Postoperative Pancreatic Fistula Research Articles

Pancreatic Neuroendocrine Tumors: What Is the Best Surgical Option?

Background: Pancreatic neuroendocrine tumors (pNETs) represent a rare subset of pancreatic cancer. Functional tumors cause hormonal changes and clinical syndromes, while non-functional ones are often diagnosed late. Surgical management needs multidisciplinary planning, involving enucleation, distal pancreatectomy with or without spleen preservation, central pancreatectomy, pancreaticoduodenectomy or total pancreatectomy. Minimally invasive approaches have increased in the last decade compared to the open technique. The aim of this study was to analyze the current diagnostic and surgical trends for pNETs, to identify better interventions and their outcomes. Methods: The study adhered to the PRISMA guidelines, conducting a systematic review of the literature from May 2008 to March 2022 across multiple databases. Several combinations of keywords were used (“NET”, “pancreatic”, “surgery”, “laparoscopic”, “minimally invasive”, “robotic”, “enucleation”, “parenchyma sparing”) and relevant article references were manually checked. The manuscript quality was evaluated. Results: The study screened 3867 manuscripts and twelve studies were selected, primarily from Italy, the United States, and China. A total of 7767 surgically treated patients were collected from 160 included centers. The mean age was 56.3 y.o. Enucleation (EN) and distal pancreatectomy (DP) were the most commonly performed surgeries and represented 43.4% and 38.6% of the total interventions, respectively. Pancreatic fistulae, postoperative bleeding, re-operation, and follow-up were recorded and analyzed. Conclusions: Enucleation shows better postoperative outcomes and lower mortality rates compared to pancreaticoduodenectomy (PD) or distal pancreatectomy (DP), despite the similar risks of postoperative pancreatic fistulae (POPF). DP is preferred over enucleation for the pancreas body–tail, while laparoscopic enucleation is better for head pNETs.

The PAncreatic Surgery Composite Endpoint PACE – Development and Validation of a Clinically Relevant Endpoint Requiring Lower Sample Sizes

Abstract Background Single endpoints in prospective and randomized studies have become impractical due to their low frequency and the marginal benefit of new interventions. Aims To provide a composite endpoint in pancreatic surgery. Methods Data from prospective studies were used to develop (n=1273) and validate (n=544) a composite endpoint based on postoperative pancreatic fistula, post-pancreatectomy hemorrhage as well as reoperation and reinterventions. All patients had pancreatectomies of different extents. The association of the developed PAncreatic surgery Composite Endpoint (PACE) with prolonged length of hospital stay (LOS) >75th percentile and mortality were assessed. A single-institution database was used for external validation (n = 2666). Sample size calculations were made for single outcomes and the composite endpoint. Results In the internal validation cohort, the PACE demonstrated an AUC of 78.0%, a sensitivity of 90.4% and a specificity of 67.6% in predicting a prolonged LOS. In the external cohort, the AUC was 76.9%, the sensitivity 73.8% and the specificity 80.1%. The 90-day mortality rate was significantly different for patients with a positive versus a negative PACE both in the development and internal validation cohort (5.1% vs 0.9%; P< 0.001), as well as in the external validation cohort (8.5% vs 1.2%, P< 0.001). The PACE enabled sample size reductions of up to 80.5% compared to single outcomes. Conclusion The PACE performed well in predicting prolonged hospital stays and can be used as a standardized and clinically relevant endpoint for future prospective trials enabling lower sample sizes and therefore improved feasibility compared to single outcome parameters.

Laparoscopic Pancreaticoduodenectomy Combined With Portal-Superior Mesenteric Vein Resection and Reconstruction: Inferior-Posterior "Superior Mesenteric Artery-First" Approach.

