Postoperative Pancreatic Fistula Grade Research Articles

Outcomes following pancreatic resections—results and challenges of an Austrian university hospital compared to nationwide data and international centres

Despite clear advances in decreasing postoperative mortality below 4% after pancreatic resections in experienced centres, specific morbidity according to standardized definitions still remains high. While some recent multicentre studies have reported on complications after pancreatic surgery in Austria, detailed outcome data from single high-volume centres over longer time-periods are scarce. This study provides an in-depth picture of patient characteristics, indications, morbidity and mortality after pancreatic surgery in an Austrian tertiary referral centre. All patients undergoing curative intent resection between 2010 and 2017 at the Medical University of Innsbruck were evaluated. Patient characteristics and procedural details, overall and specific complications including postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE) and post-pancreatectomy haemorrhage (PPH) rates according to accepted definitions are reported. Outcomes after pancreatic head resections, distal pancreatectomy and other types of resections are compared. Factors associated with severe and overall morbidity are evaluated by logistic regression modelling. A total of 343 patients underwent pancreatic resection, at a median of 64 years (53% males). Most common indications were pancreatic or bile-duct carcinoma (52%), benign/precursor lesions (22%) and neuroendocrine tumours (11%). The 90-day mortality was 2%; 90-day overall/severe morbidity was 66.2%/22.4%. POPF grade B/C occurred in 19.3%, PPH in 17.5% and DGE in 14.3%. Male gender was associated with severe morbidity, body mass index and procedures other than distal resections with overall morbidity. POPF and PPH were major causes for relaparotomy. Pancreatic resections in our centre are performed with low mortality, although morbidity still represents a relevant clinical problem, especially POPF and PPH.

Use of Neoveil or TachoSil to prevent pancreatic fistula following pancreaticoduodenectomy: A retrospective study.

The aim of this study was to evaluate the effectiveness of using Neoveil and TachoSil sponges at the pancreaticojejunostomy anastomosis site in reducing the rate and severity of postoperative pancreatic fistula (POPF).In this study, we retrospectively evaluated data that were prospectively collected on pancreaticoduodenectomy (PD) procedures. Patients were divided into 3 groups: no patch application, Neoveil patch application, and TachoSil patch application. Demographic and surgical data were analyzed.Around 165 patients with PD were enrolled in this study and were divided into 3 groups. In the standard group (n = 43), no patch was applied, while in the Neoveil and TachoSil groups (n = 84 and n = 38, respectively), the pancreaticojejunostomy anastomosis site was covered with Neoveil and TachoSil patches, respectively. POPF grade B or above occurred in 37.2% (16/43), 14.3% (12/84), and 18.8% (6/38) of patients in the standard, Neoveil and TachoSil groups, respectively, with a significant difference between patients with and without patch application (P = .004). On multivariate logistic analysis of predictive factors for POPF, male sex, patch application, and hospital day were found to be the significant independent predictors of POPF grade B or above.Significant independent predictors of POPF were male sex and patch application. This study demonstrated that the use of Neoveil or TachoSil patches may reduce the incidence of POPF after PD.

Postoperative Pancreatic Swelling Predicts Pancreatic Fistula after Pancreaticoduodenectomy

Postoperative pancreatic fistula (POPF) is a serious complication of pancreaticoduodenectomy. However, the criteria for prompting drainage have not been clarified yet. We evaluated 80 patients who underwent pancreaticoduodenectomy between 2011 and 2016. Clinically relevant POPF (International Study Group of Postoperative Pancreatic Fistula grade B or C) was evaluated on the basis of the following parameters: changes in pancreatic thickness between preoperation and postoperative day (POD) 4 identified via enhanced CT, drain amylase level, laboratory data, and operative factors. POPF occurred in 21 patients (26.3%). The median change in pancreatic thickness before and after operation was 8.33 mm in the POPF-positive group, which was significantly larger than that in the POPF-negative group (3.79 mm, P <0.001). In addition, operation time, pancreatic texture, main pancreatic duct diameter, WBC count, C-reactive protein level, and drain amylase level demonstrated significant differences between the groups. In the multivariate analysis, operation time, C-reactive protein level on POD 3, drain amylase level on POD 1, and the change in pancreatic thickness before and after operation were independent risk factors of POPF. The drastic change in pancreatic thickness before and after operation predicted POPF in this study. This might be one of the factors that determine the requirement for drainage.

