperative parameters are completed earlier; however, extensive experience is needed to master RDP.

HPB SO78 - A Novel Application of ISGPS Guidelines for Calculating Pancreatic Fistula Rates Post-Distal Pancreatectomy

Abstract Background Post-operative pancreatic fistula (POPF) remains a major cause of morbidity and mortality following distal pancreatectomy and there is continual debate regarding the optimal peri-operative practice. The impact of drain displacement on outcome is poorly understood and limited information is documented on how the ISGPS guidelines are used to determine a clinically significant POPF. This study aims to assess the POPF and drain displacement rate at our institution and identify factors predicting a clinically significant POPF. We have proposed an algorithm to standardise the interpretation of the ISGPS guidelines. Method Case records of patients undergoing left sided pancreatectomy at our institution from January 2019 to January 2024 were analysed to assess the incidence of biochemical and clinically significant POPF using ISGPS criteria. Post operative CT scans were reviewed to record drain displacement with respect to the pancreatic stump. Continuous data was represented as mean +/- SD or median(IQR) depending on normality. Appropriate statistical tests were used for comparison of continuous and categorical variables (alfa error of 5%). Receiver operating characteristic curves were performed to assess the suitability of drain fluid amylase level as a predictor of clinically significant POPF. Results A total of 56 patients qualified for analysis. There was no difference between the clinically insignificant and significant groups with respect to age, gender, BMI, pathology and surgical technique (open/laparoscopic, splenic preservation, stump reinforcement). The clinically significant group had higher day three and peak drain amylase levels. The day of peak drain amylase was significantly later in this group. The drain displacement rate was 41% and did not differ significantly between the two groups. A day 3 drain fluid amylase level of 1120(U/L) had a 74% sensitivity of predicting a clinically significant POPF. Conclusion The ISGPS guidelines do not provide explicit criteria for stratifying the grade of POPF. We propose an algorithm to standardise the interpretation of these guidelines. Drain displacement did not impact POPF rate allowing for small sample size. Day 3 fluid amylase level is a useful predictor of clinically significant POPF. Program permission yes

Comparative Assessment of Outcomes: Abdominal Drain vs. No Abdominal Drain after Left Pancreatectomy-A Systematic Review and Meta-Analysis.

This systematic review and meta-analysis aimed to compare outcomes between abdominal drain placement and no drain placement post-pancreatectomy. Left pancreatectomy (LP) is a surgical procedure commonly employed for various pancreatic conditions, often associated with postoperative complications like post-operative pancreatic fistula (POPF). While routine abdominal drainage following LP has been standard practice, recent evidence suggests potential benefits of omitting this approach. A comprehensive search was conducted on PubMed, Cochrane, and Embase from inception up to 15 March 2024, yielding nine studies comprising 15,817 patients. Data were extracted from randomized and non-randomized studies reporting primary and secondary outcomes. The analysis was performed in Revman. Risk ratios were calculated with 95% confidence intervals, and a P-value of <0.05 was considered statistically significant. A total of 13,081 patients underwent drain placement after left pancreatectomy, and 2,736 patients were included in the no-drain group. Out of the total, 45.1% (n=7140) patients were male, with 45.9% (n=6012) males in the drain group and 41.2% (n=1128) males in the no-drain group. Major morbidity, defined as Clavien-Dindo grade ≥III complications, was significantly lower in the no-drain group (relative risk [RR]: 0.77, 95% confidence interval [CI]: 0.64-0.93, P=0.006). Similarly, lower rates of postoperative pancreatic fistula (POPF) (RR: 0.51, 95% CI: 0.38-0.67, P<0.00001), readmission (RR: 0.75, 95% CI: 0.59-0.96, P=0.02), and surgical site infections (RR: 0.82, 95% CI: 0.70-0.95, P=0.009) were observed in the no-drain group. Additionally, a shorter length of hospital stay was noted in this group (mean difference MD: -1.65, 95% CI: -2.50 to -0.81, P=0.0001). Omitting routine drainage after left pancreatectomy is associated with reduced complications and shorter hospital stays, supporting its potential benefits in improving postoperative outcomes.