Laparoscopic pancreaticoduodenectomy (LPD) with portal-superior mesenteric vein (PV/SMV) resection and reconstruction is increasingly performed. We aimed to introduce a safe and effective surgical approach and share our clinical experience with LPD with PV/SMV resection and reconstruction. We reviewed data for the patients undergoing LPD and open pancreaticoduodenectomy (OPD) combined with PV/SMV resection and reconstruction at the First Hospital of Jilin University between April 2021 and May 2023. The inferior-posterior "superior mesenteric artery-first" approach was used. We compared the preoperative, intraoperative, and postoperative clinicopathological data of the 2 groups to conduct a comprehensive evaluation of LPD with major vascular resection. A cohort of 37 patients with periampullary and pancreatic tumors underwent pancreaticoduodenectomy (PD) with major vascular resection and reconstruction, consisting of 21 LPDs and 16 OPDs. The LPD group had a longer operation time (322 vs. 235 min, P=0.039), reduced intraoperative bleeding (152 vs. 325mL, P=0.026), and lower intraoperative blood transfusion rates (19.0% vs. 50.0%, P=0.046) compared with the OPD group. The LPD group had significantly shorter operation times in end-to-end anastomosis (26 vs. 15 min, P=0.001) and artificial grafts vascular reconstruction (44 vs. 22 min, P=0.000) compared with the OPD group. There was no significant difference in the rate of R0 resection (100% vs. 87.5%, P=0.096). The length of hospital stay and ICU stay did not show significant differences between the 2 groups (15 vs. 18d, P=0.636 and 2.5 vs. 4.5d, P=0.726, respectively). However, the postoperative hospital stay in the LPD group was notably shorter compared with the OPD group (11 vs. 16d, P=0.007). Postoperative complication rates, including postoperative pancreatic fistula (POPF) Grade A/B, biliary leakage, and delayed gastric emptying (DGE), were similar between the two groups (38.1% vs. 43.8%, P=0.729). In addition, 1 patient in each group developed thrombosis, with vascular patency improving after anticoagulation treatment. LPD combined with PV/SMV resection and reconstruction can be easily and safely performed using the inferior-posterior "superior mesenteric artery-first" approach in cases of venous invasion. Further studies are required to evaluate the procedure's long-term outcomes.

Efficacy of Pancreatic Dissection With a Triple-row Stapler in Laparoscopic Distal Pancreatectomy: A Retrospective Observational Study.

Postoperative pancreatic fistulas (POPFs) occur after 20% to 30% of laparoscopic distal pancreatectomies. This study aimed to evaluate the clinical efficacy of laparoscopic distal pancreatectomy using triple-row staplers in preventing POPFs. Between April 2016 and May 2023, 59 patients underwent complete laparoscopic distal pancreatectomies. There were more females (n=34, 57.6%) than males (n=25, 42.4%). The median age of the patients was 68.9 years. The patients were divided into slow-compression (n=19) and no-compression (n=40) groups and examined for pancreatic leakage. Both groups were examined with respect to age, sex, body mass index (BMI), pancreatic thickness at the pancreatic dissection site, pancreatic texture, diagnosis, operative time, blood loss, presence of POPF, date of drain removal, and length of hospital stay. In addition, risk factors for POPF were examined in a multivariate analysis. Grade B POPFs were found in 9 patients (15.3%). Using univariate analysis, the operative time, blood loss, postoperative pancreatic fluid leakage, day of drain removal, and hospital stay were shorter in the no-compression group than in the slow-compression group. Using multivariate analysis, the absence of POPFs was significantly more frequent in the no-compression group (odds ratio, 5.69; 95% CI, 1.241-26.109; P=0.025). The no-compression pancreatic dissection method was a simple method for reducing POPF incidence. The method of quickly dissecting the pancreas without compression yielded better results than the method of slowly dissecting the pancreas with slow compression. This quick dissection without compression was a simple and safe method that minimized postoperative pancreatic fluid leakage, shortened the operative time and length of hospital stay, and reduced medical costs. Therefore, this method might be a clinically successful option.

Evaluation of Patients with Postoperative Pancreatic Fistula After Isolated Splenectomy: A Retrospective Study