Management and outcomes of intraductal papillary mucinous neoplasms.

BackgroundThis study evaluated the outcome and survival of patients with radiologically suspected intraductal papillary mucinous neoplasms (IPMNs).MethodsIPMN management was reviewed according to Fukuoka risk factors and IPMN localization, differentiating main‐duct (MD), mixed‐type (MT) and branch‐duct (BD) IPMNs. Perioperative results were compared with those of patients undergoing resection of pancreatic ductal adenocarcinoma (PDAC) over the same interval (2010–2014). Overall (OS) and disease‐specific (DSS) survival rates were calculated and subgroups compared.ResultsOf 142 patients with IPMNs, 26 had MD‐IPMN, eight had MT‐IPMN and 108 had BD‐IPMN. Some 74 per cent of patients with MD‐ and MT‐IPMN were managed by primary resection, whereas this was used in only 27·8 per cent of those with BD‐IPMN. The risk of secondary resection and malignant transformation for BD‐IPMNs smaller than 20 mm was 8 and 2 per cent respectively during follow‐up. Pancreatic head resection of IPMNs was associated with an increased risk of postoperative pancreatic fistula grade B/C compared with resection of PDAC (12 of 33 (36 per cent) versus 41 of 221 (18·6 per cent) respectively; P = 0·010), and greater morbidity and mortality (Clavien–Dindo grade III: 15 of 33 (45 per cent) versus 56 of 221 (25·3 per cent) respectively; grade IV: 1 (3 per cent) versus 7 (3·2 per cent); grade V: 2 (6 per cent) versus 2 (0·9 per cent); P = 0·008). Five‐year OS and DSS rates in patients with MD‐IPMN were worse than those for MT‐ and BD‐IPMN (OS: 44, 86 and 97·4 per cent respectively, P < 0·001; DSS: 60, 100 and 98·6 per cent; P < 0·001). Patients with invasive IPMN had worse OS and DSS rates than those with non‐invasive dysplasia (OS: IPMN‐carcinoma (10 patients) 33 per cent, high‐grade dysplasia 100 per cent, intermediate‐grade dysplasia 63 per cent, low grade‐dysplasia 100 per cent, P < 0·001; DSS: IPMN‐carcinoma 43 per cent, all grades of dysplasia 100 per cent, P < 0·001). Patients with high‐risk stigmata had poorer survival than those without risk factors (OS: high‐risk stigmata (35 patients) 55 per cent, worrisome features (31) 95 per cent, no risk factors (76) 100 per cent, P < 0·001; DSS: 71, 100 and 100 per cent respectively, P < 0·001).ConclusionThe risk of malignant transformation was very low for BD‐IPMNs, but the development of high‐risk stigmata was associated with disease‐specific mortality. Patients with IPMN had greater morbidity after resection than those having resection of PDAC.

Pancreatoduodenectomy in the German DGAV StuDoQ|Pancreas and Dutch pancreatic cancer audit: differences in patients, indications, surgery, centralization and outcome

Background: Nationwide audits facilitate quality and outcome assessment of pancreatic surgery. Differences may exist between countries but studies comparing nationwide outcomes of pancreatic surgery based on audits are lacking. This study aimed to compare the German and Dutch audits for external data validation. Methods: Anonymised data from patients undergoing pancreatoduodenectomy (2014–2016) were extracted from the German DGAV StuDoQ|Pancreas and Dutch Pancreatic Cancer Audit. Results: Overall, 4495 patients (2489 German, 2006 Dutch) were included. In the Netherlands, adenocarcinoma was more often the indication for pancreatic resection. German patients had higher ASA class but Dutch patients had more pulmonary comorbidity. Dutch patients underwent more minimally invasive surgery and venous resection, but less multivisceral resection. No difference was found in rates of postoperative pancreatic fistula grade B/C, post-pancreatectomy haemorrhage grade C and in-hospital mortality. There was more centralization in the Netherlands (1% versus 13% PD in very low volume centres, P = 0.001). After multivariable analysis, both hospital stay (2.5 days difference, 95% CI 1.17–3.80) and the odds of reoperation (OR 1.55, 95% CI 1.21–1.95) were higher in the German audit, whereas the odds of postoperative pneumonia (OR 0.57, 95% CI 0.37–0.86) and readmission (OR 0.38, 95% CI 0.31–0.49) were lower, see Table. Several baseline and surgical characteristics, including hospital volume, but not country, predicted mortality. Conclusion: Although in-hospital mortality, and rates of pancreatic fistula and haemorrhage are similar, noteworthy differences exist between patients, indications, surgical technique and centralization for pancreatoduodenectomy between Germany and the Netherlands.