Analysis of Factors Determining Spleen Preservation during Laparoscopic Distal Pancreatectomy - A Cohort Study.

Spleen preservation during laparoscopic distal pancreatectomy (LSPDP) should be pursued if safe and oncologically justified. The aim of the presented study was to compare surgical outcomes and identify risk factors for unplanned splenectomy during laparoscopic distal pancreatectomy and evaluate short and long-terms outcomes. The following study is a retrospective cohort study of consecutive patients who underwent laparoscopic distal pancreatectomy, with the intention of preserving the spleen, for benign tumors of the body and tail of the pancreas between August 2012 and December 2022. Follow-up for patients' survival was completed in January 2023. In all, 106 patients were in total included in this study. Median age was 58 (41 to 67) years. The study population included 29 males (27.4%) and 77 females (72.6%). Spleen preservation was possible in 67 (63.2%) patients. The tumor size was larger in the splenectomy group (respectively, 30 (16.5 to 49) vs. 15 (11 to 25); P <0.001). Overall, serious postoperative morbidity was 13.4% in the LSPDP group and 20.5% in the second group ( P =0.494). There were no perioperative deaths. The postoperative pancreatic fistula rate was 18% in the splenectomy group and 14.9% in the LSPDP group, while B and C fistulas were diagnosed in 15.4% and 10.5% of patients, respectively. In the multivariate logistic regression model, tumor size >3 cm was found to independently increase odds for unplanned splenectomy (OR 8.41, 95%CI 2.89-24.46; standardized for BMI). Unplanned splenectomy during the attempt of LSPDP does not increase the risk for postoperative morbidity and postoperative pancreatic fistula. The independent risk factor for unplanned splenectomy during LSPDP is tumor size above 3cm.

Development and validation of a novel pancreaticojejunostomy strategy based on the anatomical location of the main pancreatic duct that can reduce the risk of postoperative pancreatic fistula after pancreatoduodenectomy.

Postoperative pancreatic fistula (POPF) is a common complication after pancreaticoduodenectomy (PD). The effect of the location of the main pancreatic duct on POPF development is not completely elucidated. This study aimed to investigate the association between the location of the main pancreatic duct and POPF, and the effect of pancreaticojejunostomy based on the location of the main pancreatic duct on the risk of POPF. This retrospective study enrolled 871 patients who underwent PD between January 2018 and December 2021. Logistic regression analysis was performed to identify the independent risk factors associated with POPF. Predictive performance was evaluated using the receiver operating characteristic curves. In addition, a novel pancreaticojejunostomy strategy that could reduce the risk of POPF was adopted. Based on the multivariate analysis, the pancreatic texture and the location of the main pancreatic duct were the independent risk factors of POPF. A threshold ratio of 0.397 was used to distinguish the central from the eccentric pancreatic ducts. Notably, patients with the central pancreatic duct had a significantly lower incidence rate of POPF than those with the eccentric pancreatic ducts (10.6% vs. 44.8%, P<0.001). The novel group exhibited a significantly lower incidence rate of POPF than the conventional group (13.7% vs. 23.0%, P=0.02), and the incidence rate of other complications was not high. The location of the main pancreatic duct is associated with POPF development. However, implementing the novel pancreaticojejunostomy approach can effectively reduce the risk of POPF while ensuring safety.

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

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

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

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

Prospective Validation of the Pancreatic Fistula Risk Classification by the International Study Group for Pancreatic Surgery (PARIS trial).