Objective: Postoperative pancreatic fistula (POPF) is a potentially life-threatening complication. This complication occurs not only after pancreatic surgery but may also arise after other abdominal procedures. In this study, we aimed to determine the incidence and risk factors of POPF in patients undergoing isolated splenectomy. Methods: Patients who underwent isolated splenectomy were identified. POPF was defined according to the 2016 update of International Study Group of Pancreatic Fistula classification and graded as biochemical leak (BL), grade B fistula, and grade C fistula. Characteristics and perioperative variables were compared between patients who had pancreatic fistula and those who have not. Results: The study cohort consisted of 59 patients with median age 38.9 years, and 50.8% male. The indication was trauma in 18 (30.5%) patients. Twenty (33.9%) patients were operated upon emergently. Thirty-seven (62.7%) splenectomies were performed open. Out of all patients, 14 (23.7%) developed any sort of pancreatic fistula. BL occurred in 11 (18.6%) patients and 3 (5.1%) patients developed a grade B fistula. Comparison of patients with and without BL/POPF demonstrated no significant differences in demographics, surgical indication, operative method, surgical approach, or postoperative outcome. Conclusions: Despite higher incidence of pancreatic leak, the rate of clinically relevant fistula is relatively low. In this study, we did not identify any factors associated with BL/POPF. Thus, further studies are needed on pancreatic fistula after splenectomy.

How I do it. Pancreatojejunostomy: surgical tips to mitigate the severity of postoperative pancreatic fistulas after open or minimally invasive pancreatoduodenectomy.

Pancreatoduodenectomy is the most appropriate technique for the treatment of periampullary tumors. In the past, this procedure was associated with high mortality and morbidity, but with improvements in patient selection, anesthesia, and surgical technique, mortality has decreased to less than 5%. However, morbidity remains increased due to various complications such as delayed gastric emptying, bleeding, abdominal collections, and abscesses, most of which are related to the pancreatojejunostomy leak. Clinically relevant postoperative pancreatic fistula is the most dangerous and is related to other complications including mortality. The incidence of postoperative pancreatic fistula ranges from 5-30%. Various techniques have been developed to reduce the severity of pancreatic fistulas, from the use of an isolated jejunal loop for pancreatojejunostomy to binding and invagination anastomoses. Even total pancreatectomy has been considered to avoid pancreatic fistula, but the late effects of this procedure are unacceptable, especially in relatively young patients. Recent studies on the main techniques of pancreatojejunostomy concluded that duct-to-mucosa anastomosis is advisable, but no technique eliminates the risk of pancreatic fistula. The purpose of this study is to highlight technical details and tips that may reduce the severity of pancreatic fistula after pancreatojejunostomy during open or minimally invasive pancreatoduodenectomy.

Successful treatment for pseudoaneurysm following distal pancreatectomy with celiac axis resection without postoperative pancreatic fistula: a case report

BackgroundDistal pancreatectomy with celiac axis resection (DP–CAR) represents an innovative surgical approach for locally advanced pancreatic body cancer in cases involving celiac axis invasion. However, this procedure carries significant perioperative risks, including arterial aneurysms and organ ischemia. Understanding these risks is crucial for optimizing patient outcomes and guiding treatment decisions.Case presentationThis case report describes a unique case of a 74-year-old male patient who was diagnosed with locally advanced pancreatic body cancer with invasion of the celiac and splenic arteries. He underwent DP–CAR after six cycles of chemotherapy. His postoperative course was uneventful without any evidence of postoperative pancreatic fistula. However, at the 10-month postoperative follow-up, pseudoaneurysm was incidentally detected in the anterior superior pancreaticoduodenal artery by follow-up computed tomography. It was successfully treated with coil embolization. He had no signs of tumor recurrence or relapse of pseudoaneurysm formation 2 years postoperatively. This case report discusses the potential risks of pseudoaneurysm formation in patients undergoing DP–CAR due to hemodynamic changes. We emphasize the significance of close monitoring in such cases.ConclusionsThe case highlights the importance of recognizing and managing potential complications associated with DP–CAR in patients with pancreatic cancer. Despite its effectiveness in achieving complete resection, DP–CAR carries inherent risks, including the development of pseudoaneurysms. Vigilant surveillance and prompt intervention are crucial for optimizing patient outcomes and minimizing postoperative complications.

