Postoperative Pancreatic Fistula Research Articles

Reconsidering Abdominal Drainage After Left Pancreatectomy - The Randomized Controlled PANDRA II Trial.

Intraabdominal drainage following left pancreatectomy (LP) has been a longstanding practice to mitigate postoperative complications, particularly postoperative pancreatic fistulas (POPF). Recent studies challenge the necessity of routine drainage, suggesting potential benefits in omitting drains. The PANDRA II trial was a randomized controlled non-inferiority study conducted at the University Hospital Heidelberg between 2017 and 2023. It compared outcomes between patients undergoing open or minimally-invasive LP with and without abdominal drainage. The primary endpoint was overall postoperative morbidity assessed by the Comprehensive Complication Index (CCI). A total of 246 patients were included in the intention-to-treat analysis (125 with drainage, 121 without drainage). The no-drain group demonstrated non-inferiority to the drain group in terms of CCI (13.90 ± 16.51 vs. 19.43 ± 16.92, P<0.001 for non-inferiority). Moreover, the no-drain group had lower overall complication rates (50.41% vs. 78.40%, P<0.001). Specific complications such as POPF (14.88% vs. 20.8%, P=0.226) and postpancreatectomy hemorrhage (PPH) (4.96% vs. 4.80%, P>0.999) did not differ significantly between groups. The results of the PANDRA II trial demonstrate that omitting routine abdominal drainage after LP is non-inferior to placing a routine abdominal drainage regarding morbidity measured by the CCI. Omitting a routine abdominal drainage even led to a significant reduction of the overall complication rate.

Hemorrhage after pancreaticoduodenectomy

To analyze the incidence, clinical manifestations and treatment of post-pancreaticoduodenectomy hemorrhage in patients with pancreaticoduodenal tumors. There were 362 pancreaticoduodeneectomies for ductal adenocarcinoma of the pancreatic head and pancreatoduodenal tumors in 2016-2023. Post-pancreatectomy hemorrhage (PPH) occurred in 52 (14.4%) patients. Delayed post-pancreatectomy hemorrhage followed postoperative pancreatitis, pancreatic fistula or non-drained fluid collections. Bleeding was diagnosed considering clinical manifestations with verification through contrast-enhanced CT. Emergency re-laparotomy was required in 15 (28.8%) patients with unstable hemodynamics; 9 (60%) people died. Thirty-seven patients with stable hemodynamics underwent emergency contrast-enhanced CT and subsequent endovascular hemostasis. Bleeding was stopped in 31 patients (89.2%). Endovascular hemostasis was ineffective in 1 patient who underwent re-laparotomy. We found no the cause of bleeding in 3 patients, and there was no hemorrhage recurrence. Six (18.7%) people died. The overall mortality among patients with PPH was 28.8% (15 out of 52 postoperative patients). PPH follows postoperative pancreatitis, pancreatic fistula or non-drained fluid collection. In case of stable hemodynamics, endovascular hemostasis is preferable for this complication.

Serosal Patching with Glubran®2 on the Pancreatic Stump for Reducing Postoperative Pancreatic Fistulae After Robot-Assisted Distal Pancreatectomy: A Single-Center Retrospective Study

Background: Postoperative pancreatic fistulae (POPFs) are a significant cause of morbidity following left pancreatectomy. We hypothesized that incorporating serosal patching with the application of a synthetic sealant, a modified cyanoacrylate (Glubran®2), to the pancreatic stump, would decrease the incidence rate of clinically significant POPFs. Methods: This is a retrospective study of consecutive patients who underwent robot-assisted left pancreatectomy. The primary outcome was clinically significant POPFs within 90 days of surgery. Secondary outcomes included the incidence rate of POPFs (all the grades), 90-day morbidity, and 90-day mortality. Results: We compared outcomes between Glubran®2 sealant with serosal patching (GSP, n = 6) and Glubran®2 sealant without serosal patching (GNSP, n = 12) groups. The GSP group had significantly lower incidence rates of clinically significant POPFs (grades B/C) (p = 0.034) and overall POPFs (all the grades) (p = 0.046). No significant differences in 90-day postoperative morbidity were observed between the two groups (p = 0.56), and no 90-day mortality occurred in either group. Conclusions: Incorporating serosal patching along with Glubran®2 sealant in the management of the pancreatic stump during left pancreatectomy demonstrates promising results in reducing the incidence rate of clinically significant POPFs. This finding highlights the need for further research with larger sample sizes in order to confirm the observed outcomes and explore the long-term implications for postoperative complications and recovery in patients undergoing this procedure during pancreatic surgery.

