Postoperative Pancreatic Fistula Research Articles

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 post-operative 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

Background: 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. Methods: 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. Results: 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 &gt; 0.186 and SI &lt; 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. Conclusions: It is possible that stapler cartridge selection using our new criteria in combination with CI and SI may reduce the incidence of POPF.

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 2015-2021. 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 minutes vs. 342 minutes 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 – 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). ConclusionsCOPD 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.

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.

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.

Stent A pancreaticojejunostomy after pancreatoduodenectomy: Is it always necessary?

The establishment of a postoperative pancreatic fistula (POPF) is considered the most common and, concomitantly, the most serious complication associated with pancreaticoduodenectomy (PD). The search for either technical modifications of the operative technique or pharmaceutical interventions that could possibly aid in decreasing the incidence of this often-devastating complication appears justified. The stenting of the pancreatic duct, with the use of either internal or external stents, has been evaluated in this direction. In theory, it is an approach that could eliminate many pathophysiological factors responsible for the occurrence of a POPF. The purpose of the present study was to review the current data regarding the role of pancreatic duct stenting on the incidence of POPF, after PD, by using PubMed and Reference Citation Analysis. In general, previous studies seem to highlight the superiority of external stents over their internal counterparts in regard to the incidence of POPF; this is at the cost, however, of increased morbidity associated mainly with the stent removal. Certainly, the use of an internal stent is a less invasive approach with acceptable results and is definitely deprived of the drawbacks arising through the complete diversion of pancreatic juice from the gastrointestinal tract. Bearing in mind the scarcity of high-quality data on the subject, an approach of reserving stent placement for the high-risk for POPF patients and individualizing the selection between the use of an internal or an external stent according to the distinct characteristics of each individual case scenario appears appropriate.

Whether T-tube biliary drainage is necessary after pancreaticoduodenectomy: a single-center retrospective study

BackgroundPostoperative complications of pancreaticoduodenectomy (PD) are still a thorny problem. This study aims to verify the preventative impact of T-tube on them.MethodsThe electronic medical records and follow-up data of patients who received pancreaticoduodenectomy in our center from July 2016 to June 2020 were reviewed. According to whether T tube was placed during the operation, the patients were divided into T-tube group and not-T-tube group. Propensity score matching analysis was performed to minimize selection bias.ResultsA total of 330 patients underwent PD (Not-T-tube group =226, T-tube group=104). Propensity score matching resulted in 222 patients for further analysis (Not-T-tube group =134, T-tube group=88). Patients' demographics were comparable in the matched cohorts. Significantly higher incidences of clinically relevant postoperative pancreatic fistula (CR-POPF) ((14 (10.45%) VS 20 (22.73%)), P=0.013) were observed in the T-tube group. The total incidence of biliary anastomotic stricture (BAS) was 3.15%. The incidence was slightly lower in the T-tube group, but there was no statistically significant differentiation (6 (4.48%) VS 1 (1.14%), P=0.317).ConclusionsIt is not feasible to prevent postoperative complications with the application of a T-tube in PD.

Surgical management of pancreatic neoplasms in children: a single-institution experience over 15 years.

Pancreatic neoplasms are rare among children and very few studies have reported on surgical outcomes for pediatric pancreatic neoplasms. Therefore, we aimed to describe patient and tumor characteristics and report on the surgical outcomes of pediatric pancreatic neoplasm. In this retrospective single-center study, we reviewed and analyzed the data of patients who underwent surgery for pediatric pancreatic neoplasms at Severance Children's Hospital between January 2007 and December 2022. Clinical data including demographics, surgical procedures, and postoperative and long-term outcomes were evaluated. A total of 28 patients underwent surgical treatment for pancreatic neoplasms with a median age of 11.7 years (range: 0.4-17.8). The most common histological diagnosis among benign tumors was solid pseudopapillary neoplasm (SPN), which occurred in 20 patients (71.4%). This was followed by a mucinous cyst, nesidioblastosis, pseudocyst, duplication cyst, and benign cyst, each occurring in one patient (3.5%). Regarding malignant tumors, pancreatoblastoma, solid pseudopapillary carcinoma, and malignant pheochromocytoma were noted in one patient each (3.5%). Tumor locations included the head in 4 patients (14.2%), the body in 7 (25%), and the tail in 16 (57.1%), and was diffuse in 1 (3.5%). The most common surgical resection range was distal pancreatectomy, found in 22 patients (78.5%), followed by pylorus-preserving pancreaticoduodenectomy, found in 2 (7.2%); duodenum-preserving pancreatic resection, central pancreatectomy, tumor enucleation, and near-total pancreatectomy were performed in one patient each (3.5%). Overall, 4 patients developed grade B or C postoperative pancreatic fistulas, and 1 experienced postoperative mortality due to uncontrollable bleeding. The mean follow-up period was 6.1 years (range: 1-15.6 years), during which no significant impact on growth after surgery was detected. Among the 20 patients with SPN, tumor rupture occurred in 4 (20%), among whom 2 experienced tumor recurrences. Histological diagnosis of benign tumors was predominant in this case series and various extents of surgical resection were performed. Surgical treatment for pediatric pancreatic neoplasms appears to be safe and effective. However, considering the long-term prognosis of these patients, it is essential to determine the appropriate extent of surgical resection based on the location of the tumor.

