Postoperative Pancreatic Fistula In Group Research Articles

A novel laparoscopic pancreaticoduodenal training model: optimization of the learning curve and simplification of postoperative complications.

Laparoscopic pancreaticoduodenectomy requires a long learning curve. A preoperative training system was established to optimize the surgeons' learning curve and reduce the incidence rate of complications at the beginning of the curve. The laparoscopic pancreaticojejunostomy model, and choledochojejunostomy and gastrojejunostomy training systems were developed, and corresponding evaluation systems were also defined. Surgeons B and C performed laparoscopic pancreaticoduodenectomy after completing training session. Surgical outcomes, postoperative complications and their learning curves were analyzed. Patients operated by surgeons B and C experienced shorter operative durations following training session than those in nontrained group (called A) ( P <0.001). B and C began entering the inflection point at the 26th and 20th case in learning curve, respectively. The incidence of postoperative pancreatic fistula in group B was 3.3%, significantly lower than 13.1% in group A ( P =0.047). Patients in group B showed significantly lower incidence of biliary-enteric anastomosis leakage (0% vs. 8.2%, P =0.029) and Clavien-Dindo classification greater than or equal to 3 (3.3% vs. 14.8%, P =0.027) compared with those in group A. The incidence of surgical site infection in groups B (3.3%, P =0.004) and C (4.9%, P =0.012) was significantly lower than that in group A (19.7%). Moreover, the length of postoperative hospital stay was significantly shorter in groups B (12.5±5.9days, P =0.002) and C (13.7±6.5days, P =0.002) compared with group A (16.7±8.5days). The laparoscopic pancreaticojejunostomy training model and evaluation system can shorten the operative duration, lower the risk of postoperative complications, and shorten the length of hospital stay.

Quantitative edge analysis of pancreatic margins in patients with head pancreatic tumors: correlations between pancreatic margins and the onset of postoperative pancreatic fistula.

To assess the correlation between pancreatic quantitative edge analysis as a surrogate of parenchymal stiffness and the incidence of postoperative pancreatic fistula (POPF), in patients undergoing pancreaticoduodenectomy (PD). All consecutive patients who underwent PD at our Institution between March 2018 and November 2019 with an available preoperative CT were included. Pancreatic margin score (PMS) was calculated through computer-assisted quantitative edge analysis on the margins of the pancreatic body and tail (the expected pancreatic remnant) on non-contrast scans with in-house software. Intraoperative assessment of pancreatic stiffness by manual palpation was also performed, classifying pancreatic texture into soft and non-soft. PMS values were compared between groups using an unpaired T-test and correlated with the intraoperative evaluation of stiffness and with the grading of postoperative pancreatic fistula according to the International Study Group on Pancreatic Surgery (ISGPS). Patient population included 200 patients (mean age 64.6years), 146 without onset of POPF (73%, non-POPF group), and 54 with POPF (27%, POPF group). A significant difference in PMS values was observed between POPF and non-POPF (respectively 1.88 ± 0.05 vs 0.69 ± 0.01; p < 0.0001). PMS values of pancreatic parenchymas intraoperatively considered "soft" were significantly higher than those evaluated as "non-soft" (1.21 ± 0.04 vs 0.73 ± 0.02; p < 0.0001). A significant correlation between PMS values and POPF grade was observed (r = 0.8316), even in subgroups of patients with soft (r = 0.8016) and non-soft (r = 0.7602) pancreas (all p < 0.0001). Quantitative edge analysis with dedicated software may stratify patients with different pancreatic stiffness, thus potentially improving preoperative risk assessment and strategies for POPF mitigation. This study proposes quantitative pancreas edge analysis as a predictor for postoperative pancreatic fistula. The test has high accuracy and correlation with fistula grade according to the International Study Group on Pancreatic Surgery. • Prediction of postoperative pancreatic fistula (POPF) onset risk after pancreaticoduodenectomy is based only on intraoperative evaluation. • Quantitative edge analysis may preoperatively identify patients with higher risk of POPF. • Quantification of pancreatic stiffness through the analysis of pancreatic margins could be done on preoperative CT.