Preoperative stereotactic radiotherapy to prevent pancreatic fistula in high-risk patients undergoing pancreatoduodenectomy (FIBROPANC): prospective multicentre phase II single-arm trial.

Postoperative pancreatic fistula is the main driver of morbidity and mortality after pancreatoduodenectomy. In high-risk patients, the rate of postoperative pancreatic fistula approaches 50%, whereas it is below 5% in patients with pancreatic cancer who receive neoadjuvant chemoradiotherapy. The aim of this study was to evaluate the safety, feasibility, and efficacy of preoperative stereotactic body radiotherapy on the pancreatic neck transection margin in high-risk patients undergoing pancreatoduodenectomy to prevent postoperative pancreatic fistula. In this prospective multicentre open-label single-arm trial (progressing from a safety run-in phase to a phase II design), patients undergoing pancreatoduodenectomy for neoplasms other than pancreatic ductal adenocarcinoma received a single preoperative stereotactic body radiotherapy dose of 12 Gy. Primary endpoints included safety (less than or equal to 15% grade 3-5 toxicity), feasibility (a significant change in pancreatic texture measured using a durometer), and efficacy (a 15% reduction in the grade B/C postoperative pancreatic fistula rate compared with patients from the Dutch Pancreatic Cancer Audit who were eligible but not included in this study). Secondary endpoints assessed tissue fibrosis (collagen density). Overall, 38 patients were included, of whom 33 (87%) completed the study protocol and were included in the per-protocol analysis. The safety cut-off was met, with 3% grade 3-5 toxicity. Pancreatic tissue treated with stereotactic body radiotherapy showed increased firmness using a durometer (median of 47 (interquartile range 36-57) versus 37 (interquartile range 30-41) Shore OO units; P < 0.001) and a higher collagen density (median of 6.1% (interquartile range 4.4%-9.5%) versus 4.6% (interquartile range 2.5%-7.4%); P = 0.003). The grade B/C postoperative pancreatic fistula rate with stereotactic body radiotherapy was 57.6% (95% c.i. 41% to 74%), compared with 34% (95% c.i. 27% to 42%) in audit controls (P = 0.011). Preoperative stereotactic body radiotherapy is safe in high-risk patients undergoing pancreatoduodenectomy and increases parenchymal firmness and fibrosis, but fails to show evidence of efficacy.

Impact of pancreatic tumour biomechanics on diagnosis and post-operative complications.

