Postoperative Pancreatic Fistula Research Articles

Predictors of post-operative pancreatic fistula after pancreaticoduodenectomy: systematic review and meta-analysis protocol

Abstract Pancreaticoduodenectomy is the standard treatment for resectable pancreatic head and periampullary cancers. Despite advancements, post-operative pancreatic fistula (POPF) remains a significant complication. The pathophysiology of POPF is multifactorial, involving patient-related factors, surgical technique, and postoperative management. Identifying reliable predictors for POPF is crucial for risk stratification and improving patient outcomes. This study aims to systematically review the literature and perform a meta-analysis to identify the most consistent and significant predictors of POPF following pancreaticoduodenectomy. The objectives are to evaluate preoperative, intraoperative, and postoperative factors and determine their relative importance and strength of association with POPF. This systematic review and meta-analysis will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and is registered with PROSPERO. The systematic review and meta-analysis will also follow the Population, Intervention, Comparators and Outcomes framework. A comprehensive literature search will be conducted across PUBMED, SCOPUS, and the Cochrane Library. Studies will be selected based on inclusion criteria, and data will be extracted and assessed for quality using standardized tools. Meta-analysis will be performed using a random-effects model, and the confidence in cumulative evidence will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach.

Proposal of a revised 3-tier "2mm" risk classification model for postoperative pancreatic fistula in robotic pancreatoduodenectomy.

The recent International Study Group for Pancreatic Surgery (ISGPS) risk classification for postoperativepancreatic fistula (grade B/C) was developed based on data from open and mixed minimally invasive pancreatoduodenectomy. The ISGPS risk classification model has not been validated specifically for POPF after robotic pancreatoduodenectomy (RPD). We calculated the rate of POPF (ISGPS 2016 definition, grade B/C) by analyzing consecutive patients after RPD by surgeons after their learning curves (80 RPDs per surgeon). The validation of the ISGPS 4-tier and the simplified 3-tier risk classification was conducted using the area under the receiver operating curve (AUC). From 2019 to 2023, 187 patients after RPD were included. Neither the ISGPS 4-tier nor the simplified 3-tier classification model showed robust discrimination (AUC: 0.696 and 0.685, respectively). Moreover, both risk classifications failed to differentiate the rates of POPF and major complications among subgroups. Multivariate analysis suggested that soft pancreatic texture and pancreatic duct ≤ 2mm were independent risk factors for POPF after RPD. After adjusting the duct size's cutoff from 3 to 2mm, the revised 4-tier "2mm" classification model showed no significant difference between risk categories B and C (6.7% vs. 9.4%, P = 0.063). The revised 3-tier "2mm" classification model stratified patients into A (n = 54), B (n = 68), and C (n = 65) groups, with corresponding POPF rates of 0.0%, 8.8%, and 23.1% (P < 0.001), and major complication rates of 5.6, 14.7, and 24.6% (P = 0.014), respectively. Compared to the simplified 3-tier classification model, the revised 3-tier "2mm" classification model showed improved discrimination (AUC: 0.753 vs. 0.685, P = 0.034) and clinical utility. The current ISGPS 4-tier and the simplified 3-tier classification models lacked sufficient discrimination in patients after RPD. We propose a revised 3-tier "2mm" risk classification model for RPD with a robust discrimination, which requires further international validation with prospectively obtained data.

Advantage of Postoperative Inflammatory Status after Laparoscopic Distal Pancreatectomy

Introduction: Laparoscopic distal pancreatectomy (LDP) is a safe and effective procedure; however, its impact on perioperative inflammatory reactions compared with open distal pancreatectomy (ODP) remains unclear. This study aimed to assess short-term outcomes following LDP and ODP regarding inflammatory reactions. Methods: This retrospective study of 77 consecutive patients who underwent distal pancreatectomy for low-grade malignancies between 2005 and 2022 compared white blood cell (WBC) count, C-reactive protein (CRP) level, serum albumin level, and CRP/albumin ratio (CAR) between LDP and ODP. Complications, especially postoperative pancreatic fistula (POPF), recovery program, and hospital stay period, were also compared. Results: POPF (17.1% vs. 38.7%, p = 0.039) and surgical morbidity (≥Clavien-Dindo grade III, 12.2% vs. 32.3%, p = 0.038) were significantly lower in LDP than in ODP, as for the difference in postoperative inflammatory response, including CRP and CAR, was just temporary. By multivariate analysis, CAR ≥6.94 on POD 3 was significant predictor of POPF (42.1% vs. 13.2%, odds ratio 4.828, p = 0.030). Conclusion: LDP has lower POPF and earlier postoperative recovery. CAR could be a predictor of POPF.