The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After

Background: In 2005, the International Study Group of Pancreatic Fistula (ISGPF) developed a definition and grading of postoperative pancreatic fistula (POPF) that has been accepted universally. Eleven years later, because POPF remains one of the most relevant and harmful complications of pancreatic surgery, the ISGPF classification has become the gold standard in defining POPF in clinical practice. Methods: The ISGPF re-convened as the International Study Group in Pancreatic Surgery (ISGPS) in order to perform a review of the recent literature and consequently to update and revise the grading system of POPF. Results: The former “Grade A POPF” is now redefined and called a “biochemical leak (BL)”, because it has no clinical importance and is no longer referred to a true pancreatic fistula. POPF Grades B and C are confirmed but defined more strictly. In particular, Grade B requires a change in the postoperative management; drains are either left in place for more than three weeks or repositioned through endoscopic or percutaneous procedures. Grade C POPF refers to those POPF that require reoperation or lead to single or multiple organ failure and/or mortality attributable to the pancreatic fistula. Conclusion: This new definition and grading system of POPF should lead to a more universally consistent evaluation of surgical outcomes after pancreatic surgery and will allow for a better comparison of techniques used to mitigate the rate and clinical impact of a pancreatic fistula

The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After

Background: In 2005, the International Study Group of Pancreatic Fistula (ISGPF) developed a definition and grading of postoperative pancreatic fistula (POPF) that has been accepted universally. Eleven years later, because POPF remains one of the most relevant and harmful complications of pancreatic surgery, the ISGPF classification has become the gold standard in defining POPF in clinical practice. Methods: The ISGPF re-convened as the International Study Group in Pancreatic Surgery (ISGPS) in order to perform a review of the recent literature and consequently to update and revise the grading system of POPF. Results: The former “Grade A POPF” is now redefined and called a “biochemical leak (BL)”, because it has no clinical importance and is no longer referred to a true pancreatic fistula. POPF Grades B and C are confirmed but defined more strictly. In particular, Grade B requires a change in the postoperative management; drains are either left in place for more than three weeks or repositioned through endoscopic or percutaneous procedures. Grade C POPF refers to those POPF that require reoperation or lead to single or multiple organ failure and/or mortality attributable to the pancreatic fistula. Conclusion: This new definition and grading system of POPF should lead to a more universally consistent evaluation of surgical outcomes after pancreatic surgery and will allow for a better comparison of techniques used to mitigate the rate and clinical impact of a pancreatic fistula.

Minimally Invasive Versus Open Distal Pancreatectomy (LEOPARD): A Multicenter Patient-blinded Randomized Controlled Trial.