Prevention of Postoperative Pancreatic Fistula: Systematic Review and Meta-Analysis

Background: After pancreatic surgery, the development of postoperative pancreatic fistula (POPF) is a serious concern. POPF involves the leakage of pancreatic fluids from the surgical site, which can lead to complications and even death. Preventing POPF is essential for enhancing patient recovery and lessening the impact on healthcare resources. This systematic review and meta-analysis evaluated medical methods and surgical techniques to prevent POPF. Methods: This study was registered under the International Prospective Register of Systematic Reviews (PROSPERO) with the registration number CRD42024500938. An electronic search was conducted through the PubMed, Google Scholar, Web of Science, and ScienceDirect databases for all relevant articles published in English from 2018 to 2023. The following search terms were used: ((Whipple procedure OR Pancreaticojejunal OR Pancreaticogastrostomy) AND (Prevention of postoperative pancreatic fistula) AND (Prevention OR Octreotide OR Sealant agent OR Stent OR Postoperative drain)). Results: Of 260 papers, 28 articles extracted through the database search were considered suitable for the systematic review. The included studies investigated a variety of surgical approaches for pancreatic resection. Pancreaticoduodenectomy (PD) was the most prevalent intervention. The incidence rates for POPF varied widely across the studies, ranging from as low as 11.6% to as high as 100%. The incidence rate of clinically relevant POPF (CR-POPF) ranged from 11.7% to 33.3%. The length of postoperative hospital stays also varied significantly. Discussion: Postoperative pancreatic fistula (POPF) affects 13–41% of patients post-pancreatic surgery. Despite its high incidence, mortality rates are low. Postoperative hospital stay varies, with higher rates in older patients and overweight individuals. Advancements in surgical techniques and perioperative management have reduced mortality rates to &lt;5%. Conclusions: This study provides insights into the outcomes of pancreatectomy, including the incidence of POPF, postoperative hospital stays, and mortality rate. The findings suggest that the incidence of POPF is similar to that suggested in the literature and is influenced by various factors.

Indocyanine green fluorescence in the evaluation of post-resection pancreatic remnant perfusion after a pancreaticoduodenectomy: a clinical study protocol

BackgroundPancreaticoduodenectomy is associated with an incidence of postoperative complications of approximately 41%. One of the most severe complications is a postoperative pancreatic fistula. The exact cause of postoperative fistula development is still unknown, but it appears to be multifactorial. Proper perfusion of pancreatic remnant is essential for the healing of pancreaticojejunostomy. To date, there is no method to reliably evaluate the vascular supply of the remnant. One of the methods for the assessment of organ perfusion is the indocyanine green fluorescence. This study aims to determine if indocyanine green fluorescence is a reliable method to measure the perfusion of the post-resection pancreatic remnant. The secondary outcome is to determine if intraoperative evaluation of the vascular supply of the post-resection remnant may predict the increased risk of postoperative pancreatic fistula development.MethodsThis study is designed as a prospective, observational study. All consecutive patients undergoing open or robotic pancreaticoduodenectomies at our department during the 1st May 2024-31st December 2026 period will be enrolled. The exclusion criteria are an allergy to indocyanine green and refusal by the patient. The adequacy of the vascular supply of the post-resection pancreatic remnant will be intraoperatively evaluated using a fluorescence detector. Patients will be divided into two groups: Those with high risk of pancreatic fistula development and those with low risk. The incidence of pancreatic fistulas in both groups is to be compared. Postoperative data including morbidity, mortality, hospital stay, intensive care unit stay and postoperative fistula development will be collected.DiscussionIf an intraoperative assessment of the perfusion of post-resection pancreatic remnant using indocyanine green is proven to be a suitable method to estimate the increased risk of the pancreatic fistula, the list of the existing known risk factors could be expanded. In the most high-risk patients the modification of the surgical procedure could be considered.Trial registrationNumber: NCT06198400 ClinicalTrials.Gov. Date 08.01.2024.