756 Background: Around 600 people are diagnosed with pancreatic cancer in Ireland each year, with 90% of these having pancreatic ductal adenocarcinoma (PDAC). Five-year survival for PDAC is around 10%. PDAC upregulates stromal collagen formation which contributes to tissue stiffness. Stiffer pancreatic tumours have worse oncological outcomes due to faster progression and increased chemoresistance. Softer pancreata, conversely, are more likely to develop post-operative pancreatic fistulae (POPF), a significant post-pancreatectomy complication. While incorporated in risk scores, softness is currently determined by subjective intra-operative observation. Methods: Atomic force microscopy (AFM) is the gold standard technique used to measure biomechanics at a cellular length scale. We obtained fine needle biopsies (FNBs) of pancreatic tumours during diagnostic endoscopic ultrasound. This is the first time tissue biomechanics have been measured from pancreatic biopsies. Separately, we applied this technique to pancreatic tumours and adjacent normal tissue following resection. We also assessed collagen organisation in these pancreatic tumours to understand its contribution to the observed mechanical properties. Results: Of the patients with PDAC who underwent FNB, those presenting with metastatic disease had significantly stiffer tumours than those without, 1,490 Pa (SD 2,048.03 Pa) vs 250 Pa (SD 555.06 Pa) (p&lt;0.0001). Neuroendocrine tumours exhibited larger variance compared to PDAC (p &lt; 0.0001), SD 5,885.97 Pa vs SD 1,797.23 Pa. Regarding tumours which have undergone curative resection, tumour stroma is significantly stiffer than both cancer and benign epithelium. The collagen strands in this stroma are straighter, more numerous, and more packed than epithelial tissues. Pancreata which develop post-operative pancreatic fistulae (POPF) are softer than those which do not 96.42 Pa (SD 691.14 Pa) vs 343.99 Pa (SD 1,678.37 Pa). Conclusions: We describe a novel technique to measure the biomechanical properties of pancreatic biopsies. Using this technique, we now have the opportunity to measure these properties for the first time on all pancreatic tumours, including those presenting with unresectable disease. It is possible to distinguish between different types of tumour based on the biomechanical profile of biopsies. Previous ex vivo studies have linked stiffer tumours to a higher metastatic potential, and our results are the first to suggest that this may be true in a human population. In resected tumours, we confirm the anecdotal belief that softer pancreata are associated with POPF. Overall, this research demonstrates that tissue biomechanics has potential diagnostic and prognostic applications in pancreatic cancer.

Impact of Biodegradable Stent on Pancreatic Leakage After Pancreatoduodenectomy – Systematic Review

Purpose: Postoperative pancreatic fistula (POPF) is a serious complication following pancreatoduodenectomy, due to the risk of complications related to the leak. Intraoperative internal and external stenting of the pancreaticojejunostomy, have been used as a prophylactic measure with mixed results and with a risk of complications. Biodegradable stents could be a potential way to avoid complications associated with traditional stents and reduce the risk of pancreatic leaks and fistulas. Methods: A systematic review was conducted to investigate the effectiveness of biodegradable stents in reducing POPF after pancreatoduodenectomy. Studies using biodegradable stents and reporting the incidence of POPF were included. Reviews, case reports, and non-English studies were excluded. Results: Eight observational studies with a total of 155 patients were included. A meta-analysis was conducted, and the pooled incidence of POPF was around 7% (18 out 155 patients). Apart from one study (comparing biodegradable stent to regular stent), there were no comparator groups. Using ROBINS-I tool to assess the risk of bias, there was overall a moderate risk of bias. Conclusion: Biodegradable stents may be associated with lower risk of POPF. However, the observational design of the studies, the risk of bias and sample sizes, reduced the significance of the results. Well-designed randomized controlled trials are needed to assess the effectiveness.

Novel Robotic Valvuloplastic Esophagogastrostomy Technique After Proximal Gastrectomy: A Safety and Feasibility Study.

Esophagogastrostomy is one of the reconstruction techniques after proximal gastrectomy, but reflux and esophagitis are significant concerns. We introduced a new robotic valvuloplasty technique (single-flap), taking advantage of robotic surgery to address these issues and simplify the technique, especially for tumors with esophageal invasion. Between March 2022 and March 2024, patients who underwent robotic proximal gastrectomy with the single-flap technique were included. Based on the difficulty of the surgery, patients were divided into 2 groups: one with esophageal invasion requiring anastomosis in the mediastinum and the second group with tumors in the upper third of the stomach requiring anastomosis in the abdomen. A total of 22 patients were included: 13 in the esophageal invasion group and 9 in the upper stomach group. The median size of esophageal invasion was 2cm (1 to 3cm). The median operative time was 320 minutes (esophageal invasion 326 vs. upper stomach 280min, P=0.51), with a median blood loss of 35g (31 vs. 38g, P=0.19). No postoperative mortality, anastomotic leaks, reflux symptoms, or pancreatic fistulas were observed. Eighteen patients underwent endoscopic evaluation, and no sign of esophagitis was detected. Five patients (22.7%) developed grade III strictures requiring endoscopic balloon dilation (esophageal invasion 32.1% vs. upper stomach 22.2%; P=0.96). Robotic proximal gastrectomy with single-flap valvuloplastic esophagogastrostomy is a safe and feasible option for gastroesophageal junction tumors with up to 3cm of esophageal invasion.