This trial followed a structured nationwide training program in minimally invasive distal pancreatectomy (MIDP), according to the IDEAL framework for surgical innovation, and aimed to compare time to functional recovery after minimally invasive and open distal pancreatectomy (ODP). MIDP is increasingly used and may enhance postoperative recovery as compared with ODP, but randomized studies are lacking. A multicenter patient-blinded randomized controlled superiority trial was performed in 14 centers between April 2015 and March 2017. Adult patients with left-sided pancreatic tumors confined to the pancreas without vascular involvement were randomly assigned (1:1) to undergo MIDP or ODP. Patients were blinded for type of surgery using a large abdominal dressing. The primary endpoint was time to functional recovery. Analysis was by intention to treat. This trial was registered with the Netherlands Trial Register (NTR5689). Time to functional recovery was 4 days [interquartile range (IQR) 3-6) in 51 patients after MIDP versus 6 days (IQR 5-8) in 57 patients after ODP (P < 0.001). The conversion rate of MIDP was 8%. Operative blood loss was less after MIDP (150 vs 400 mL; P < 0.001), whereas operative time was longer (217 vs 179 minutes; P = 0.005). The Clavien-Dindo grade ≥III complication rate was 25% versus 38% (P = 0.21). Delayed gastric emptying grade B/C was seen less often after MIDP (6% vs 20%; P = 0.04). Postoperative pancreatic fistulas grade B/C were seen in 39% after MIDP versus 23% after ODP (P = 0.07), without difference in percutaneous catheter drainage (22% vs 20%; P = 0.77). Quality of life (day 3-30) was better after MIDP as compared with ODP, and overall costs were non-significantly less after MIDP. No 90-day mortality was seen after MIDP versus 2% (n = 1) after ODP. In patients with left-sided pancreatic tumors confined to the pancreas, MIDP reduces time to functional recovery compared with ODP. Although the overall rate of complications was not reduced, MIDP was associated with less delayed gastric emptying and better quality of life without increasing costs.

Nutritional risk factors are associated with postoperative complications after pancreaticoduodenectomy.

PurposeThe purpose of this study was to investigate whether the indicators of nutritional risk screening tool are associated with postoperative complications following pancreaticoduodenectomy (PD).MethodsWe investigated whether nutritional risk is associated with postoperative complications based on the medical records of 128 patients who underwent PD from 2010. The tool was composed of 6 risk factors: albumin, total lymphocyte count, body mass index, weight loss, dietary intake loss, and nutritional symptoms. The patients were divided into 2 groups: a nutritional risk group and a nonrisk group. The rates of general complications and postoperative pancreatic fistula (POPF) were investigated according to this nutritional status.ResultsThere were 65 patients who did not have any risk factors. However, 63 patients had one risk factor or more. In the nonrisk group, the overall complication rate and serious complication rate were 30.8% and 15.4%, respectively. If there were one or more risk factors, the overall and serious complication rates were 59.5% and 41.3%, respectively (P = 0.001 and P = 0.001, respectively). The rate of clinically relevant POPF (grade B or C) was 9.2% in the nonrisk group. However, this rate was 23.8% in the NRS risk group (P = 0.029). In multivariate analysis, the NRS risk group was a significant factor of clinically relevant POPF (odds ratio, 9.878; 95% confidence interval, 1.527–63.914; P = 0.016).ConclusionThere were statistically significant associations between complications and nutritional indicators. A comprehensive analysis of nutritional parameters will help predict postoperative complications.

A modified definition of POPF with cost validation for PPPD

Introduction: Postoperative pancreatic fistula (POPF) is still a major complication after pylorus preserving pancreaticoduodenectomy (PPPD), despite improvements of surgical technique and perioperative management. Therefore, clear definition of POPF after the surgery is important thing to surgeons. Lately, international study group of pancreatic fistula (ISGPF) revised POPF grade system. In this study, we suggested a modified definition of POPF and evaluated the suitability of the grade system for PPPD patients with cost validation comparing to ISFPG grade system. Method: From January 2010 to December 2014, 394 medical records of the patients who underwent PPPD were retrospectively reviewed. The patients were classified according to each POPF definition. (ISGPF and modified) A modified definition was as follow. (POPF was defined as greater peritoneal amylase level than three times of serum amylase level; BL; No additional management except routine management and drain removal within POD #10; Grade A; ISGPF Grade B except radiological intervention, Grade B; radiological intervention, Grade C; hemodynamic instability or reoperation, Grade D; mortality.) After then postoperative day (POD) and admission cost was analyzed according to grading system. Result: In POD analysis, the modified grading system more precisely classified the patients than ISGPF grading system. (ISGPF; BL vs. B: 16.5 day vs. 24.0 day, p<0.001); (Modified; BL vs. A: 14.0 day vs. 21.0 day, p<0.001; A vs. B: 21.0 day vs. 26.0, p=0.002) In admission cost analysis, the modified grading system also more precisely classified the patients than ISGPF grading system. (ISGPF; BL vs. B: 5,960,000 won vs. 7,610,000 won, p=0.003); (Modified; BL vs. A: 5,490,000 won vs. 6,560,000 won, p=0.002; A vs. B: 6,560,000 won vs. 10,630,000 won, p=0.001) Conclusion: The modified POPF grade system was more precise than previous POPF grading system.