The aim of this study was a prospective validation of the recently established ISGPS pancreas classification as a parenchymal risk classification system for pancreatic fistula after pancreatoduodenectomy. Postoperative pancreatic fistula (POPF) is the major driver for complications after partial pancreatoduodenectomy (PD). Recently, the International Study Group for Pancreatic Surgery (ISGPS) published a pancreas classification containing the parameters main pancreatic duct diameter (MPD) and pancreatic texture to help assess the risk of POPF development following pancreatoduodenectomy. From January 2020 to July 2021, 271 patients receiving elective PD were included after informed consent. The postoperative course was documented prospectively up to postoperative day 30. Among the pancreas characteristics, MPD and pancreatic texture were assessed intraoperatively at the pancreatic resection margin and the pancreatic glands were assigned to one of the four pancreas classes according to the ISGPS (A to D). The primary endpoint was POPF according to the updated ISGPS definition. Secondary endpoints comprised other post-PD morbidity and mortality. Of 271 patients, 264 had available data according to the ISGPS pancreas classification. Of those, 78 were assigned to class A (30%), 53 to class B (20%), 50 to class C (19%) and 83 to class D (31%). POPF occurred in 54 of 271 patients (19.9%). The 30-day mortality was 7/271 (2.6%), with 6/7 having developed POPF (86%). POPF rates within the classes A, B, C and D were 9.0%, 11.3%, 20.0% and 37.4%, respectively (P<0.001). In the univariable regression analysis, only patients in pancreas class D demonstrated a significantly higher risk for POPF when compared to class A (OR 6.05, 95%-CI: 2.6-15.9, P<0.001). In the multivariable regression model, patients in class D had a significantly higher risk for POPF compared to class A (OR 3.45, 95%-CI: 1.15-11.3, P=0.032). The model comprised Body Mass Index, surgery duration, microscopic fibrosis and the ISGPS pancreas classification, demonstrating an AUC-value of approximately 0.82 when tested on the PARIS dataset. This prospective trial shows that the ISGPS pancreas classification is valid. Patients in risk class D are prone to POPF independently of other factors. Therefore, all future publications on pancreatic surgery should report the risk class according to the ISGPS pancreas classification to allow for a better comparison of reported cohorts.

Intraoperative intraductal ultrasonography of the main pancreatic duct during pancreatoduodenectomy: technical description of a pilot series.

The intraoperative risk stratification during pancreatoduodenectomy is gaining increasing significance. The main pancreatic duct wall is of particular importance as it represents the element of anchor of the anastomotic stiches. This study aims to describe the safety, feasibility, and reproducibility of a novel intraductal ultrasonography of the main pancreatic (MPD)-Wirsung duct (IWU) during pancreatoduodenectomy (PD).A prospective series of 58 patients underwent PD with anastomosis between the MPD and the jejunum. Just before the reconstructive phase, the remaining pancreatic stump underwent complete IWU with definition of Wirsung thickness (WT) at the anastomotic site, using a radial ultrasound probe of 1.7mm in diameter.No IWU-related complications were reported. The median WT of the MPD was 1.1mm (SD 0.2). The rates of postoperative pancreatic fistula (POPF), major morbidity, and mortality were 17, 5, and 0%, respectively.The use of IWU during PD demonstrated safety and feasibility. IWU represents a new tool aimed at determining structural characteristics of the MPD that could impact on the surgical strategy of the pancreatic anastomosis. Further validation and comparative analysis with the current standard of care are warranted within a prospective controlled framework.

Reduction of Postoperative Complications in Pancreatic Surgery by Standardizing Perioperative Management: An Observational Cohort Study

Introduction: Resection for pancreatic malignancy remains the gold standard for cure. Postoperative morbidity continues to be high even after technical innovations. This study evaluates the effectiveness of a standard perioperative pancreatic oncological surgery step-by-step protocol in reducing organ-specific complications. Methods: In this observational cohort study, we analyzed the outcomes of oncologic pancreatic head resections from 2015 to 2022 after the implementation of a standard perioperative fail-safe protocol and compared these data with a historical cohort (2013–2014). In the study group, all patients were treated with preoperative limited mechanical bowel preparation, administration of a somatostatin analog, and a “pancreatic duct tube” in pancreatoduodenectomy. The primary outcome measure was the occurrence of postoperative organ-specific complications. Results: A total of 151 patients were included in this study. The rate of postoperative pancreatic fistula (grade B and C) in the fail-safe group was 4.2%. Other organ-specific complications as postoperative hemorrhage (2.5%) and delayed gastric emptying (9.2%) also occurred less frequent than before implementation of the fail-safe protocol. Conclusion: The use of this standardized fail-safe protocol for oncologic pancreatoduodenectomy can lead to a low postoperative morbidity with improved surgical outcomes.