Risk factors and nomogram of clinically relevant pancreatic fistula after pancreaticoduodenectomy for periampullary cancer: A prospective multicenter cohort study

Abstract Background Clinically relevant postoperative pancreatic fistula (CRPF) is considered the most dangerous morbidity associated with pancreaticoduodenectomy (PD). The purpose of this study is to evaluate the risk factors and to construct a predicted model for CRPF after PD. Material and Methods Consecutive patients who underwent pancreaticoduodenectomy between August 2021 and October 2023 at Cho Ray Hospital and University Medical Center were included in a multicenter cohort research. Multivariate logistic regression analyses was used to identify the risk factors of CRPF, and a nomogram was built based on these factors. The value of the nomogram in predicting CRPF was evaluated using the area under the receiver operating characteristic (ROC) curve. Results There were 183 eligible patients in this study (mean age: 57.5 ± 12.6 years; 101 males), and the prevalence of CRPF was 13,7% overall. Multivariate analyses showed that, four risk factors related to CRPF, including preoperative serum albumin <3.5 g/dl, body mass index (BMI) ≥ 25 kg/m2, soft texture of the pancreas and estimated blood loss ≥400 ml were prognostic factors for CRPF (p < 0.05). We built a nomogram based on four variables to predict CRPF, and the area under the ROC curve for this nomogram was 0.855 (95% CI: 0,768 – 0,933). Conclusions Nomogram developed from four risk factors shows good performance to predict CRPF after PD. The clinical findings of this study will help surgeons identify perioperative risk factors for high-risk patients with pancreatic fistula who should be managed differently from other patients. Clinical Trial Registry number: ClinicalTrials.gov NCT05017207. Statement of Significance We successfully developed a nomogram to predict the risk of pancreatic fistula using four perioperative factors. By incorporating these risk factors into clinical practice, surgeons can develop appropriate treatment plans and interventions for high-risk patient populations, potentially reducing the morbidity associated with CRPF.

Retromesenteric omental flap as arterial coverage in pancreaticoduodenectomy: A novel technique to prevent postpancreatectomy hemorrhage

BackgroundClinically relevant postpancreatectomy hemorrhage occurs in 10% to 15% of patients after pancreaticoduodenectomy, mainly in association with clinically relevant postoperative pancreatic fistula. Prevention of postpancreatectomy hemorrhage by arterial coverage with a round ligament plasty or an omental flap is controversial. This study assessed the impact of arterial coverage with an original retromesenteric omental flap on postpancreatectomy hemorrhage after pancreaticoduodenectomy. MethodsThis single-center retrospective study included 812 open pancreaticoduodenectomies (2012–2021) and compared 146 procedures with arterial coverage using retromesenteric omental flap to 666 pancreaticoduodenectomies without arterial coverage. The Fistula Risk Score was calculated. The primary endpoint was a 90-day clinically relevant postpancreatectomy hemorrhage rate according to the International Study Group of Pancreatic Surgery classification. ResultsThere were more patients with a Fistula Risk Score ≥7 in the arterial coverage-retromesenteric omental flap group: 18 (12%) versus 48 (7%) (P < .01). Clinically relevant postpancreatectomy hemorrhage was less frequent in the arterial coverage- retromesenteric omental flap group than in the no arterial coverage group: 5 (3%) versus 66 (10%), respectively (P = .01). Clinically relevant postoperative pancreatic fistula occurred in 28 (19%) patients in the arterial coverage- retromesenteric omental flap group compared with 165 (25%) in the no arterial coverage group (P = .001). There were fewer reoperations for postpancreatectomy hemorrhage or postoperative pancreatic fistula in the arterial coverage- retromesenteric omental flap group: 1 (0.7%) versus 32 (5%) in the no arterial coverage group (P = .023). In multivariate analysis, arterial coverage with retromesenteric omental flap was an independent protective factor of clinically relevant postpancreatectomy hemorrhage (odds ratio 0.33; 95% confidence interval [0.12–0.92], P = .034) whereas postoperative pancreatic fistula of any grade (odds ratio = 10.1; 95% confidence interval: 5.1–20.3, P < .001) was predictive of this complication. ConclusionArterial coverage with retromesenteric omental flap can reduce rates of clinically relevant postpancreatectomy hemorrhage after pancreaticoduodenectomy. This easy and costless technique should be prospectively evaluated to confirm these results.