Laparoscopic pancreatoduodenectomy with open or laparoscopic reconstruction during the learning curve: a multicenter propensity score matched study

BackgroundLaparoscopic pancreatoduodenectomy with open reconstruction (LPD-OR) has been suggested to lower the rate of postoperative pancreatic fistula reported after laparoscopic pancreatoduodenectomy with laparoscopic reconstruction (LPD). Propensity score matched studies are, lacking. MethodsThis is a multicenter prospective cohort study including patients from 7 Dutch centers between 2014–2018. Patients undergoing LPD-OR were matched LPD patients in a 1:1 ratio based on propensity scores. Main outcomes were postoperative pancreatic fistulas (POPF) grade B/C and Clavien-Dindo grade ≥3 complications. ResultsA total of 172 patients were included, involving the first procedure for all centers. All 56 patients after LPD-OR could be matched to a patient undergoing LPD. With LPD-OR, the unplanned conversion rate was 21% vs. 9% with LPD (P < 0.001). Median blood loss (300 vs. 400 mL, P = 0.85), operative time (401 vs. 378 min, P = 0.62) and hospital stay (10 vs. 12 days, P = 0.31) were comparable for LPD-OR vs. LPD, as were Clavien-Dindo grade ≥3 complications (38% vs. 52%, P = 0.13), POPF grade B/C (23% vs. 21%, P = 0.82), and 90-day mortality (4% vs. 4%, P > 0.99). ConclusionIn this propensity matched cohort performed early in the learning curve, no benefit was found for LPD-OR, as compared to LPD.

Factors predicting mortality in patients with grade C postoperative pancreatic fistula after pancreaticoduodenectomy

Introduction: The mortality rate for postoperative pancreatic fistula (POPF) has remained stable at 2%-4% for last 25 yrs. POPF grade C is a risk factor for mortality following pancreaticoduodenectomy with a mortality rate of approximately 25%–50%. There is limited literature for factors predicting mortality in POPF C. Objective: To determine the risk factors associated with mortality in Grade C POPF Methods: We retrospectively analysed patients who underwent pancreaticoduodenectomy from January 2013 to October 2017. The pancreatico-jejunostomy was performed with duct to mucosa technique in four layers in all patients. Patient demographics, clinical data, surgery details, postsurgical recovery and complications were recorded. Results: Five hundred and ninety-two patients underwent pancreaticoduodenectomy during the study period. Clinically relevant POPF (CR-POPF) was seen 108 patients (18.2%). Grade C POPF occurred in 31 patients (5.2%). The overall mortality rate was 2.8% and the mortality rate associated with POPF grade C was 38.7% (12/31).Factors associated with increased risk of mortality in patients with POPF grade C are listed in table no 1. On multivariate analysis, none of the factors were found to be statistically significant due to high inter-variable co-relations. The strength of co-relation was found highest with bile leak, post pancreatectomy haemorrhage (PPH) and chest complications. Conclusions: Post pancreatectomy haemorrhage, bile leak and chest complications are associated with higher risk of mortality in patients with Grade C POPF. Analysis in larger cohort of patients is required to support our results.Tabled 1Table 1. Factors associated with mortalityS.noFactorsAssociation with mortality Univariate analysis1.Post pancreatectomy Haemorrhage (PPH) (n = 16)p = 0.0052.Bile leak (n = 11)p = 0.0003.Associated chest complications (n = 11)p = 0.0004.Positive blood culture ( n = 7)p = 0.0005.Number of interventionsp = 0.00016.Number of explorationsp = 0.0087.Pre-intervention Sr.Albumin levelsp = 0.0168.Post-operative day of suspicion for POPFp = 0.7509.Post-operative day/ Time of first re-explorationp = 0.093 Open table in a new tab

Impact of sarcopenia on outcomes of patients undergoing pancreatectomy: A retrospective analysis of 107 patients.