Central pancreatectomy of the remnant pancreas without reconstruction after pancreatoduodenectomy

BackgroundThere are several reports on the safety and feasibility of pancreatoduodenectomy (PD) without reconstruction of the small remnant pancreas. However, a few studies have explored central pancreatectomy (CP) for non-reconstructed small remnant pancreases after PD. This study presents a case of CP without pancreatic reconstruction after PD.Case presentationA 58-year-old man with cerebral palsy underwent PD for distal cholangiocarcinoma. Three years postoperatively, a 12-mm tumor was detected in the remnant pancreatic body and diagnosed as a pancreatic neuroendocrine neoplasm. Surgical resection was performed, because the tumor was enlarged and chemotherapy resistant. The afferent loop with pancreatojejunostomy anastomosis was dissected, and CP, including pancreatojejunostomy anastomosis, was performed. Given the remnant pancreas was hard and atrophic, the pancreatic tail was transected using a stapler without reconstructing the small remnant pancreas. The patient experienced no postoperative complications including postoperative pancreatic fistula, and the endocrine function of the pancreas was preserved.ConclusionsWe present a case of remnant pancreatic CP that did not require reconstruction after PD. Preservation of the small remnant pancreas without reconstruction during CP may be feasible to maintain endocrine function in select patients after PD.

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

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

Pancreatic fistula after gastrectomy. Retrospective single-center analysis

Objective: to determine the frequency and risk factors for postoperative pancreatic fistula (POPF) after gastrectomy. Material and Methods. From January 1, 2018 to October 31, 2023, 198 patients with stage I–III gastric cancer underwent gastrectomy with D2 lymphadenectomy at a Regional Oncological Dispensary. The characteristics of the studied patients were assessed according to a unified protocol. Statistically significant factors influencing the development of POPF were identified. Results. The incidence of POPF was 18.7 % (37/198). It was found that not all pancreatic fistulas were accompanied by acute pancreatitis. Among the patients with POPF, 5 had associated acute pancreatitis: 2 with mild, and 3 with moderate severity; no severe acute pancreatitis was observed. The statistically significant indicator for the occurrence of POPF was the neutrophil-lymphocyte index (p=0.033), in the absence of other infectious phenomena. In addition, the following significant factors were identified: lymphadenopathy of regional lymph nodes (p=0.037), tumor stage (T criterion) (p=0.002), splenectomy (p&lt;0.001), and resection of the pancreas (p&lt;0.001). Conclusion. The frequency of postoperative pancreatic fistulas after gastrectomy was 18.7 %. Statistically significant factors for the development of POPF include resection of the pancreas, splenectomy, lymph node status, tumor size, and depth of invasion. An additional indicator for the development of POPF is an increase in the neutrophil-lymphocyte index 1 day after surgery.

Dunking Pancreaticojejunostomy With Braun's Jejunojejunostomy: Perioperative Outcomes of a Hundred Pancreaticoduodenectomies.

Background The optimal surgical technique for pancreaticojejunostomy (PJ) following pancreaticoduodenectomy (PD) is still debated. Dunking and duct-to-mucosa PJ are the most commonly adopted techniques. Incorporating Braun's jejunojejunostomy (JJ) could reducetheincidence and severity of delayed gastric emptying (DGE). This retrospective descriptive study seeks to clarify the outcomes of dunking PJ with Braun's JJ in 100 PD patients. Methodology We retrospectively reviewed 100 patients who underwent PDs in a single unit of the Department of Surgical Gastroenterology of Tribhuvan University Teaching Hospital from October 2012 to February 2023. Demographic and historical data, indications, procedure-related data, complications, and mortality data were collected and analyzed. Results The mean age was 50.96 ± 14.97 years, and 64 (64%) were males. The most common indication was ampullary carcinoma (53, 53%) followed by distal cholangiocarcinoma (18, 18%) and pancreatic ductal adenocarcinoma (7, 7%). Operative time was 5.83 ± 1.09 hours, intraoperative blood loss was 515 ± 194 mL, and the average time for PJ and Braun's JJ was 22 ± 6 and 15 ± 3 minutes, respectively. Soft pancreas was encountered in 52 (52%) patients and clinically significant postoperative pancreatic fistula (Grade B, C) was seen in 23 (23%). Postpancreatectomy hemorrhage was seen in 21 (21%) patients (Grades A: 3, B: 12, C: 6). DGE (Grade B) occurred in two (2%) patients, and bile leak was observed in 4% of patients (Grades A: 1, B: 2, C: 1). Major complications (Clavien-Dindo ≥IIIA) occurred in 24%, and 11 patients died. Conclusions The dunking technique is easily adaptable, less time-consuming, and can be performed in the pancreas of any texture or duct size but is associated with an increased incidence of post-pancreatectomy hemorrhage. Incorporation of Braun's anastomosis lowers DGE, allows early initiation of feeding, and reduces complication rates.