The role of minimally invasive surgery in resectable distal pancreatic adenocarcinoma

BackgroundIn distal pancreatectomy (DP) for pancreatic ductal adenocarcinoma (PDAC), we hypothesize that minimally invasive DP (MIDP) carries short-term benefits over ODP (ODP) in the absence of postoperative pancreatic fistula (POPF). MethodsNSQIP database was queried to select patients who underwent DP for PDAC with available report on POPF. The population was divided into No-POPF vs. POPF groups. In each group, propensity-score matching was applied to compare 30-day outcomes of ODP vs. MIDP. ResultsThere were 2,824 patients; 2,332 (82%) had No-POPF and 492 (21%) had POPF. In No-POPF patients, 921 pairs were matched between ODP and MIDP. MIDP patients had slightly longer operations (227 vs. 205 minutes; p < 0.001), but lower rates of surgical site complications (1% vs. 2.9%; p = 0.002), postoperative transfusion (7.1% vs. 11.0%; p = 0.003), overall morbidity (21.1% vs. 26.3%; p = 0.009), and one-day shorter median length of stay (LOS) (5 vs. 6 days; p = 0.001).In the POPF group, 172 pairs were matched. There was no difference in morbidity, mortality, reoperation, LOS, and home discharge. Similar conclusions were drawn in the intention-to-treat and per-protocol analyses. ConclusionPOPF is common following DP for PDAC. In the absence of POPF, MIDP is associated with fewer postoperative morbidities and shorter LOS.

Preoperative C-Reactive Protein-to-Albumin Ratio Predicts Postoperative Pancreatic Fistula following Pancreatoduodenectomy: A Single-Center, Retrospective Study

Postoperative pancreatic fistula (POPF) following pancreatoduodenectomy (PD) is a potentially lethal complication, and it is clinically important to determine its risk preoperatively. Although C-reactive protein-to-albumin ratio (CAR) is reported to be a prognostic marker for postoperative complications in several cancers, no evidence is currently available regarding the association between preoperative CAR and POPF following PD for periampullary tumors. This study examined whether preoperative CAR could predict POPF following PD. Clinical data were retrospectively retrieved from Ehime University Hospital. The optimal cut-off value for CAR was determined using receiver operating characteristic (ROC) curve analysis. This study enrolled 203 consecutive patients undergoing PD for periampullary tumors. The CAR value was significantly higher in the POPF group than in the non-POPF group (p < 0.001). According to the ROC curve analysis, the optimal cut-off value for CAR was 0.09. Patients with CAR ≥ 0.09 had higher incidence rates of POPF than their counterparts. CAR ≥ 0.09 was a risk factor for POPF in the multivariate logistic regression analysis (odds ratio 34.5, 95% confidence interval 11.75-101.38, p < 0.001). This is the first report demonstrating an association between CAR and POPF following PD. Preoperative CAR is an independent predictive marker for POPF following PD.

Postoperative arterial lactate levels can predict postoperative pancreatic fistula following pancreaticoduodenectomy: A single cohort retrospective study

Background/Objectives: Postoperative pancreatic fistula (POPF) is a serious complication after pancreaticoduodenectomy (PD). Thus, identification of the risk factors for POPF is urgently needed. In this study, we aimed to identify whether arterial lactate (LCT) levels following PD might be a marker of the potential risk of POPF. MethodsBetween September 2009 and December 2020, 151 patients who underwent elective PD were retrospectively enrolled. Patient characteristics, perioperative clinicopathological variables, postoperative blood biochemistry data were analyzed in univariable and multivariable analyses. Pancreatic fistula of Grade B and C was considered as POPF. ResultsPatients were divided into the POPF group (n = 33, 21.9%) and non-POPF group (n = 118, 78.1%). Higher body mass index (p = 0.017), increased estimated blood loss (p = 0.047), soft textured pancreas (p = 0.007), smaller main pancreatic duct (p = 0.016), higher LCT levels (p < 0.001), higher aspartate aminotransferase levels (p = 0.023) and higher procalcitonin levels (p = 0.024) were significantly associated with POPF. Receiver operating characteristic curve analysis revealed that 2.1 mmol/L was the optimal cut-off value of LCT (sensitivity = 78.8%, specificity = 61.2%) for predicting POPF occurrence. Univariate and multivariate analyses confirmed that an LCT of ≥2.1 mmol/L was independently associated with the risk of POPF following PD (odds ratio = 6.78, 95% confidence interval = 2.22–20.74; p = 0.001). ConclusionsHigher LCT is a predictive marker for POPF following PD.