Application of 3D Printing to Design and Manufacture Pancreatic Duct Stent and Animal Experiments.

Objective: Postoperative pancreatic fistula (POPF) is a common and challenging complication following pancreaticoduodenectomy (PD), occurring in 2% to 46% of cases. Despite various pancreaticojejunostomy techniques, an effective method to prevent POPF has not been established. This study aimed to develop and evaluate a novel 3D-printed biodegradable pancreatic duct stent to simplify the surgical process of pancreaticojejunostomy, reduce anastomotic complexity, and minimize postoperative complications. Methods: Data from 32 patients undergoing total laparoscopic pancreaticoduodenectomy were utilized. Preoperative CT scans were transformed into 3D reconstructions to guide the design and printing of customized stents using polylactic acid (PLA). The stents were assessed for mechanical integrity, surface texture, and thermal stability. Animal experiments were conducted on 16 mini pigs, with the experimental group receiving the novel stent and the control group receiving traditional silicone stents. Results: The 3D-printed stents demonstrated accurate dimensional replication and mechanical reliability. In the animal experiments, the experimental group showed no significant difference in postoperative complications compared to the control group. At 4 weeks post-surgery, CT scans revealed well-healed anastomoses in both groups, with no significant inflammation or other complications. Histological examination and 3D reconstruction models confirmed good healing and device positioning in the experimental group. Conclusion: The 3D-printed biodegradable pancreatic duct stent offers a promising solution for pancreaticojejunostomy, with comparable safety and efficacy to traditional methods. Further research is needed to validate its clinical application.

The safety and efficacy of stapler method for transection of the pancreatic parenchyma during pancreatoduodenectomy (STRAP-PD trial): study protocol for a randomized control trial.

Pancreaticoduodenectomy is a highly difficult and invasive type of gastrointestinal surgery. Prevention of postoperative pancreatic fistula is important, and this may be possible by the stapler method. STRAP-PD is a single center randomized controlled trial. We compare a method of transecting the pancreatic parenchyma in pancreaticoduodenectomy using a surgical stapler device with a conventional transecting method using energy devices (e.g., scalpel, ultrasonic coagulator and incision devices). Patients with soft pancreas who are scheduled to undergo pancreaticoduodenectomy are randomized to arm A (conventional method) or arm B (stapler method). We aim to examine the safety and usefulness of dissection by the automatic suture device, with attention to the rate of pancreatic fistula ISGPF grade B or C and to postoperative complications. This is a single-center randomized study, which began in September 2023 at Wakayama Medical University Hospital. Pancreatic parenchymal transection is typically performed either by direct incision using a scalpel or by employing energy devices such as ultrasonic coagulating cutting devices during pancreaticoduodenectomy. In a prospective pilot study, we conducted pancreatic parenchymal transection in 20 consecutive normal pancreatic cases during pancreaticoduodenectomy, observing postoperative pancreatic fistula grade B in one case (5%). Traditional methods involving scalpel incision or the use of ultrasonic coagulating cutting devices have been historically favored but perceived as technically challenging, and they have been reliant upon the surgeon's skill. Notably, relatively high incidences of postoperative pancreatic fistula among patients with soft pancreas have also been observed. Our proposed stapler method may therefore be a useful method responsible for reducing the development of pancreatic fistula. This method would be as part of minimally-invasive surgery for pancreaticoduodenectomy. It uses an endoscopic linear stapler to cut the pancreatic parenchyma, so it is likely to be more convenient than conventional methods and can be used universally. TRIALREGISTRATION: University Hospital Medical Information Network Clinical Trials Registry,UMIN000052089. the Registration Date on 1st September 2023.