Surgical and oncological implications of the presence of hepatic artery anatomical variations in patients undergoing pancreaticoduodenectomy: a single center experience.

The presence of an aberrant right hepatic artery (a-RHA) could influence the oncological and postoperative outcomes after pancreaticoduodenectomy (PD). A comparative study was conducted, including patients who underwent PD with a-RHA or with normal RHA anatomy. The primary endpoints were R1 resection in all margins (pancreatic, anterior, posterior, superior mesenteric artery, and portal groove), overall survival (OS), and disease-free survival (DFS). The secondary endpoints were morbidity, mortality, biliary leak (BL), postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), post pancreatectomy hemorrhage (PPH), length of stay (LOS), and operative time (OT). The selection bias was measured using the d-value and limited using entropy balancing analysis. Patients with arterial variants were 84 (37.5%), 39 (17.4%) of whom had a-RHA from SMA. The patients with a-RHA were more frequently symptomatic (d = 0.652), often affected by PDAC (d = 0.369), and judged borderline resectable (d = 0.588). Neoadjuvant therapy was more frequently proposed for patients with a-RHA (d = 0.465). The patients with a-RHA often had the Wirsung dilated compared to those without a-RHA (d = 0.336). After bias correction, the R1 resection rate on the superior mesenteric artery (SMA) margin was higher in the a-RHA group than in patients with normal RHA anatomy (OR 2.3; 1.1-5.2; P = 0.045). OS, DFS, morbidity, mortality, biliary leak (BL), postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), post pancreatectomy hemorrhage (PPH), length of stay (LOS), and operative time (OT) were similar in unmatched and matched population. The presence of a-RHA seems to increase the risk of R1 resection in the SMA margin.

Positive drain fluid culture on postoperative day one is associated with an increased risk of late postoperative pancreatic fistula after pancreaticoduodenectomy

PurposeTo investigate the risk factors for late postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy (PD), with a focus on positive drain fluid culture (DFC) results on postoperative day (POD) 1.MethodsMedical records of 198 patients who underwent PD with drain fluid amylase (DFA) on POD 5 < 3x upper limit of normal (ULN) were included. Late POPF was defined as POPF diagnosed post-POD 6, with DFA on POD 5 < 3xULN. Risk factors analyses were performed, with a focus on DFC on POD 1.ResultsNineteen patients (9.6%) were diagnosed with late POPF. Age > 65 years (OR: 4.019, P = 0.034) and positive DFC on POD 1 (OR: 10.151, P < 0.001) were identified as independent predictors of late POPF. Patients with positive DFC on POD 1 (n = 25) had higher rates of late POPF (44% vs. 4.6%, P < 0.001), postpancreatectomy hemorrhage (20% vs. 5.8%, P = 0.027) and Clavien–Dindo ≥ IIIa complications (44% vs. 6.4%, P < 0.001). The majority of patients (57.9%) with late POPF had positive DFC on POD 1 (11 of 19, 57.9%). The isolates from 11 patients with positive DFC on POD 1 yielded 12 microorganisms, the most prevalent of which were Enterobacter (n = 7), followed by Enterococcus (n = 3) and Staphylococcus (n = 2). Cefmetazole resistance was detected in 66.7% (8 of 12) of the microorganisms.ConclusionAge > 65 years and positive DFC on POD 1 were independent predictors of late POPF after PD. Positive DFC on POD 1 was associated with a higher rate of complications.

Suture material in pancreticojejunal anastomosis: a systematic review.