P-P44 Clinical outcomes of consecutive patients undergoing distal pancreatectomy over the last decade at a high volume tertiary pancreatic surgery unit

Abstract Background Distal pancreatectomy (DP) enables resection of lesions in the body and tail of the pancreas. Over the past decade, the Laparoscopic approach has become frequently employed. There remains scarce outcome data available following laparoscopic distal pancreatectomy over a long time period from high volume centres. Postoperative pancreatic fistula (POPF) remains the main source of morbidity and mortality after DP. The causes of POPF are multifactorial and poorly understood. The optimal method of pancreatic stump closure is still debated with variation in clinical practice. Methods All patients that underwent distal pancreatectomy at a UK tertiary pancreatic surgery centre between January 2011 and January 2021 were identified and clinical outcomes examined. Patients undergoing completion pancreatectomies were excluded. Clinical, pathological and surgical data for the included patients was retrospectively collected from the electronic patient record. Clinically significant POPF was defined as Grade B or C as per the ISGPF guidelines. For stapled stump closure, the Compression Index (CI) was calculated using closed staple height (mm) divided by the pancreatic thickness (mm). High and low CI was defined around the median. Results 233 patients (n = 90 open and n = 143 laparoscopic) were included in the final analysis. The laparoscopic approach was associated with comparable morbidity and significantly lower blood loss, shorter operative time and shorter length of stay. There were no significant differences in age, sex, final histology, closure technique, or ASA Score of 3 or more amongst patients with clinically relevant POPF (CR-POPF). The POPF group had a significantly higher BMI, drain duration and readmission rate. CI data was available for 78 cases (range 0.04-0.21). There was no significant difference in low vs high CI for patients with CR-POPF. Conclusions Laparoscopic distal pancreatectomy is associated with favourable clinical outcomes in this series. Stapled vs sutured closure of the pancreatic stump offered equivocal outcomes with relation to POPF. POPF continues to have a significant impact on a clinical recovery as evident from longer drain duration and high readmission rates. Further research is required to try to establish methods for reducing the incidence of POPF after distal pancreatectomy.

Reducing the risk of postoperative pancreatic fistula in radical gastrectomy: pre-assessment with computed tomography for the diagnosis of pancreatic steatosis.

To determine whether pancreatic steatosis (PS) is associated with the risk of postoperative pancreatic fistula (POPF) after radical gastrectomy, and if so, to investigate whether pre-assessment by diagnostic imaging can mitigate the risk. The clinical records of 276 patients with cStage I gastric cancer who underwent laparoscopic gastrectomy with D1 + lymphadenectomy between 2012 and 2015 were reviewed. In the first phase up to July 2013 (n = 138), PS was classified from computed tomography (CT) findings into type S (superficial fat deposition) or type D (diffuse fatty replacement) and examined for association with POPF. In the second phase (n = 138), the preoperative CT assessment of PS was routinized. Separate samples from pancreatoduodenectomy consistent with each type were histologically examined. In the first phase, the incidence of POPF was significantly higher in group S, but not in group D, compared with normal pancreas (16.3% and 9.1% vs. 3.6%, respectively; P = 0.03). The drain amylase level was lowest in group D, reflecting exocrine insufficiency. Histologically, the loose connective-tissue space between the fat infiltrating the pancreas and the peripancreatic fat containing the lymph nodes was unclear in type D but conserved in type S. In the second phase, surgery was performed with more intention on accurately tracing the dissection plane and significantly lowered incidence of POPF in Group S (16.3% to 2.1%; P = 0.047). Peripancreatic lymphadenectomy is more challenging and likely to cause POPF in patients with PS. However, the risk may be reduced using appropriate dissection techniques based on the CT pre-assessment findings.