Appropriate linear stapler selection for avoiding postoperative pancreatic fistula after distal pancreatectomy: A retrospective cohort study.

Despite the progress in surgical techniques and perioperative managements, the incidence of postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) remains high. Recently, pancreatic dissection using a linear stapler has been widely performed; however, risk factors influencing the occurrence of POPF after DP using a liner stapler is not fully understood. The purpose of this paper was to evaluate whether the relations between staple height and pancreatic thickness or main pancreatic duct (MPD) diameter influenced the incidence of POPF. Patients who underwent DP without other organ resections between 2015 and 2022 were retrospectively reviewed. Compression Index (CI) was defined as staple height/pancreatic thickness, and Suturing Index (SI) was defined as staple height/ MPD diameter. In 51 patients undergoing DP, 16 patients (31.4%) developed POPF. ROC analyses revealed that lower CI and higher SI significantly increased the incidence of POPF, and the cutoff values were 0.186 and 0.821, respectively. Univariate and multivariate analyses revealed that CI ≤ 0.186 and SI ≥ 0.821 were independent risk factors for POPF after DP. Moreover, the incidence of POPF in patients fulfilling both CI > 0.186 and SI < 0.821 was 5.9%, which was extremely lower than in those without fulfilling the criteria (44.1%), suggesting that this new criteria in combination with CI and SI was an excellent predictor of POPF. It is possible that stapler cartridge selection using our new criteria in combination with CI and SI may reduce the incidence of POPF.

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.

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.

Construction and verification of pancreatic fistula risk prediction model after pancreaticoduodenectomy based on ensemble machine learning

Objective: To construct an ensemble machine learning model for predicting the occurrence of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy and evaluate its application value. Methods: This is a research on predictive model. Clinical data of 421 patients undergoing pancreaticoduodenectomy in the Department of Pancreatic Surgery,Union Hospital, Tongji Medical College,Huazhong University of Science and Technology from June 2020 to May 2023 were retrospectively collected. There were 241 males (57.2%) and 180 females (42.8%) with an age of (59.7±11.0)years (range: 12 to 85 years).The research objects were divided into training set (315 cases) and test set (106 cases) by stratified random sampling in the ratio of 3∶1. Recursive feature elimination is used to screen features,nine machine learning algorithms are used to model,three groups of models with better fitting ability are selected,and the ensemble model was constructed by Stacking algorithm for model fusion. The model performance was evaluated by various indexes,and the interpretability of the optimal model was analyzed by Shapley Additive Explanations(SHAP) method. The patients in the test set were divided into different risk groups according to the prediction probability (P) of the alternative pancreatic fistula risk score system (a-FRS). The a-FRS score was validated and the predictive efficacy of the model was compared. Results: Among 421 patients,CR-POPF occurred in 84 cases (20.0%). In the test set,the Stacking ensemble model performs best,with the area under the curve (AUC) of the subject's work characteristic curve being 0.823,the accuracy being 0.83,the F1 score being 0.63,and the Brier score being 0.097. SHAP summary map showed that the top 9 factors affecting CR-POPF after pancreaticoduodenectomy were pancreatic duct diameter,CT value ratio,postoperative serum amylase,IL-6,body mass index,operative time,albumin difference before and after surgery,procalcitonin and IL-10. The effects of each feature on the occurrence of CR-POPF after pancreaticoduodenectomy showed a complex nonlinear relationship. The risk of CR-POPF increased when pancreatic duct diameter<3.5 mm,CT value ratio<0.95,postoperative serum amylase concentration>150 U/L,IL-6 level>280 ng/L,operative time>350 minutes,and albumin decreased by more than 10 g/L. The AUC of a-FRS in the test set was 0.668,and the prediction performance of a-FRS was lower than that of the Stacking ensemble machine learning model. Conclusion: The ensemble machine learning model constructed in this study can predict the occurrence of CR-POPF after pancreaticoduodenectomy,and has the potential to be a tool for personalized diagnosis and treatment after pancreaticoduodenectomy.