Post-operative pancreatic fistula is a common and morbid complication of pancreaticojejunal anastomosis. While gastrointestinal anastomosis is typically performed using absorbable sutures, this issue has prompted experimentation with non-absorbable sutures. This study aims to assess the available literature to provide recommendations on suture choice in this anastomosis. Two independent reviewers performed searches of EMBASE, MEDLINE, PubMed, Google Scholar, and the Cochrane Library of Systematic Review. References were screened for additional articles. Articles comparatively assessing suture choice in pancreaticojejunal anastomosis were included. Of 2237 records screened, nine articles were included in this review. Suture materials assessed include polydioxanone, polyglactin 910, polyglycolic acid, polypropylene, polyester, silk, nylon, plain and chromic catgut, and polybutester. Clinical studies suggested polyester reduced rates of fistula formation. Ex vivo findings favoured polydioxanone and polyglactin 910. 5-0 was found to be favourable to 6-0 in duct-to-mucosa anastomosis with monofilament absorbable sutures. Barbed sutures were suggested to reduce fistula formation. Limitations were identified in many of the included articles. There is limited research available on this topic, and it is not possible to strongly recommend any single suture as superior to others. Polyester is promising in clinical studies, and would benefit from further studies assessing validity. Polydioxanone and polyglactin 910 have rational indications for use. In particular, polydioxanone is suggested when poor healing is expected. Barbed sutures may reduce rates of fistula formation. More research is required to draw a strong conclusion.

Impact of robotic surgery on postoperative pancreatic fistula for high-risk pancreaticojejunostomy after pancreatoduodenectomy.

The safety and feasibility of robotic pancreatoduodenectomy (RPD) in high-risk patients with postoperative pancreatic fistula (POPF) have rarely been investigated, although the rate of POPF is lower than in open pancreatoduodenectomy (OPD). This study aimed to examine the impact of robotic surgery on POPF in high-risk patients after pancreatoduodenectomy (PD). This retrospective analysis included 204 patients who underwent RPD between January 2018 and June 2023. Of the 204 patients, 126 with high-risk POPF were included. The outcomes of RPD and OPD were compared. Multivariate analyses were conducted to identify risk factors associated with the development of clinically relevant POPF (CR-POPF) after surgery. Of the 126 patients, 50 underwent RPD and 76 underwent OPD. The incidence of CR-POPF was significantly lower in the RPD group than in the OPD group (6.0% vs. 38.2%, P < 0.001). Multivariate analyses identified OPD as an independent risk factor associated with CR-POPF (odds ratio [OR]: 7.87, 95% confidence interval [CI]: 2.11-29.4, P = 0.002). This study demonstrated the impact of robotic surgery on POPF in high-risk patients after PD. These results suggest that RPD may be significantly associated with a decreased incidence of CR-POPF in high-risk anastomoses.

ASO Author Reflections: The Effects of Perioperative Corticosteroids on Postoperative Complications After Pancreatoduodenectomy: A Debated Topic of Systematic Review and Meta-analysis.

Pancreatoduodenectomy (PD) is a complex surgery with high morbidity and mortality, often associated with complications like post-pancreatectomy hemorrhage (PPH) and postoperative pancreatic fistulas (POPF). The corticosteroids administered intraoperatively has been shown to improve postoperative outcomes in patients undergoing surgery. However, their impact on complications following PD remains controversial. A comprehensive review of literature found no significant impact of perioperative corticosteroids on postoperative complications in PD, including postoperative major complications (PMCs), POPF, infectious complications, delayed gastric emptying (DGE), post-pancreatectomy hemorrhage (PPH), bile leakage, reoperation, or 30-days mortality. Other medications, such as octreotide, antibiotics, and probiotics, have shown potential in reducing complications, but further research is needed, especially for corticosteroids in PD. In the near future, more randomized controlled trials should be conducted, along with well-designed clinical studies, to provide high-level evidence for the potential benefits of corticosteroids in PD for targeted populations.

Huscher modified technique for robotic pancreaticojejunostomy: a video report.