Thirty-day prevalence and clinical impact of fluid collections at the resection margin after distal pancreatectomy: Follow-up of a multicentric randomized controlled trial

BackgroundPostoperative fluid collections at the resection margin of the pancreatic stump are frequent after distal pancreatectomy, yet their clinical impact is unclear. The aim of this study was to assess the 30-day prevalence of postoperative fluid collections after distal pancreatectomy and the factors associated with a clinically relevant condition. MethodsPatients enrolled in a randomized controlled trial of parenchymal transection with either reinforced, triple-row staple, or ultrasonic dissector underwent routine magnetic resonance 30 days postoperatively. Postoperative fluid collection was defined as a cyst-like lesion of at least 1 cm at the pancreatic resection margin. Postoperative fluid collections requiring any therapy were defined as clinically relevant. ResultsA total of 133 patients were analyzed; 69 were in the triple-row staple transection arm, and 64 were in the ultrasonic dissector transection arm. The overall 30-day prevalence of postoperative fluid collections was 68% (n = 90), without any significant difference between the two trial arms. Postoperative serum hyperamylasemia was more frequent in patients with postoperative fluid collections than those without (31% vs 7%, P = .001). Among the postoperative fluid collection population, an early postoperative pancreatic fistula (odds ratio 14.9, P = .002), post pancreatectomy acute pancreatitis (odds ratio 12.7, P = .036), and postoperative fluid collection size larger than 50 mm (odds ratio 6.6, P = .046) were independently associated with a clinically relevant postoperative fluid collection. ConclusionPostoperative fluid collections at the resection margin are common after distal pancreatectomy and can be predicted by early assessment of postoperative serum hyperamylasemia. A preceding pancreatectomy acute pancreatitis and/or postoperative pancreatic fistula and large collections (>50 mm) were associated with a clinically relevant postoperative fluid collection, representing targets for closer follow-up or earlier therapeutic interventions.

Lipase-to-Amylase Ratio for the Prediction of Clinically Relevant Postoperative Pancreatic Fistula following Pancreaticoduodenectomy.

Postoperative pancreatic fistula(POPF) represents a leading cause of morbidity and mortality following major pancreatic resections. This study aimed to evaluate the use of post-operative drain fluid lipase-to-amylase ratio(LAR) for the prediction of clinically relevant fistulae(CR-POPF). Consecutive patients undergoing pancreaticoduodenectomy between 2017-2021 at a tertiary centre were retrospectively reviewed. Univariable and multivariable analyses were performed to identify predictors for CR-POPF(ISGPS Grades B/C). Receiver operator characteristic(ROC) curve analyses were conducted to evaluate the performance of LAR and determine optimum prediction thresholds. Among 130 patients, 28(21.5%) developed CR-POPF. Variables positively associated with CR-POPF included soft gland texture, acinar cell density, diagnosis other than PDAC or chronic pancreatitis, resection without neoadjuvant therapy, and postoperative drain fluid lipase, amylase, and LAR(all p < 0.05). Multivariable regression analysis identified LAR as an independent predictor of CR-POPF(p < 0.05). ROC curve analysis showed that LAR had moderate ability to predict CR-POPF on POD1(AUC = 0.64,95%CI = 0.54-0.74) and excellent ability on POD3(AUC = 0.85,95%CI = 0.78-0.92) and POD5(AUC = 0.86,95%CI = 0.79-0.92). Optimum thresholds were consistent over POD1-5 (ratio > 2.6) and associated with 92% sensitivity and 46-71% specificity. Postoperative drain fluid LAR represents a reliable predictor for the development of CR-POPF. With early prognostication, the postoperative care of patients deemed at risk of developing high-grade fistulas may be optimised.

Grading the Whipple’s procedure: a strategy for structured skill advancement in surgical training