Perioperative efficacy of laparoscopic duodenal-preserving pancreatic head resection

Objective: To compare the perioperative outcomes of laparoscopic duodenal-preserving pancreatic head resection(LDPPHR) with laparoscopic pancreaticoduodenectomy(LPD) in the treatment of borderline and benign diseases of the pancreatic head. Methods: This is a retrospective cohort study. Perioperative data from 87 patients with non-malignant pancreatic head diseases who underwent LDPPHR or LPD were retrospectively collected in the Department of Biliary-Pancreatic Surgery,Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology from January 2020 to December 2022. There were 49 male and 38 female patients with an age (M(IQR)) of 57.0(16.5) years (range: 20 to 75 years). Forty patients underwent LDPPHR and 47 patients underwent LPD. Quantitative data following a normal distribution were compared using Student's t-test, while quantitative data not following a normal distribution were compared using the Mann-Whitney U test. Comparisons of categorical or ordinal variables were made using χ2 test or Fisher's exact test. Logistic regression analysis was used to estimate the risk factors associated with the rate of complications. Results: There were no statistically significant differences between the LDPPHR group and the LPD group in terms of reoperation rate,total hospital stay duration,postoperative hospital stay duration,90-day mortality rate,30-day and 90-day readmission rates,and 2-year tumor recurrence rate (all P>0.05). The complication rate was higher in the LDPPHR group compared to the LPD group (80.0%(32/40) vs. 51.1%(24/47), χ2=7.89,P=0.005),but there was no difference in the rate of Clavien-Dindo classification of surgical complications ≥Ⅲ between the two groups (10.0%(4/40) vs. 12.8%(6/47), χ2<0.01, P=0.947). Additionally,the rate of delayed gastric emptying (DGE) was higher in the LDPPHR group compared to the LPD group (χ2=10.79,P=0.001),but there was no statistically significant difference in the rate of B,C grade DGE between the two groups (χ2=0.48, P=0.487). There were no statistically significant differences in the rates of postoperative pancreatic fistula,bile leakage,post-pancreatectomy hemorrhage,intra-abdominal infection,and pulmonary infection between the two groups (all P>0.05). The results of the univariate logistic regression analysis showed that LDPPHR (compared to LPD, OR=3.83, 95%CI: 1.46 to 10.04, Z=2.73,P=0.006) and preoperative biliary stent placement (compared to non-use of biliary stent, OR=5.30, 95%CI: 1.13 to 25.00, Z=2.11, P=0.035) were risk factors for the complication rate,but neither was an independent risk factor for complication rate (all P>0.05). Conclusion: The preliminary results suggest that LDPPHR can achieve perioperative safety and effectiveness comparable to LPD.

Clinical Outcomes of Surgery after Neoadjuvant Chemotherapy in Locally Advanced Pancreatic Ductal Adenocarcinoma.

Clinical outcomes of surgery after neoadjuvant chemotherapy have not been investigated for locally advanced pancreatic cancer (LAPC), despite well-established outcomes in borderline resectable pancreatic cancer (BRPC). This study aimed to investigate the clinical outcomes of patients with LAPC who underwent curative resection following neoadjuvant chemotherapy. We retrospectively reviewed the records of patients diagnosed with pancreatic adenocarcinoma between January 2017 and December 2020. Among 1,358 patients, 260 underwent surgery following neoadjuvant chemotherapy. Among 356 LAPC patients, 98 (27.5%) and 147 (35.1%) of 418 BRPC patients underwent surgery after neoadjuvant chemotherapy. Compared to resectable pancreatic cancer (resectable PC) with upfront surgery, both LAPC and BRPC exhibited higher rates of venous resection (28.6% vs. 49.0% vs. 4.0%), arterial resection (30.6% vs. 6.8% vs. 0.5%) and greater estimated blood loss (260.5 vs. 213.1 vs. 70.4 mL). However, hospital stay, readmission rates, and postoperative pancreatic fistula rates (grade B or C) did not differ significantly between LAPC, BRPC, and resectable PC. Overall and relapse-free survival did not differ significantly between LAPC and BRPC patients. The median overall survival was 37.3 months for LAPC and 37.0 months for BRPC. The median relapse-free survival was 22.7 months for LAPC and 26.0 months for BRPC. Overall survival time and postoperative complications in LAPC patients who underwent curative resection following neoadjuvant chemotherapy showed similar results to those of BRPC patients. Further research is needed to identify specific sub-populations of LAPC patients who benefit most from conversion surgery and to minimize postoperative complications.