Drain management after distal pancreatectomy based on a predictive model, including drainage fluid amylase and biochemical inflammatory markers: a preliminary study

Introduction Postoperative pancreatic fistula (POPF) is the Achilles’ heel of distal pancreatectomy. Surgeons use abdominal drains for early prediction, diagnosis, and timely management of POPF. The utility of drainage fluid in the prediction and diagnosis of POPF is a matter of debate. Patients and methods This is a retrospective cohort study of all patients who underwent distal pancreatectomy between January 2018 and January 2020. The present study aims to evaluate the association between drainage fluid amylase (DFA) and systemic inflammatory markers in the prediction of clinically relevant POPF. Results This study included 44 patients with a mean age of 40.3±16.3 years, and the female : male ratio was 2.7 : 1. POPF occurred in 11 (25%) patients. Of them, nine (20.5%) patients were managed by additional ultrasound-guided tube drainage. Higher drainage fluid amount and DFA-D1 were associated with a higher risk of POPF (P=0.036, and 0.009, respectively). The leukocytic count was significantly higher in POPF in the third postoperative day (POD) (P=0.032). POPF group had a significantly higher level of serum lactate dehydrogenase (LDH) on the fourth POD (P=0.001). Patients with high DFA-D1 (>330 IU/l), rising leukocytic count, and high serum LDH were significantly at higher risk of POPF (9/11 developed POPF, P=0.0001). Conclusion DFA-D1, rising leukocytic count, and high serum LDH level compromised a more robust predictive model for POPF. The cutoff value of DFA proposed by the ISGPF is applicable when combined with leukocytic count and serum LDH. Prospective large-scale studies are needed.

The Late Phase/Early Phase Ratio of Pancreatic CT Values as a Novel Predictor of Pancreatic Fistula after Distal Pancreatectomy.

Post-operative pancreatic fistula (POPF) remains the most common complication after distal pancreatectomy (DP). In this retrospective study, we reviewed the data from patients who underwent DP between 2008 and 2019 in our institute to determine whether the late phase/early phase ratio (L/E ratio) by preoperative computed tomography (CT) scan in the pancreas could predict POPF occurrence after DP. We examined the relationship between preoperative or intraoperative factors and the occurrence of POPF after DP using statistical methods in 23 males and 21 females with a mean age of 73. The mean L/E ratio was significantly lower in the POPF group than the non-POPF group (p=0.035). The L/E ratio had moderate diagnostic accuracy, with a calculated optimal cutoff value of 0.77. In univariate analysis, a significant association was noted between POPF and stump thickness ≥ 16.9, body mass index ≥ 27.5, and L/E ratio ≤ 0.77. In the multivariate analysis, the L/E ratio (odds ratio, 5.96; p=0.036) was an independent risk factor for POPF. Our findings suggest that the pancreatic L/E ratio may predict the occurrence of POPF after DP. This measure may be useful in preoperative risk stratification, patient counseling, and perioperative patient management, improving clinical outcomes after DP.

Clinical evaluation of modified invaginated pancreaticojejunostomy for pancreaticoduodenectomy