Introduction: The Whipple’s procedure or pancreatoduodenectomy (PD), is recognized for its technical intricacy in surgical practice. This study aims to categorize PD into four types based on procedural complexity and anticipated postoperative outcomes, intending to integrate this classification into the progressive training of surgical fellows. Methods: In this retrospective cohort study, 242 PDs, performed by a single unit across multiple centers from January 2016 to December 2022, were categorized into four types based on technical complexity and extent of surgical intervention. These types were: Type 1 (dilated duct, firm pancreas), Type 2 (as Type 1 + vascular reconstruction), Type 3 (nondilated duct, soft pancreas), and Type 4 (as Type 3 + vascular reconstruction). The study assessed patient characteristics, surgical parameters, and perioperative morbidity and mortality, comparing the outcomes of the four PD types. Results: Type 1 PD was predominant (65.2%), with the lowest 30-day mortality (2.53%). Conversely, Type 4 PD, though least performed (3.3%), exhibited the highest mortality (25%) and major complications (25%). Statistically significant differences were noted in the incidence of clinically relevant-postoperative pancreatic fistula, delayed gastric emptying, and wound complications among the PD types, with overall surgical morbidity being higher in Types 3 and 4. Conclusion: In conclusion, our data compellingly links morbidity, such as postoperative pancreatic fistula, with the technical challenges of the procedure, even though not all mortality can be attributed solely to surgical factors. The implementation of this system offers a structured approach to surgical training, paving the way for trainees to adeptly navigate and proficiently perform this complex surgical technique.

Efficacy of pancreaticojejunostomy of the pancreatic stump during distal or central pancreatectomy.

A stapler is usually used for transection and closure of the pancreas in distal pancreatectomy (DP) or central pancreatectomy (CP). When the pancreas is transected to the right of the portal vein, it is difficult to use a stapler and clinically relevant postoperative pancreatic fistula (CR-POPF) frequently occurs. We report on the efficacy of pancreaticojejunostomy (PJ) of the pancreatic stump for patients in whom stapler use is difficult. Patients who underwent DP or CP were enrolled in this study. The pancreas was usually transected by a stapler, and ultrasonic coagulating shears (UCS) were used depending on the tumor situation. When using UCS, hand-sewn closure or PJ was performed for the pancreatic stump. The relationship between clinicopathological factors and the methods of pancreatic transection and closure were investigated. In total, 164 patients underwent DP or CP, and the pancreas was transected with a stapler in 150 patients and UCS in 14 patients. The rate of CR-POPF was higher and the postoperative hospital stay was longer in the UCS group than in the stapler group. PJ of the pancreatic stump, which was performed for 7 patients, did not worsen intraoperative factors. CR-POPF was not seen in these 7 patients, which was significantly less than that with hand-sewn closure. PJ of the pancreatic stump during DP or CP reduces CR-POPF compared with hand-sewn closure and may be useful especially when the pancreas is transected to the right of the portal vein.

Post operative pancreatic fistula associated with failure to rescue on pancreatic cancer undergoing pancreatic resection: a single centre experience

Pancreatic resection was known as the gold standard treatment for resectable pancreatic cancer. Post operative pancreatic fistula was common following pancreatic resection for tumor of the pancreas (head, body or tail of the pancreas). According to the Clavien-Dindo classification, the presence of the pancreatic fistula after resection was associated with increased rate of morbidity and mortality for the patients. We would evaluate cases of resectable pancreatic cancer (head and tail of the pancreas) undergoing open pancreatic resection in our centre (low volume centre). Post operative pancreatic fistula were evaluated by abdominal CT scanning and increased amylase level from intra peritoneal drain. The patients whose cannot survive after pancreatic resection were classified as failure to rescue. The presence of cardio-pulmonary morbidity was excluded from this study. Six cases were recorded in this study, 4 cases were head pancreatic cancer and 2 cases was tail pancreatic cancer. The histopathology results were acinar cell pancreatic cancer. Post operative pancreatic fistula was found on 1 case of head pancreatic cancer, classified as Clavien-Dindo grade IV, relaparotomy was done. This patient had sepsis associated post operative pancreatic fistula and can not survive during evaluation (on 14th post operative days). For the rest of the patients, there were no pancreatic fistula and had good outcome with no post operative morbidity. The presence of uncontrolled post operative pancreatic fistula was associated with failure to rescue on pancreatic cancer undergoing resection.

The detours of pancreatic ducts, internal pancreatic fistulas: a rare complication of chronic pancreatitis

Internal pancreatic fistula occurs due to the disruption of the pancreatic duct, resulting in communication with it and another epithelial surface. A rare variant is the pancreaticopleural and pancreaticogastric fistula, typically associated with chronic necrotising pancreatitis, resulting from posterior disruption of the pancreatic duct. It is a complex disease with different aetiologies, varied clinical presentations and multiple management options. Unlike postoperative pancreatic fistula, internal pancreatic fistula lacks guidelines for classification and management. Once an internal fistula is suspected, further imaging work-up and biochemical analysis needs to be performed. Here, we present an unprecedented case of pancreaticopleural fistula on a background of chronic necrotising pancreatitis, and an asymptomatic pancreatico-gastric fistula. To our knowledge, no such case has been previously reported.