Reappraisal of the Parenchyma-Sparing Resections for Pancreatic Neuroendocrine Tumors: A Chinese High-volume Center Experience

Background: Parenchyma-sparing resections (PSRs) are increasingly used for small pancreatic neuroendocrine neoplasms (PNENs) to preserve the function of the gland. However, the data are extremely limited due to the rarity of this tumor. Aims: This study sought to describe the indications, operative technique, short and long-term outcomes of PSRs for PNENs, with a focus on postoperative pancreatic fistula (POPF) and oncologic outcomes. Methods: From 2008 to 2018, data collected retrospectively from 113 PNENs that underwent PSRs (113/421, 27%) were reviewed. A comparison was conducted of PSRs of PNENs without (group1, n=101) or with pancreatic transection (group 2, n=12). Results: Of the 113 patients, the most common indication for PSRs was insulinoma (80%), followed by NF-PNEN (20%). The majority of lesions were WHO G1 grade (80/113, 71%). The mean maximum diameter of the tumors was 19 mm. Patients who underwent PSRs had a low rate of severe postoperative morbidity (7/113, 6%). Pancreatic endocrine and exocrine insufficiency occurred in only 1% and 7% of patients respectively. And there was no evidence of tumor recurrence after PSRs detected during follow-up. Age was identified as the only independent positive risk factor of POPF in group 1. Patients in group 2 had significantly higher rates of POPF (p=0.002), overall morbidity (p=0.002), severe morbidity (p=0.026) and readmission (p=0.004). Conclusions: PSRs of PNENs appear to be feasible and safe, preserving the endocrine and exocrine function of the gland with no increased risk of recurrence or metastasis. In contrast, PSRs involving transection of the pancreas should be performed more cautiously.

Incidence of clinically relevant postoperative pancreatic fistula in patients undergoing open and minimally invasive pancreatoduodenectomy: a population-based study.

Postoperative pancreatic fistula (POPF) remains a devastating complication of pancreatoduodenectomy (PD). Minimally invasive PD (MIPD), including laparoscopic (LPD) and robotic (RPD) approaches, have comparable POPF rates to open PD (OPD). However, we hypothesize that the likelihood of having a more severe POPF, as defined as clinically relevant POPF (CR-POPF), would be higher in an MIPD relative to OPD. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) targeted pancreatectomy dataset (2014-2020) was reviewed for any POPF after OPD. Propensity score matching (PSM) compared MIPD to OPD, and then RPD to LPD. Among 3,083 patients who developed a POPF, 2,843 (92.2%) underwent OPD and 240 (7.8%) MIPD; of these, 25.0% were LPD (n = 60) and 75.0% RPD (n = 180). Grade B POPF was observed in 45.4% (n = 1,400), and grade C in 6.0% (n = 185). After PSM, MIPD patients had higher rates of CR-POPF (47.3% OPD vs. 54.4% MIPD, p = 0.037), as well as higher reoperation (9.1% vs. 15.3%, p = 0.006), delayed gastric emptying (29.2% vs. 35.8%, p = 0.041), and readmission rates (28.2% vs. 35.1%, p = 0.032). However, CR-POPF rates were comparable between LPD and RPD (56.8% vs. 49.3%, p = 0.408). The impact of POPF is more clinically pronounced after MIPD than OPD with a more complex postoperative course. The difference appears to be attributed to the minimally invasive environment itself as no difference was noted between LPD and RPD. A clear biological explanation of this clinical observation remains missing. Further studies are warranted.