BackgroundPancreaticoduodenectomy (PD) remains the major curative operation for malignant neoplasm of pancreas or cancerous tumors near the pancreas. Despite advancements in recent years, the postoperative recurrence rate of these neoplasms and tumors remains high. Moreover, overall morbidity remains high due to clinically relevant postoperative pancreatic fistula (POPF).MethodsTo compare the clinical outcomes of modified invaginated anastomosis and mucosa-to-mucosa anastomosis, this retrospective study included 343 patients who underwent PD from January 2008 to January 2019 at Beijing Friendship Hospital, Capital Medical University. The patients’ general conditions and disease status were preoperatively evaluated. The surgical procedure was recorded, and operative management was appropriately performed.ResultsCompared with mucosa-to-mucosa anastomosis, modified invaginated anastomosis resulted in a higher intraoperative blood transfusion rate (P < 0.001) and lower hospitalization expenses (P = 0.049). However, no significant differences were found in operation time (P = 0.790), intraoperative bleeding (P = 0.428), postoperative recovery exhaust time (P = 0.442), time to normal flow of food (P = 0.163), and hospitalization time (P = 0.567). Operation time was a risk factor for POPF (odds ratio 1.010; 95% confidence interval 1.003–1.016; P = 0.003). The incidence of pancreatic fistula (grades B and C) was lower in the patients who underwent modified invaginated anastomosis (14.1%) than in those who underwent mucosa-to-mucosa anastomosis (15.3%). The operation time was greater in the POPF group than in the non POPF group among the patients who received modified invaginated anastomosis (P = 0.003) and mucosa-to-mucosa anastomosis (P = 0.002).ConclusionModified invaginated pancreaticojejunostomy for PD resulted in a decreased incidence of POPF; it may serve as a new approach for PD while managing patients who have undergone PD.

Computed Tomography Enhancement Pattern of the Pancreatic Parenchyma Predicts Postoperative Pancreatic Fistula After Pancreaticoduodenectomy.

The aim of this study was to assess the relationship between the computed tomography (CT) pancreatic parenchyma attenuation value and clinically relevant postoperative pancreatic fistula (POPF). The medical records of 115 patients who underwent pancreaticoduodenectomy and preoperative dynamic CT were retrospectively reviewed. The CT attenuation values of the nonenhanced (N), arterial (A), portal venous (P), and late (L) phase in the pancreatic parenchyma were determined via CT, and the A/N, A/P, and P/L ratios were calculated. The CT attenuation values and value ratios were compared between the POPF and non-POPF groups. Thirty-two patients (28%) were categorized in the POPF group. On univariate analysis, the A/P ratio (P < 0.001) and P/L ratio (P = 0.018) were significantly higher in the POPF group. On receiver operating characteristic curve analysis, the A/P and P/L ratio cutoff values for predicting POPF were 1.19 and 1.17, respectively. Of the preoperative evaluable factors, A/P ratio of 1.19 or greater (P < 0.001; odds ratio, 10.3) and P/L ratio of 1.17 or greater (P = 0.049; odds ratio, 3.23) were independent predictive factors for POPF, and the combination of the 2 ratios was useful in detecting POPF preoperatively. The enhancement pattern of the pancreatic parenchyma is associated with the development of clinically relevant POPF.

Serum C-reactive protein level on first postoperative day can predict occurrence of postoperative pancreatic fistula after laparoscopic gastrectomy.

Purpose : Postoperative pancreatic fistula (POPF) is a serious complication after gastrectomy for gastric cancer. The purpose of this study is to identify the risk factor of POPF and evaluate C-reactive protein on postoperative day 1 (POD1) as the predictor for POPF after laparoscopic gastrectomy (LG). Methods : Between May 2013 and September 2016, 226 patients who underwent LG for gastric cancer were investigated. Patients were divided into 2 groups; POPF group (n = 17) and control group (n = 209). Clinicopathological factors were compared between 2 groups. Results : In POPF group, there are more male patients (p = 0.003) compared with control group. Preoperative factors, such as age, BMI, and prevalence of previous operation and comorbidity showed no significant difference between 2 groups. Regarding tumor factors and perioperative data such as blood loss and operative time, there were also no significant difference between 2 groups. POPF group showed longer postoperative hospital stay, and higher serum CRP level on POD1 (p < 0.0001). Multivariate analysis revealed that high CRP level on POD1 ( ≥ 3mg/dl) was independent risk factor of POPF. Conclusions : High serum CRP level on POD1 can predict the occurrence of POPF. J. Med. Invest. 66 : 285-288, August, 2019.

Measurement of Pancreatic Fat Fraction by CT Histogram Analysis to Predict Pancreatic Fistula after Pancreaticoduodenectomy.