Prophylactic intra-abdominal drainage during pancreaticoduodenectomy: A systematic review and meta-analysis

Background: Prophylactic abdominal drainage during pancreaticoduodenectomy (PD) is a common treatment strategy for pancreatic fistula. However, its benefits and safety have been the subject of debate. The objective of this meta-analysis and system review is to assess the effects of prophylactic drainage, various types of drainage (active and passive), and the timing of drainage removal (early and late) on the postoperative outcomes of PD. Methods: A systematic literature search was conducted in the PubMed, Web of Science, and Cochrane Library databases as of April 28, 2024. Randomized controlled trials (RCTs) comparing prophylactic abdominal drainage, different drainage patterns, and the timing of drainage removal after PD were included, and the postoperative outcomes were evaluated. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated to aggregate dichotomous outcomes. Meta-analysis was performed using the Mantel-Haenszel fixed- and random-effects models. Results: Nine RCTs, including a total of 1638 patients, were incorporated in our study. The meta-analysis showed no statistically significant differences in postoperative outcomes between the closed-suction drain (CSD) group and the passive drain to gravity (PDG) group. Compared to the late drain removal (LDR) group, the early drain removal (EDR) group had a significant reduction in the incidence of Clinically relevant postoperative pancreatic fistula (CR-POPF) (OR=0.39, 95% CI=0.20 to 0.79; P=0.009), morbidity (OR=0.41, 95% CI=0.20 to 0.84; P=0.01) and intra-abdominal infection (OR=0.40, 95% CI=0.22 to 0.75; P=0.004). For the group of present of drainage and the group of absent of drainage, the patient inclusion criteria of the included studies were too heterogeneous, making meta-analysis inappropriate. Conclusion: The existing evidence is insufficient to negate the necessity of prophylactic drainage after PD. The meta-analysis did not show superiority of any specific approaches of drainage tube. But this review did indicate that patients benefit from EDR in terms of CR-POPF, morbidity and intra-abdominal infection. EDR was recommended for low/intermediate risk patients.

Robotic versus open pancreaticoduodenectomy in octogenarians: a comparative propensity score analysis of perioperative outcomes

IntroductionCompared to open pancreaticoduodenectomies (OPD), the robotic (RPD) approach improves the rate of complication and the length of stay. However, it remains unknown if these benefits persist in octogenarians, who are at higher risk for perioperative morbidity and mortality. MethodsA retrospective analysis of the ACS-NSQIP database was performed to identify patients aged 80 years or older who underwent PD for pancreatic adenocarcinoma between 2015 and 2021. Patients who underwent RPD or OPD were compared using inversed probability weighting of the propensity score to control for known confounding variables. Outcomes assessed include operative time, length of stay (LOS), non-home discharge, major complications, unplanned readmission, return to the operating room (OR), mortality, and clinically relevant postoperative pancreatic fistula (CRPOPF). ResultsOf 30,751 patients undergoing PD, 1720 were 80 or older. One thousand six hundred twenty-five patients (94 %) underwent OPD, and 95 (6 %) underwent RPD. RPD was significantly associated with a reduced incidence of major complications (32.6 % vs. 45.6 % in OPD; p < 0.01) and a lower rate of non-home discharge (24.7 % vs. 34.3 % in OPD; p < 0.05). However, RPD was associated with a longer operative time (438 min vs. 342 min for OPD; p < 0.0001). There was no difference in other assessed outcomes between the two groups. ConclusionRPD may reduce major postoperative complications and non-home discharges compared to the open approach for octogenarians.

Preoperative risk-stratified analysis: External versus internal pancreatic stents in pancreatoduodenectomy