Does perioperative hydrocortisone or indomethacin improve pancreatoduodenectomy outcomes? A triple arm, randomized placebo-controlled trial.

This trial evaluated whether anti-inflammatory agents hydrocortisone (H) and indomethacin (I) could reduce major complications after pancreatoduodenectomy (PD). Between June 2018 and June 2020, 105 patients undergoing PD with > 40% of acini on the intraoperative frozen section were randomized into three groups (35 patients per group): 1) intravenous H 100 mg 8 hourly, 2) rectal I suppository 100 mg 12 hourly, and 3) placebo (P) from postoperative day (POD) 0-2. Participants, investigators, and outcome assessors were blinded. The primary outcome was major complications (Clavien-Dindo grades 3-5). Secondary outcomes were overall complications (Clavien-Dindo grades 1-5), Clinically relevant postoperative pancreatic fistula (CR-POPF), delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), surgical site infections (SSI), length of stay, POD-3 serum amylase, readmission rate, and mortality. Major complications were comparable (8.6%, 5.7%, and 8.6% in groups H, I, and P, respectively). However, overall complications were significantly lower in group H than in group P (45.7% vs. 80.0%, p = 0.006). CR-POPF (14.3% vs. 25.7%, p = 0.371), PPH (8.6% vs. 14.3%, p = 0.710), DGE (8.6% vs. 22.9%, p = 0.188), and SSI (14.3% vs. 25.7%, p = 0.371) were comparable between groups H and P. Major complications and overall complications in group I were 5.7% and 60.0%, respectively, which were comparable to those in groups P and H. CR-POPF rates in groups H, I, and P were 14.3%, 17.1%, and 25.7%, respectively, which was comparable. H and I did not decrease major complications in PD.

The Impact of Body Mass Index on Multiple Complications, Respiratory Complications, Failure to Rescue and In-hospital Mortality After Laparoscopic Pancreaticoduodenectomy: A Single-Center Retrospective Study.

Background: Pancreaticoduodenectomy serves as the standard surgical treatment for periampullary tumors. Previous studies have suggested that high body mass index (BMI) is associated with an unfavorable prognosis following laparoscopic pancreaticoduodenectomy (LPD). However, the relationship between low BMI and postoperative complications remains unclear. Materials and Methods: A retrospective analysis of clinical data from 1130 patients who underwent LPD between April 2014 and December 2022 was conducted. Multivariate regression and restricted cubic spline analyses were utilized to explore the correlations between BMI and short-term outcomes, with adjustments for potential confounders. Results: Multivariable logistic regression revealed that overweight, obese, or severely underweight patients had an elevated risk of postoperative pancreatic fistula (POPF) compared to those with a normal BMI. Moreover, obesity was significantly correlated with a higher proportion of "failure to rescue." BMI exhibited a J-shaped relationship with respiratory complications and in-hospital mortality, a W-shaped relationship with multiple complications and anastomotic leakage (pancreatic fistula), and a U-shaped association with "failure to rescue" rates. The lowest risk was observed at BMI levels of 20 and 25 kg/m2 for multiple complications and pancreatic fistula, respectively. Conclusion: Both high and low BMI are identified as risk factors for the occurrence of postoperative POPF and in-hospital mortality following LPD. Notably, patients with higher BMI and severe underweight conditions are associated with an increased likelihood of "failure to rescue."

Analysis of the Short-Term Complications of Laparoscopic Pancreaticoduodenectomy in Patients with Metabolic Syndrome.