To evaluate the prevalence of sarcopenia in patients undergoing pancreatic surgery and to examine its impact on the surgical outcomes and survival of patients.Skeletal muscle index (SMI) was measured on preoperative CT. A patient was considered sarcopenic if SMI was <38.5 cm2/m2 for a female or <52.4 cm2/m2 for a male. Postoperative pancreatic fistula (POPF) and severe morbidity (Clavien≥3) were analyzed. Survival of patients with cancer was calculated using the Kaplan–Meier method.In total, 107 consecutive patients were included. Among them, 50 (47%) patients were sarcopenic and 65 (60%) were undernourished. The rates of severe morbidity and mortality were comparable between sarcopenic and nonsarcopenic groups. However, all POPF grade B or C and deaths occurred in the sarcopenic or nonsarcopenic overweight group (BMI > 25) with significantly lengthened hospital stays (P = .003). After pancreatectomy for cancer, 31 (40.2%) patients showed postoperative recurrence and 23 (29.9%) died after a median follow-up of 15 ± 13.5 months. Despite comparable histological types and stages, the median overall and disease-free survivals were lower in sarcopenic patients (16 months vs not reached, P = .02 and 11.1 months vs 22.5 months; P = .04, respectively). The multivariate analysis revealed that, sarcopenia trended to increase the risk of death (HR = 2.04, P = .07).Sarcopenia negatively impacted short- and long-term outcomes in patients undergoing pancreatectomy.

Postoperative C-reactive protein ≥ 15 mg/dl and its relation with clinical relevant intra-abdominal abscess and postoperative pancreatic fistula grade B-C after pancreaticoduodenectomy

Postoperative C-reactive protein ≥ 15 mg/dl and its relation with clinical relevant intra-abdominal abscess and postoperative pancreatic fistula grade B-C after pancreaticoduodenectomy

The modified duct-to-mucosa pancreaticojejunostomy for small pancreatic duct during pancreaticoduodenectomy

Purpose: Postoperative pancreatic fistulas(POPFs) due to anastomotic leak are closely related to significant morbidity and mortality following pancreaticoduodenectomy(PD).The aim of this study is to introduce modification of the conventional duct-to-mucosa (DM) pancreaticojenunostomy(PJ) and the improved outcomes of this modified PJ technique for small main pancreatic duct. Methods: The modified DM anastomosis is characterized that matching internal stent was inserted into the pancreatic duct remnant and secured with suture at the opening of the pancreatic duct to enhance sealing, prior to the anastomosis. From January 2012 to October 2017, 102 patients underwent PD for small main pancreatic duct (≤ 3mm). In total, 33 cases received conventional DM pancreaticojejunal anastomosis and 69 cases received modified DM pancreaticojejunal anastomosis. Results: The postoperative stay time, diet resumption time and timing of drain removal in the modified DM group were lower than those in conventional DM group. The overall incidence of POPFs was not significantly different between two groups. But, the clinical POPFs (grade B/C) in the modified DM group occurred less frequently than those in the conventional DM group. (4.3 % vs. 24.2 %, p=0.002). Moreover, neither grade C POPF nor in-hospital mortality occurred in the modified DM group. In addition, multivariate analysis showed a significant difference between both groups on significant POPFs (OR 0.211, 95% CI 0.09 to 0.51, P=0.001). Conclusion: The modified DM anastomosis technique in our study is a safer anastomotic method than the traditional DM pancreaticojejunostomy technique. This new technique could effectively reduce the incidence of POPF.

Does the Anatomy of the Transected Pancreatic Neck Influence Post Whipple’s Operation Pancreatic Fistula?