BackgroundSeveral risk-stratified studies have compared the outcomes of external and internal pancreatic stents in pancreatoduodenectomy (PD), but no resolute standard for a fistula-mitigation strategy exists. The study investigated the efficacy of these stents in a preoperative risk-stratified setting. MethodsData from 285 patients who underwent PD with pancreaticojejunostomy using an external or internal stent from 2015 to 2023 were analyzed. The preoperative pancreatic fistula score (preFRS) was used to classify patients into low-risk (preFRS: 0–5) and high-risk (preFRS: 6–8) groups. ResultsPreFRS accurately predicted the risk of clinically relevant postoperative pancreatic fistula (CR-POPF) as 0% and >40% in patients with preFRS ≤1 and ≥7, respectively. Although no significant difference was observed in postoperative outcomes in low-risk patients, the external stent significantly reduced CR-POPF (21% vs 44%, P = .024) and postpancreatectomy hemorrhage (PPH, 0% vs 19%, P = .02) in high-risk patients, leading to the superiority of the external stent in the entire cohort in terms of CR-POPF (12% vs 24%, P = .033) and PPH (1% vs 11%, P = .013). There were no significant differences in stent-related complications or pancreatic dysfunction. External stent malfunction occurred in 14% and significantly affected CR-POPF development in both low- (20% vs 0%, P < .01) and high-risk groups (60% vs 14%, P = .021). ConclusionThe external pancreatic stent showed a more beneficial effect on CR-POPF and PPH, especially in high-risk patients, without increasing other complications. Risk-stratified strategy and improving stent management might enhance postoperative outcomes.

The impact of chronic obstructive pulmonary disease on risk for complications after pancreatoduodenectomy - a single centre cohort study

BackgroundThe association between chronic obstructive pulmonary disease (COPD) and risk for postoperative complications after pancreatic surgery has not been clarified. The aim of this study was to investigate if COPD is associated with increased risk for postoperative complications after pancreatoduodenectomy. MethodsAll patients aged ≥18 years undergoing pancreatoduodenectomy from 2008 to 2019 at a high-volume tertiary centre for pancreatic cancer surgery were included. COPD was defined as an established diagnosis according to the International Statistical Classification of Diseases. The primary outcome was Clavien-Dindo-score (CD) ≥ IIIa. ResultsOut of 1009 available patients, 57 (5.6 %) had a diagnosis of COPD. There was no association between COPD and CD ≥ IIIa (25.5 % vs. 29.8 % p-value 0.471). COPD was associated with an increased risk for postoperative pancreatic fistula (odds ratio [OR] 3.06, 95 % confidence interval [CI] 1.62–5.89; p < 0.001). The 12 months mortality rate was higher among patients with COPD compared to patients without COPD, although not statistically significant (28.07 per cent vs., 18.17 per cent, p-value = 0.063). ConclusionCOPD was associated with increased risk for postoperative pancreatic fistula. These results imply that among patients deemed fit enough to undergo surgery, COPD should be thoroughly evaluated in the risk stratification.

Indocyanine green fluorescence imaging: Assessment of perfusion at pancreatic resection margin during pancreatoduodenectomy: A cross sectional study.

Clinically relevant-postoperative pancreatic fistula (CR-POPF) is one of the dreaded complications of pancreatoduodenectomy. Vascularity of the stump of the pancreas during pancreatico-enteric anastomosis is considered one of the major determinants of POPF. Indocyanine green (ICG) is one of the modality for vascular assessment; hence, we aimed to evaluate the role of ICG fluorescence imaging to assess the vascularity of the pancreatic stump during pancreatoduodenectomy. The study was conducted at Kathmandu Medical College, Kathmandu, Nepal, during the period of 1 year (June 01, 2022-July 31, 2023). All of the patients who were undergoing pancreatoduodenectomy were included in the study. In all cases, intraoperatively, ICG fluorescence detection at the pancreatic stump margin was evaluated using near-infrared light. A total of 28 patients underwent PD during this period. The ICG fluorescence imaging was positive at the pancreatic stump margin in 25 out of the 28 patients (89%), and in three cases, the florescence was negative. In patients who had negative fluorescence, revision of the stump margin was performed. Clinically relevant POPF was noted in 2 out of 28 cases, which had a soft pancreas with a small duct, although the pancreatic stump margin had good ICG florescence per-operatively. ICG is inexpensive and a safe dye to use in clinical practice. We can objectively assess the pancreatic stump vascularity using intraoperative ICG fluorescence imaging, thereby potentially decreasing postoperative pancreatic fistula.

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.

The establishment and validation of a clinical prediction model for postoperative biliary fistula after pancreaticoduodenectomy.