Pancreaticojejunostomy (PJ) is a critical step in pancreaticoduodenectomy (PD), often complicated by the risk of postoperative pancreatic fistula (POPF). This video report demonstrates a novel robotic PJ technique employing a self-expandable metallic stent. The method involves the use of the Da Vinci Xi robotic system and the WallFlex™ Biliary RX Stent for improved anastomotic support, particularly in high-risk cases defined by soft pancreatic texture and narrow duct diameter (<3 mm). Key steps include precise deployment of the self-expandable stent using a modified Seldinger technique and completion of the anastomosis with barbed sutures. The self-expandable stent dynamically adapts to the pancreatic duct, reducing tension and enhancing ductal drainage during the critical postoperative period, without requiring balloon expansion or fluoroscopy. This innovation addresses limitations associated with traditional stents and facilitates robotic procedures. Compared to Huscher's use of coronary artery stents (CAS), this technique offers simplicity and adaptability to minimally invasive settings. Outcomes of the robotic PJ approach highlight potential benefits, including reduced POPF rates and improved anastomotic precision. The integration of barbed sutures enhances efficiency and reproducibility, though considerations of pancreatic tissue fragility remain essential. This report underscores the feasibility and advantages of combining advanced robotic surgery with innovative stenting techniques to optimize outcomes in pancreatic surgery.

Predicting Factor for Occurrence of Postoperative Pancreatic Fistula in Patients with Pancreatic Neuroendocrine Tumors

Background: Neuroendocrine tumors are tumors that can develop in any organ but show a predilection for the pancreas. These can be secreting or non-secreting tumors, or they can be well differentiated or poorly differentiated, or neuroendocrine carcinomas. Surgical treatment is the only treatment with curative intent, but postoperatively, it shows an increased incidence of postoperative pancreatic fistulas. Methods: We carried out a retrospective study which included 26 patients with neuroendocrine tumors and neuroendocrine carcinomas, for whom we performed cephalic duodenopancreatectomies, distal pancreatic resections or enucleation. Results: In our study group, the incidence of pancreatic fistulas was 28%, and a series of risk factors such as the type of surgery (duodenopancreatectomy and enucleation were associated with the highest incidence of POPF), histological type (pancreatic neuroendocrine carcinomas were associated with lowest incidence of POPF), obesity (the incidence of POPF was double in the obese group), functioning tumors (with p = 0.032 and AUC = 746) and dynamic hemoglobin value (AUC = 705 shows a good predicting power, with a cutoff value = 1.8 drop hemoglobin) were indicated. Conclusions: Neuroendocrine tumors show a predisposition for the occurrence of postoperative complications, especially postoperative pancreatic fistulas. There are multiple risk factors that interact in the production of postoperative complications.

Pancreatic Fistula and Intraabdominal Fluid Collections after Distal Pancreatectomy: Incidence, Implications, and Natural History.

To investigate the incidence and management of pancreatic fistula and fluid collections (FC) after distal pancreatectomy (DP). Pancreatic fistula and FC are common after DP. The relationship between pancreatic fistula, FC, and surgical drain placement remains unclear. We retrospectively reviewed patients who underwent DP at a single institution between June 2000 and August 2023. 1,212 patients were reviewed. Amongst them, 300 (24.9%) developed a biochemical leak, and 162 (13.4%) developed a postoperative pancreatic fistula (POPF). Of the 949 patients who had at least one postoperative cross-sectional imaging, 500 (52.7%) had a FC. Most FCs were asymptomatic (68%); however, when associated with POPF, the majority (n=121, 89%) became symptomatic and required treatment. Patients with POPF were significantly more likely to develop FC (OR 9.49), whereas biochemical leakage did not significantly increase this risk. Surgical drains did not significantly decrease the likelihood of FC (52% vs. 66%, P=0.06), but did increase POPF (13.9% vs. 4.7%, P<0.001) and the need for intervention for FC (33.6% vs. 12.9%, P=0.019). FC develop in over half of the patients undergoing DP, with approximately one-fourth of these cases associated with POPF. In most instances, FC remain asymptomatic; however, when linked to POPF, they are nine times more likely to become symptomatic and require therapeutic intervention. Although surgical drain placement may not contribute to FC, it was associated with a higher rate of POPF.

Perioperative risk factors for overall survival of patients with pancreatic ductal adenocarcinoma underwent laparoscopic pancreaticoduodenectomy.