ObjectiveTo evaluate the effectiveness of computed tomography (CT) Hounsfield unit histogram analysis (HUHA) in postoperative pancreatic fistula (PF) prediction.Materials and MethodsFifty-four patients (33 males and 21 females; mean age, 65.6 years; age range, 37–89 years) who had undergone preoperative CT and pancreaticoduodenectomy were included in this retrospective study. Two radiologists measured mean CT Hounsfield unit (CTHU) values by drawing regions of interest (ROIs) at the level of the pancreaticojejunostomy site on preoperative pre-contrast images. The HUHA values were arbitrarily divided into three categories, comprising HUHA-A ≤ 0 HU, 0 HU < HUHA-B < 30 HU, and HUHA-C ≥ 30 HU. Each HUHA value within the ROI was calculated as a percentage of the entire area using commercial 3-dimensional analysis software. Pancreas texture was evaluated as soft or hard by manual palpation.ResultsFifteen patients (27.8%) had clinically relevant PFs. The PF group had significantly higher HUHA-A (p < 0.01) and significantly lower mean CTHU (p < 0.01) values than those of the non-PF group. The HUHA-A value had a moderately strong correlation with PF occurrence (r = 0.60, p < 0.01), whereas the mean CTHU had a weak negative correlation with PF occurrence (r = −0.27, p < 0.01). The HUHA-A and mean CTHU areas under the curve (AUCs) for predicting PF occurrence were 0.86 and 0.65, respectively, with significant difference (p < 0.01). The HUHA-A and mean CTHU AUCs for predicting pancreatic softness were 0.86 and 0.64, respectively, with significant difference (p < 0.01).ConclusionThe HUHA-A values on preoperative pre-contrast CT images demonstrate a strong correlation with PF occurrence.

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.

Rate of Clinically Significant Postoperative Pancreatic Fistula in Pancreatic Neuroendocrine Tumors

In 2005, the International Study Group of Pancreatic Fistula (ISGPF) developed a definition and grading system for postoperative pancreatic fistula (POPF). The authors sought to determine the rate of POPF after enucleation and/or resection of pancreatic neuroendocrine tumors (PNET) and to identify clinical, surgical, or pathologic factors associated with POPF. A retrospective analysis of pancreatic enucleations and resections performed from March 1998 to April 2010. We defined a clinically significant POPF as a grade B that required nonoperative intervention and grade C. One hundred twenty-two patients were identified; 62 patients had enucleations and 60 patients had resections of PNET. The rate of clinically significant POPF was 23.7 % (29/122). For pancreatic enucleation, the POPF rate was 27.4 % (17/62, 14 grade B, 3 grade C). The pancreatic resection group had a POPF rate of 20 % (12/60, 10 grade B, 2 grade C). This difference was not significant (p = 0.4). In univariate analyses, patients in the enucleation group with hereditary syndromes (p = 0.02) and non-insulinoma tumors (p = 0.02) had a higher POPF rate. Patients in the resection group with body mass index (BMI) > 25 (p < 0.01), multiple endocrine neoplasia type 1 (MEN-1; p < 0.01) and those who underwent simultaneous multiple procedures (p = 0.02) had a higher POPF rate. Multivariate analyses revealed that hereditary syndromes were able to predict POPF in the enucleation group, while having BMI > 25 and increasing lesion size were also associated with POPF in the group undergoing resection. We found a clinically significant POPF rate after surgery in PNET to be 23.7 % with no difference by the type of operation. Our POPF rate is comparable to that reported in the literature for pancreatic resection for other types of tumors. Certain inherited genetic diseases-von Hippel-Lindau disease (VHL) and MEN-1-were associated with higher POPF rates.