At present, pancreaticoduodenectomy (PD) is a classic surgical treatment for benign and malignant tumors around ampulla. The operation is complicated and postoperative complications are frequent. Biliary fistula is the most common anastomotic fistula after pancreatic fistula. Our objective is to analyze the risk factors for biliary fistula after PD and to construct a nomogram to predict biliary fistula after PD. The clinical data of a total of 196 patients who underwent PD from March 2014 to March 2024 in Yueyang Hospital Affiliated to Hunan Normal University and The Third Xiangya Hospital of Central South University were retrospectively analyzed. The number of included patients was divided in the ratio of 7:3 using the random split method, with 130 patients in the training set and 66 patients in the validation set. Predictors were screened and a nomogram prediction model was constructed by one-way logistic regression analysis, Lasso regression analysis and multifactorial logistic regression analysis. The discriminative ability, consistency and clinical effectiveness of the models were assessed by area under the curve (AUC) of the working characteristics of the subjects, calibration curve and decision curve analysis (DCA). The results of multifactorial logistic regression analysis showed that diabetes, low albumin, postoperative gastroparesis, abdominal bleeding, abdominal infection, and postoperative pancreatic fistula were the independent risk factors for biliary fistula after PD (P<0.05). The AUC of the column-line graph prediction model constructed from the above factors was 0.807 [95% confidence interval (CI): 0.652-0.962] in the training set and 0.782 (95% CI: 0.517-1.000) in the validation set, suggesting that the diagnostic efficacy of the model was better, and the calibration curves plotted in the training and validation sets were closer to the standard curves, suggesting that the model consistency was better. The plotted DCA curves also indicated a significant positive net gain. The nomogram prediction model constructed by diabetes, albumin, postoperative gastroparesis, abdominal bleeding, abdominal infection, and postoperative pancreatic fistula can well identify high-risk patients with postoperative biliary fistula (POBF) in PD, which has a good clinical application value.

Computed tomography-based radiomics and body composition analysis for predicting clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy.

Preoperative risk assessment of clinically relevant postoperative pancreatic fistula (CR-POPF) is still lacking. This study aimed to develop and validate a combined model based on radiomics, pancreatic duct diameter, and body composition analysis for the prediction of CR-POPF in patients undergoing pancreaticoduodenectomy (PD). Multivariable logistic regression was used to construct a combined model in conjunction with radiomics score (Rad-score), pancreatic duct diameter, and visceral fat area/total abdominal muscle area index (VFA/TAMAI). The models were internally validated using 1,000 bootstrap resamples. The predictive performance of these models was assessed using receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA). The preoperative combined model was validated by 1,000 bootstrap resampling with the area under the ROC curve (AUC) of 0.839 (95% confidence interval: 0.757-0.907). The calibration curves and DCA showed that the combined model outperformed the clinical model and radiomics model. The combined model was presented as a web-based calculator (https://whyyjyljz.shinyapps.io/DynNomapp/). We explored a method of combining radiomics features, pancreatic duct diameter, and body composition analysis predictors in preoperative assessment for risk of CR-POPF and developed a combined model that showed relatively good performance, but future studies with a larger sample size are needed to verify the stability and generalizability of this model.

Powered stapler and polyglycolic acid sheet for pancreatic fistula after distal pancreatectomy

BackgroundAlthough distal pancreatectomy (DP) is crucial for the treatment of pancreatic diseases, it often leads to postoperative pancreatic fistula (POPF), a complication with significant management challenges and health effects. Despite the use of various techniques, including suturing methods, staplers, and biodegradable materials, the optimal strategy to reduce POPF remains unclear. This study investigated the combined use of powered staplers and polyglycolic acid (PGA) sheets to mitigate POPF. MethodsThis study retrospectively analyzed the data of 165 patients who underwent DP at Sapporo Medical University Hospital between January 2013 and August 2023. This study compared the incidence of clinically relevant POPF (CR-POPF) between patients treated without (group O, n = 50) and with powered staplers and PGA sheets (group P, n = 115). In addition, the surgical techniques, patient demographics, and postoperative outcomes were examined. ResultsThis study found no significant difference in the overall incidence of POPF between the groups. However, group P had a significantly lower incidence of CR-POPF than group O (20.9% vs 40.0%, respectively; P = .011). Multivariate analysis demonstrated that male sex (odds ratio [OR], 2.81; 95% CI, 1.26–6.26; P = .012) and pancreatic thickness of more than 14 mm (OR, 2.85; 95% CI, 1.17–6.95; P = .021) were independent risk factors for CR-POPF. The use of powered staplers and PGA sheets (OR, 0.38; 95% CI, 0.17–0.85; P = .017) was associated with reduced CR-POPF risk. ConclusionThe combined use of powered staplers and PGA sheets can significantly decrease the incidence of CR-POPF in patients with DP.