Few studies correlate anatomical parameters of the transected pancreatic neck to occurrence of the dangerous complication-post Whipple's pancreaticoduodenectomy pancreatic fistula. To evaluate the correlation between anatomical details of the transected neck of the pancreas and post-operative pancreatic fistula (POPF) following Whipple's pancreaticoduodenectomy. Observational study. The study included 66 patients undergoing Whipple's pancreaticoduodenectomy with pancreaticojejunostomy at tertiary care centre between December 2009 and December 2014. Student's t test, Fisher's exact test, Pearson's chi-squared test and forward stepwise. Clinically relevant POPF (grade B and C) was noted in 12 patients. Morbidity/mortality was 30.30% and 4.54% respectively. Among the fistula v/s no fistula groups, (a) mean thickness of the pancreatic stump was 12.17 ± 1.40mm v/s 14.94 ± 1.87mm (P = 0.000), (b) mean width of the pancreatic stump was 24.33 ± 4.14mm v/s 25.87 ± 4.02mm (P = 0.238) and (c) mean pancreatic duct (PD) diameter was 2.92 ± 0.79mm v/s 4.27 ± 1.39mm (P = 0.001). Mean distances of PD from anterior, posterior, superior and inferior pancreatic borders in the fistula group v/s no fistula group were 6.08 ± 1.62mm, 3.17 ± 0.72mm, 9.92 ± 2.15mm, and 11.42 ± 3.45mm v/s 5.93 ± 1.71mm, 4.83 ± 1.26mm, 11.83 ± 2.79mm and 9.96 ± 3.25mm respectively. Eleven of 38 patients (28.9%) with soft pancreas developed POPF. Pancreatic duct < 3mm diameter, < 3mm from posterior border, < 12mm from superior border, pancreatic neck thickness < 12mm and soft pancreas consistency were significantly associated with POPF.

Pancreatic Stiffness Quantified with MR Elastography: Relationship to Postoperative Pancreatic Fistula after Pancreaticoenteric Anastomosis.

Purpose To describe the relationship between conventional magnetic resonance (MR) imaging parameters and MR elastography of the pancreas in association with pancreatic histologic features and occurrence of postoperative pancreatic fistula (POPF). Materials and Methods Patients who underwent preoperative MR imaging (MR elastography and diffusion-, T1-, and T2-weighted imaging) followed by pancreatectomy with pancreaticoenteric anastomosis were included. The relationships between preoperative MR imaging parameters, demographic data, and intraoperative factors with POPF risk were analyzed with logistic regression analyses. The correlation of MR imaging parameters with histologic characteristics was evaluated with multivariate regression analysis. Results A total of 112 patients (64 men, 48 women; median age, 58 years) were evaluated. Forty-two patients (37.5%) developed POPF and 20 (17.9%) developed high-grade POPF (grades B and C). Lower pancreatic stiffness (≤1.43 kPa; odds ratio [OR], 9.196; 95% confidence interval [CI]: 1.92, 43.98), nondilated main pancreatic duct (MPD) diameter (<3 mm; OR, 7.298; 95% CI: 1.51, 35.34), and larger stump area (≥211 mm2; OR, 9.210; 95% CI: 1.53, 55.26) were risk factors for POPF. Lower pancreatic stiffness (≤1.27 kPa; OR, 8.389; 95% CI: 1.88, 37.41) was the only independent predictor of high-grade POPF. Log-transformed pancreatic stiffness was independently associated with fibrosis (β = 0.060; 95% CI: 0.052, 0.068), acinar atrophy (β = 0.015; 95% CI: 0.003, 0.028), and lipomatosis (β = -0.016; 95% CI: -0.026, -0.006). Conclusion Preoperative MR assessment of pancreatic stiffness, MPD diameter, and stump area are important predictors of POPF.

International validation of the updated international study group of pancreatic surgery definition of postoperative pancreatic fistula after distal pancreatectomy