Objective: To investigate the impact of metabolic syndrome (MetS) on short-term complications of laparoscopic pancreaticoduodenectomy (LPD). Materials and Methods: We retrospectively analyzed perioperative data of patients who underwent LPD in our department from January 2020 to January 2022. The patients were divided into the MetS group and non-MetS group based on whether they had MetS. The incidence of postoperative complications and mortality rate was compared between the two groups. Results: The study involved 279 patients, with 30 having MetS and 249 without. However, the MetS and non-MetS groups differed significantly in terms of postoperative pancreatic fistula rate (26.6% versus 8.4%), abdominal infection rate (33.3% versus 10.0%), pulmonary complications rate (16.7% versus 6.42%), Clavien-Dindo ≥3 rate (20% versus 8.0%), multiple complications rate (23.3% versus 9.6%), percutaneous drainage rate (33.3% versus 10.0%), 90-day mortality rate (6.7% versus 1.2%), and length of postoperative hospital stay (15.00 ± 12.78 versus 10.63 ± 5.23 days). However, the two groups differed no significantly with respect to age, gender, American Society of Anesthesiologists score, preoperative CA125/CA199 levels, surgery time, specimen removal time, and intraoperative blood loss. Conclusion: MetS increases the incidence of postoperative complications and perioperative mortality rate in LPD.

Comparing cefazolin/ metronidazole, piperacillin-tazobactam, or c efoxitin as surgical antibiotic prophylaxis in patients undergoing pancreaticoduodenectomy: A retrospective cohort study.

Preoperative antibiotic options for pancreaticoduodenectomy (PD) include cefoxitin (CX), piperacillin-tazobactam (PT), or combined cefazolin and metronidazole (CM). Recent studies suggest the superiority of PT over CX, but evidence for CM is unclear. To explore the impact of preoperative antibiotic selection (CM vs. PT and CX vs. PT) on the development of surgical site infections (SSI). Consecutive adult patients at oneinstitution who underwent PDfrom November 2017 to December 2021 and received either CM, PT, or CX preoperatively, were included. The primary outcome was SSI. Secondary outcomes included postoperative infections and clinically significant postoperative pancreatic fistula (POPF). Logistic regression models were used. Among 127 patients included in the study, PT, CM, and CX were administered in 46 (36.2%), 44 (34.6%), and 37 (29.4%) patients, respectively. There were 32 (27.1%) SSI, 20 (36.1%) infections, and 21 (22.9%) POPF events. PT use was associated with reduced risk of SSI compared to CX (OR: 0.32, 95% CI: 0.11-0.89, p = 0.03), but there was no difference as compared to CM (OR: 0.75, 95% CI: 0.27-2.13, p = 0.59). There were no differences in secondary outcomes. PT reduced SSI rates compared to CX but was no different to CM among patients undergoing PDat our center.

Somatostatin vs. Octreotide for Prevention of Postoperative Pancreatic Fistula The PREFIPS Randomized Clinical Trial A FRENCH 007 - ACHBT Study.

Pharmacological prevention of postoperative pancreatic fistula (POPF) after pancreatectomy is open to debate. The present study compares clinically significant POPF rates in patients randomized between somatostatin versus octreotide as prophylactic treatment. Multicentric randomized controlled open study in patient's candidate for pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) comparing somatostatin continuous intravenous infusion for 7 days versus octreotid 100μg, every 8 hours subcutaneous injection for 7 days, stratified by procedure (PD vs. DP) and size of the main pancreatic duct (>4mm) on grade B/C POPF rates at 90 days based on an intention-to-treat analysis. Of 763 eligible patients, 651 were randomized: 327 in the octreotide arm and 324 in the somatostatin arm, with comparable the stratification criteria - type of surgery and main pancreatic duct dilatation. Most patients had PD (n=480; 73.8%), on soft/normal pancreas (n=367; 63.2%) with a non-dilated main pancreatic duct (n=472; 72.5%), most often for pancreatic adenocarcinoma (n=311; 47.8%). Almost all patients had abdominal drainage (n=621; 96.1%) and 121 (19.5%) left the hospital with the drain in place (median length of stay=16d). A total of 153 patients (23.5%) developed a grade B/C POPF with no difference between both groups: 24.1%: somatostatin arm and 22.9%: octreotide arm (Chi-2 test, P=0.73, ITT analysis). Absence of statistically significant difference persisted after adjustment for stratification variables and in per-protocol analysis. Continuous intravenous somatostatin is not statistically different from subcutaneous octreotide in the prevention of grade B/C POPF after pancreatectomy.