The postoperative overall survival of patients with pancreatic ductal adenocarcinoma is not optimal. The aim of this study was to explore the perioperative risk factors for overall survival after laparoscopic pancreaticoduodenectomy (LPD) in patients with pancreatic ductal adenocarcinoma (PDAC). From January 2015 to January 2022, consecutive patients who underwent LPD with a pathological diagnosis of PDAC at our center were included in the study. LASSO regression and multivariate Cox regression were used to explore perioperative risk factors associated with overall survival. A total of 159 patients were included in the study. The median overall survival was 21months. In the multivariate analysis, the level of direct bilirubin in serum (HR: 1.01, 95% CI 1.00-1.02, P = 0.043), postoperative pancreatic fistula (HR: 0.36, 95% CI 0.18-0.86, P = 0.010), and adjuvant therapy after surgery within 12weeks (HR: 0.53, 95% CI 0.34-0.83, P = 0.001) were identified as independent risk factors associated with overall survival. A high level of direct bilirubin in the serum, happened with postoperative pancreatic fistula and delayed postoperative adjuvant therapy are prognostic risk factors affecting the overall survival of patients with PDAC after LPD.

Total Pancreatectomy for Locally Advanced Pancreatic Adenocarcinoma with Coeliac Trunk Resection and Retrograde Gastric Revascularization Through Aorto-Hepato-Spleno Allograft.

Locally advanced pancreatic adenocarcinomas (LA-PDAC) are more frequently operated now than in the past because of new regimen chemotherapy and improvement in surgical technique.1 Resection of the coeliac trunk (CT) during pancreatoduodenectomy (PD) or total pancreatectomy (TP) is not routinely done owing to the risk of liver and gastric ischaemia.2 In this video, a patient with LA-PDAC underwent TP with CT resection and retrograde gastric revascularization through the distal splenic artery. A 57-year-old male with LA-PDAC at the head-neck junction with circumferential invasion of the CT and the mesentericoportal axis showed excellent response to chemotherapy (FOLFIRINOX, 12 cycles) and radiotherapy (54 Gy) with normalization of tumour markers. One year later, TP instead of PD was decided to avoid postoperative pancreatic fistula.3 An allograft (en Y) from bank vessels was anastomosed between the aorta and the propre hepatic artery. For gastric revascularization and to avoid the small left gastric artery, the arterial anastomosis was done on the distal part of the splenic artery, allowing retrograde vascularization through short gastric vessels. Segmental venous resection was done. Venous and arterial liver ischaemia times were 11 min and 31 min, respectively. The postoperative outcome showed asymptomatic pseudoaneurysm on the hepatic anastomosis. Pathology confirmed T1cN1R0. Nine months after surgery, no recurrence was observed. CT resection may be needed during PD. If the right gastric pedicle cannot be preserved, retrograde gastric revascularization through the splenic artery is an important technical modification. The availability of allografts from bank vessels is very useful, and the outcome is mitigated by TP.

Risk factors for delayed gastric emptying after pancreatoduodenectomy: a 10-year retrospective study

Background Delayed gastric emptying (DGE) is a frequent complication of pancreatoduodenectomy (PD) and is associated with prolonged hospital stay, readmission, increased hospital costs and decreased quality of life. However, the pathophysiology of DGE remains unclear. Methods This is a retrospective study of patients who underwent PD for pancreatic or periampullary tumours. All these patients were operated between January 2012 and February 2023. The patients were divided into four groups according to the development of DGE after PD: No DGE, DGE grade A, DGE grade B and DGE grade C. The groups were compared in terms of outcomes and complications. We also analysed the preoperative and perioperative risk factors for DGE development. Results Between January 2012 and February 2023, a total of 250 patients underwent PD. These patients were divided into four groups: No DGE (n = 152); DGE grade A (n = 42); DGE grade B (n = 45); and DGE grade C (n = 11). The incidence of the postoperative pancreatic fistulas (POPFs) grade B/C was significantly higher in the DGE grade C group (p < .001), and the rates of post-pancreatectomy haemorrhage (p = .004) and reoperation (p < .001) were significantly higher in the DGE grade B/C groups. A significantly higher rate of grade III–IV Clavien–Dindo complications (p < .001), longer intensive care unit (p < .001) and longer hospital stays (p < .001) were observed in the DGE grade C group; and 90-day mortality (p < .001) and morbidity (p < .001) were significantly higher in the DGE grade B/C groups. Multivariate analysis demonstrated that the POPF grade B/C was a risk factor of DGE grade B/C (OR: 9.147; 95%CI: 4.125–20.281; p < .001). Conclusions POPF B/C is a risk factor for grade B/C DGE. Prevention of surgical complications and early treatment could contribute to the decreased incidence of DGE.