Background: Postoperative pancreatic fistula (POPF) remains the most common complication after distal pancreatectomy (DP). The International Study Group of Pancreatic Surgery (ISGPS) recently updated their POPF definition. This study aimed to validate the updated definition in patients after DP. Methods: In this international retrospective cohort study, performed in 5 centers on patients after DP from 2005 to 2016, main focus was the effect of discarding grade A and the change of POPF grade B by comparing the distribution of complications amongst POPF grades according to the old (2005) and updated (2016) definitions. Results: In total, 1089 patients were included. The incidence of POPF grade B/C decreased with the updated definition (355(33%) vs 260(24%) <0.01), mostly because of less POPF grade B (328(30%) vs 234(21%) <0.01). The rate of POPF grade C was comparable for the old and updated definition (27(2%) vs 26(2%) >0.99). The old no POPF group was comparable regarding distribution of complications with the updated no POPF group (including biochemical leak) (Clavien-Dindo ≥3 29(5%) vs 46(6%) = 0.32, ICU 15(3%) vs 20(2%) = 0.6 and hospital stay 7(6–9) vs 7(6–9) = 0.30). In patients with a POPF grade B according to the updated definition more Clavien-Dindo ≥3 complications (124(38%) vs 119(51%) <0.01) and longer hospital stay (9(9–13) vs 9(7–15) <0.01) were seen. The rate of ICU admissions amongst POPF grade B patients was comparable (10(3%) vs 9(4%) = 0.25). The decrease in POPF grade B/C with the updated definition was similar in minimally invasive (149 (42%) vs 101(39%)) and open DP (206(58%) vs 159(61%)) (=0.05). Conclusion: The updated 2016 ISGPS POPF definition showed an improvement in the ability to discriminate between patients with and without a (clinically relevant) POPF after DP. This improvement was present in both minimally invasive and open DP.

Evaluation of Drain Amylase Level after Pancreaticoduodenectomy with Special Reference to Delayed Pancreatic Fistula

Postoperative pancreatic fistula (PF) is a relatively frequent and occasionally fatal complication of pancreatoduodenectomy (PD). Several risk factors for PF have been reported, including high drain amylase level (D-AMY). Among the 140 consecutive patients who underwent PD, we analyzed 110 cases with D-AMY measurements over time after PD. According to the D-AMY change, we divided patients into five patterns and defined delayed PF cases. We analyzed clinical characteristics, including serum amylase and D-AMY, and examined the correlation between the period of drain insertion and PF grade. In 15 delayed PF cases, 12 cases were grade B or C, pancreatic cancer was less frequent, pancreatic ducts were smaller, and soft pancreas texture was more commonly observed. The D-AMY on postoperative day (POD) 1 was higher in cases of delayed PF compared with non-PF cases (P < 0.0001). In 28 cases with drain removal before POD 7, grade B or C PF was not observed afterward. The average D-AMY on POD 1 in cases with drain removal before POD 1 was significantly lower than in delayed PF cases. Although further studies are required to determine the most appropriate timing of drain removal, it is thought that intra-abdominal drains should be removed within seven days of PD in cases without signs of PF. On the other hand, delayed PF should be considered in cases of soft pancreas texture and/or high D-AMY on POD 1, even if D-AMY levels are low on POD 3 or decreasing on POD 5.

Reproducibility of preoperative endoscopic injection of botulinum toxin into the sphincter of Oddi to prevent postoperative pancreatic fistula.

BackgroundA postoperative pancreatic fistula (POPF) is the most common and potentially life-threatening surgical complication in pancreatic surgery. One possible pharmacological treatment could be the endoscopic injection of botulinum toxin (BTX) into the sphincter of Oddi to prevent POPF. Promising data reported a significantly reduced rate of clinically relevant POPF. We analyzed the effect of BTX injection in our patients undergoing distal pancreatectomy (DP).MethodsA retrospective analysis of patients undergoing DP was performed. Patients with preoperative endoscopic injection of BTX into the sphincter of Oddi were included. The end points were postoperative outcomes including POPF. BTX patients were compared with a historical cohort and matched in a 1:1 ratio using a propensity score analysis.ResultsA total of 19 patients were treated with endoscopic injection of BTX before open (n=8) or laparoscopic (n=11) DP. The median age of the patients was 67 years and the mean body mass index was 25.9 kg/m2. In median, the intervention was performed 1 day (range, 0–14 days) before the operation. There were no intervention-related complications. The incidence of POPF was not statistically different between the two groups: a clinically relevant POPF grade (B/C) occurred in 32% (BTX) and 42% (control; p=0.737). Likewise, there were no significant differences in postoperative drain fluid amylase levels, morbidity, and mortality.ConclusionThe present study could not reproduce the published results of a significant lowering of grade B/C POPF. The explanations could be the timing of BTX injection before surgery and the endoscopic technique of BTX injection. However, the conflicting results after BTX injection in two high-volume centers prompt a randomized controlled multicenter trial with trained endoscopists.