Histomorphological Features of the Pancreatic Remnant as Independent Risk Factors for Postoperative Pancreatic Fistula: A Matched-Pairs Analysis

Background/Aims: Postoperative pancreatic fistula (POPF) is a major complication after resective pancreatic surgery. This study aimed to identify histomorphological features of the pancreatic remnant as independent determinants for the development of POPF. Methods: Twenty-five patients, 3.6% of 696 resections over a period of 5 years, who developed POPF were matched for age, gender, diagnosis, comorbidities, surgeon and procedure with 25 controls without POPF. Pancreatic duct size and index, fibrosis grade, fat content, edema, and signs of chronic and acute inflammation were measured in frozen sections of the resection margin and were then compared. Results: The POPF rate was 12.2 and 2.6% after distal pancreatectomy and pancreatoduodenectomy, respectively. The POPF group was characterized by a longer ICU and total postoperative stay, higher rate of reoperations and complications. Their pancreata were softer at palpation (88 vs. 56%). Their pancreatic duct was smaller (2.5 vs. 3.2 mm) and their pancreatic fat content higher (16 vs. 8%). High inter- and intralobular fat content, small duct size, low interlobular fibrosis grade and lack of signs of chronic pancreatitis were predictors of POPF development. A score including these parameters identified high-risk patients with a sensitivity of 92% and a specificity of 84%. Conclusion: Histomorphological features of the pancreatic remnant play an independent role as risk factors for the development of POPF. A simple histological score based on the frozen sections may already intraoperatively predict the risk of POPF development.

Technical and Mechanical Risk Factors for Postoperative Pancreatic Fistula in Pancreaticojejunostomy

The purpose of this study was to identify basic risk factors for postoperative pancreatic fistula (POPF) after pancreaticojejunostomy. Seventy-one patients underwent pancreaticojejunostomy with duct-to-mucosa anastomosis (DMA). Between POPF group (n=8) and non- POPF group (n=63), the following clinical parameters were compared; pancreatic texture evaluated pathologically with score, diameter of the pancreatic duct, total number of sutures, interval between sutures and the size of suture (5-0 vs. 6-0) for DMA. The mean diameter of the pancreatic duct (POPF/non-POPF) was 3.0±1.4/4.2±2.0mm, total number of sutures for DMA was 6.8±1.6/7.0±2.8, whereas mean interval between sutures was 1.4±0.5/2.1±1.1mm, which failed to achieve significant difference. All cases except one that produced POPF had soft pancreas (p=0.0022). However, for the soft pancreas, the score of pancreatic texture did not achieve significant difference between POPF and non-POPF. 5-0 sutures had less chance of POPF (p=0.0035). As a result of multivariate analysis, suture size and pancreatic texture correlated with POPF. The suture size and pancreatic texture were risk factors for POPF. Since these factors are related to surgical techniques, gentle handling during pancreaticojejunostomy seems important.

Postoperative Pancreatic Fistula and the Risk Factors of Laparoscopy-Assisted Distal Gastrectomy for Early Gastric Cancer

Laparoscopy-assisted distal gastrectomy (LADG) was introduced as minimally invasive surgery for early gastric cancer (EGC) in Japan. This study investigated postoperative pancreatic fistula (POPF) and associated risk factors of the procedure. From January 2005 to December 2009, 798 patients with EGC diagnosed before surgery underwent LADG. Thirty-four patients developed postoperative pancreatic fistula (POPF group), whereas the other 764 patients did not experience POPF (NPOPF group). POPF was defined and graded according to the International Study Group on Pancreatic Fistula Definition (ISGPF). Patient characteristics and operative and postoperative outcomes were compared between the two groups. Risk factors associated with POPF were analyzed. POPF occurred in 34 (4.3%) patients; among them 3 developed grade C POPF, a complication that required aggressive clinical intervention, and only 1 underwent reoperation. Compared with the NPOPF group, the POPF group had higher percentage of male patients (88.2% vs. 60.5%, P=0.001), higher mean body mass index (24.8±2.5kg/m(2) vs. 22.5±3.2kg/m(2), P<0.001), longer mean operation time (251.3±46.7min vs. 229.7±53.9min, P=0.022), higher postoperative complications (100% vs. 8.6%, P<0.001), and longer mean postoperative hospital stay (29.6±19.9days vs. 12.6±6.7days, P<0.001). Univariate and multivariate analysis identified sex and body mass index as risk factors associated with POPF after LADG. LADG can be performed safely in patients with EGC in terms of the low incidence of POPF. To decrease the risk of POPF, LADG should be performed cautiously in male patients with high body mass index.