Combined robotic/open pancreaticoduodenectomy in the young aged < 50years.

Impact of age on surgical and survival outcomes after combined robotic/open pancreaticoduodenectomy (CR/OPD) has not been extensively studied. This study aimed to evaluate the surgical and survival outcomes of patients aged < 50years who underwent CR/OPD. A comparative study was conducted on patients who underwent CR/OPD divided into two groups: the young (age < 50years) and the old (age ≥ 50years). A total of 555 patients were included in this study, with 53 (9.5%) in the young group and 502 (90.5%) in the old group. Periampullary adenocarcinomas were less common in the young group (32.1% vs. 76.5%), whereas solid and pseudopapillary tumors (9.4% vs. 1.0%) and neuroendocrine tumors (15.1% vs. 3.6%) were more common. Soft pancreatic parenchyma (77.4% vs. 76.5%) and non-dilated (≤ 3mm) pancreatic ducts (77.4% vs. 62.5%) were more prevalent in the young group. The young group had a shorter length of stay (median, 16 vs. 20days). No significant differences were observed in the other surgical outcomes and risks, including postoperative pancreatic fistula (POPF) (7.5% vs. 8.0%). Survival outcomes for overall periampullary adenocarcinoma favored the young group, with a 5-year survival rate of 76.4% vs. 46.7% in the old group. In conclusion, RPD in the young patients (< 50years) is associated with comparable surgical outcomes and favorable survival outcomes for periampullary adenocarcinoma compared with the older patients (≥ 50years). These findings highlight the feasibility and safety of RPD in the young population, although the prevalence of soft pancreatic parenchyma and non-dilated pancreatic ducts was higher in the young group.

Pretreatment red blood cell distribution width as a predictive marker for postoperative complications after laparoscopic pancreatoduodenectomy.

Red blood cell distribution width (RDW) is associated with the development and progression of various diseases. To explore the association between pretreatment RDW and short-term outcomes after laparoscopic pancreatoduodenectomy (LPD). A total of 804 consecutive patients who underwent LPD at our hospital between March 2017 and November 2021 were retrospectively analyzed. Correlations between pretreatment RDW and clinicopathological characteristics and short-term outcomes were investigated. Patients with higher pretreatment RDW were older, had higher Eastern Cooperative Oncology Group scores and were associated with poorer short-term outcomes than those with normal RDW. High pretreatment RDW was an independent risk factor for postoperative complications (POCs) (hazard ratio = 2.973, 95% confidence interval: 2.032-4.350, P < 0.001) and severe POCs of grade IIIa or higher (hazard ratio = 3.138, 95% confidence interval: 2.042-4.824, P < 0.001) based on the Clavien-Dino classification system. Subgroup analysis showed that high pretreatment RDW was an independent risk factor for Clavien-Dino classification grade IIIb or higher POCs, a comprehensive complication index score ≥ 26.2, severe postoperative pancreatic fistula, severe bile leakage and severe hemorrhage. High pretreatment RDW was positively associated with the neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio and was negatively associated with albumin and the prognostic nutritional index. Pretreatment RDW was a special parameter for patients who underwent LPD. It was associated with malnutrition, severe inflammatory status and poorer short-term outcomes. RDW could be a surrogate marker for nutritional and inflammatory status in identifying patients who were at high risk of developing POCs after LPD.