Perioperative outcomes of robot-assisted pancreatoduodenectomy (PD) and totally laparoscopic PD after overcoming learning curves with comparison of oncologic outcomes between open PD and minimally invasive PD.

Minimally invasive pancreatoduodenectomy (MIPD), such as totally laparoscopic pancreatoduodenectomy (TLPD) or robot-assisted pancreatoduodenectomy (RAPD), is increasingly performed worldwide. This study aimed to compare the perioperative outcomes of TLPD and RAPD, and compare the oncologic outcomes between MIPD and open pancreatoduodenectomy (OPD) for malignant disease. This retrospective study was conducted at two hospitals that followed similar oncological surgical principles, including the extent of resection. RAPD was performed at Seoul National University Hospital, and TLPD at Seoul National University Bundang Hospital. Patient demographics, perioperative outcomes, and oncological outcomes were analyzed. Propensity score matching (PSM) analysis was performed to compare oncologic outcomes between MIPD and OPD. Between 2015 and 2020, 332 RAPD and 178 TLPD were performed. The rates of Clavian-Dindo grade ≥ 3 complications (19.3% vs. 20.2%, p = 0.816), clinically relevant postoperative pancreatic fistula (9.9% vs. 11.8%, p = 0.647), and open conversions (6.6% vs. 10.5%, p = 0.163) were comparable between the two groups. The mean operation time (341 minutes vs. 414 minutes, p < 0.001) and postoperative hospital stay were shorter in the RAPD group (11 days vs. 14 days, p = 0.034). After PSM, the 5-year overall survival rate was comparable between MIPD and OPD for overall malignant disease (58.4% vs. 55.5%, p = 0.180). Both RAPD and TLPD are safe and feasible, and MIPD has clinical outcomes that are comparable to those of OPD. Although RAPD exhibits some advantages, its perioperative outcomes are similar to those associated with TLPD. A surgical method may be selected based on the convenience of surgical movements, medical costs, and operator experience.

Clinical outcomes of preservation versus resection of portal/superior mesenteric vein during pancreaticoduodenectomy in pancreatic cancer patients who respond to neoadjuvant treatment: A retrospective cohort study

Background: R0 rates have increased as neoadjuvant treatment (NAT) has become the primary treatment for pancreatic ductal adenocarcinoma (PDAC) with venous involvement, suggesting a decrease in venous tumor infiltration. The aim of this study was to investigate the clinical outcomes of preserving the portal/superior mesenteric vein (PV/SMV) during pancreaticoduodenectomy (PD) in PDAC patients who underwent NAT. Material and Methods: The 113 patients with resectable and borderline resectable PDAC with venous involvement who responded to NAT and underwent curative PD between 2012 and 2022 were retrospectively reviewed. Results: Among the 113 patients, PV/SMV preservation (PVP) was performed in 68 patients (60.2%), and PV/SMV resection (PVR) was performed in 45 patients (39.8%). There was no significant difference in the R0 rate, 5-year overall survival (OS) and recurrence-free survival between the two groups. PV/SMV stenosis within 3 months after surgery was more common in the PVR group than in the PVP group (1.5% versus 22.2%; P &lt; 0.001), and 5-year PV/SMV stenosis-free survival was significantly higher in the PVP group than in the PVR group (76.5% versus 53.4%; P=0.014). Multivariate analysis showed that gemcitabine-based neoadjuvant chemotherapy was associated with poor OS. PVR, clinically relevant postoperative pancreatic fistula, and locoregional recurrence were independent risk factors for PV/SMV stenosis. Conclusion: The PVP group had similar oncologic outcomes and better vessel-functional outcomes than the PVR group. Therefore, if dissection is possible and there is a high likelihood of achieving R0 resection after NAT, routine PVR may be unnecessary in PDAC patients with venous involvement.