Postoperative Pancreatic Fistula Rate Research Articles

High serum CA19–9 preoperatively reduces POPF risk after pancreatoduodenectomy in PDAC

Recent groundbreaking work revealed CA19–9 is not only a tumor marker for PDAC. It also induces severe pancreatitis and promotes pancreatic fibrosis. The aim of this study was evaluation if due fibrosis CA19–9 may stratify for reduced postoperative pancreatic fistula (POPF) risk. Retrospective analysis of our institutional database of 954 consecutive patients having undergone PD between 2001 and 2018. Potential risk factors for POPF were evaluated. 436 (46%) patients with pancreatic ductal adenocarcinoma (PDAC) were analysed separately. POPF rate, degree of pancreatic fibrosis, inflammation and acinar cell area at the cut edge of pancreas (CEP) were investigated in correlation of CA19–9. The median age was 67 (range 9–89) years. 533 (56%) were male, 22% of patients developed clinically relevant POPF (CR-POPF). Overall postoperative mortality was 3.4%. Elevated preoperative CA19–9, elevated bilirubin and postoperative low serum amylase were significantly ( p <0.01) associated with a reduced POPF rate in patients with PDAC. In addition, elevated CA19–9 was significantly associated with more pancreatic fibrosis ( p <0.02), inflammation ( p <0.01) and acinar atrophy ( p <0.01). In our experience, increased CA19–9 correlates with pancreatic fibrosis and reduced CR-POPF. CA19–9 could be complementary for preoperative POPF-scores.

What is the pancreatic duct size limit for a safe duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy? A retrospective study

Backgrounds/AimsPostoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) remains a dreadful complication. Duct-to-mucosa pancreaticojejunostomy (DTMPJ) is a commonly performed anastomosis after PD. This study aims to evaluate whether there is a size limit of pancreatic duct below which POPF rate increases significantly after DTMPJ.MethodsA retrospective study was performed from a database with prospectively collected data on consecutive patients undergoing DTMPJ.ResultsBetween the years 2003 and 2019, a total of 288 patients with DTMPJ were recruited. POPF occurred in 56.3% of the patients, of which 43.8% were biochemical leak, 8.7% were grade B, and 1.4% were grade C. Overall operative morbidity was 51.4%, of which 19.1% were major complications. Five patients (1.7%) died within 90 days of operation. Patients with grade B/C POPF had significantly soft pancreas (p < 0.001), smaller duct size (p = 0.031), and a diagnosis of carcinoma of the pancreas (p = 0.027). When a clinically significant POPF rate was analysed based on the pancreatic duct diameter, pancreatic duct size ≤ 1 mm had the highest POPF rate (35.7%). There was a significant difference in POPF rate between adjacent ductal diameter ≤ 1 mm and > 1 mm to 2 mm (35.7% vs 13.3%; p = 0.040). Multivariable analysis showed that for the soft pancreas, pancreatic duct diameter ≤ 1 mm was the only significant predictive factor for POPF (p = 0.027).ConclusionsDTMPJ can be safely performed for pancreatic duct > 1 mm without significantly increased POPF risk.

Effect of Modified Blumgart Anastomosis on Surgical Outcomes After Pancreaticoduodenectomy.

Surgeons continue to be concerned about complications after pancreaticoduodenectomy, especially postoperative pancreatic fistula. Among the factors that cause postoperative pancreatic fistula, the pancreaticojejunostomy technique has stood out in recent studies. In this study, we aimed to compare the surgical outcomes, especially POPF, of the modified Blumgart and the traditional anastomosis techniques in patients who underwent pancreaticoduodenectomy. A total of 144 patients who underwent pancreaticoduodenectomy were divided into 2 groups according to the performed pancreaticojejunostomy technique (modified Blumgart anastomosis, n = 91 and traditional anastomosis, n = 53). Preoperative clinicodemographic data, perioperative findings, and postoperative results were compared between the groups. Additionally, factors associated with clinically relevant postoperative pancreatic fistula were analyzed. The modified Blumgart anastomosis group had lower clinically relevant postoperative pancreatic fistula rate than traditional anastomosis group (n = 8 (8.8%) versus n = 14 (26.4%), P = .005). On the contrary, the biochemical leakage rate was higher in the modified Blumgart anastomosis group (n = 30 (33%) versus n = 9 (17%), P = .037). While postoperative pancreatic fistula-related reoperation rate was lower (n = 2 (2.2%) versus n = 7 (13.2%), P = .013), the length of hospital stay was also shorter (11 days (5-47 days) versus 21 days (6-46 days), P < .001) in the modified Blumgart anastomosis group. Univariate and multivariate analyses revealed that modified Blumgart anastomosis was an independent and negative predictive factor for clinically relevant postoperative pancreatic fistula (odds ratio = 0.274, 95% confidence interval = 0.103-0.728, P = .009). Compared to the traditional anastomosis, modified Blumgart anastomosis decreases the rate of transition from biochemical leakage to clinically relevant postoperative pancreatic fistula and postoperative pancreatic fistula-related reoperation and also shortens the length of hospital stay. In addition, modified Blumgart anastomosis is an independent and negative predictive factor for the development of clinically relevant postoperative pancreatic fistula.

Analysis of Intraoperative Frozen Pancreatic Resection Margin and Prediction of Postoperative Pancreatic Fistula Risk During Pancreatoduodenectomy.

Pancreatic duct diameter and pancreatic texture are important predictive factors for a postoperative pancreatic fistula (POPF) and are assessed intraoperatively by the surgeon. However, surgical evaluation is arbitrary and difficult to objectify, especially in minimally invasive approaches in pancreatic surgery. We conducted a retrospective analysis of 275 patients that underwent pancreatoduodenectomy from 2012 to 2019 at our institution. Pancreatic duct diameter and pancreatic fibrosis were assessed by histopathologic examination of the pancreatic resection margin using intraoperative frozen sections and correlated with the occurrence of POPF and clinically relevant POPF (CR-POPF). The POPF and CR-POPF rates were 27% and 19%, respectively. Univariate analysis indicated that the indication for surgery, the surgically determined pancreatic duct diameter, and pancreatic texture, as well as the histopathologically determined pancreatic duct diameter and pancreatic fibrosis were significant predictive factors for POPF and CR-POPF. A multivariate analysis revealed histopathologically determined pancreatic duct diameter and pancreatic fibrosis as independent risk factors for POPF (OR [odds ratio] 2.3 [1.1 to 4.5], p = 0.022 and OR 2.4 [1.1 to 5.1], p = 0.023, respectively) and CR-POPF (OR 2.2 [1.1 to 4.8], p = 0.037 and OR 2.6 [1.1 to 6.1], p = 0.036). Histopathologically determined pancreatic duct diameter and pancreatic fibrosis are quantitatively measurable independent risk factors for POPF and CR-POPF. An intraoperative objective histopathologic evaluation of these parameters using frozen sections could support the surgical assessment of the pancreatic duct diameter and the pancreatic texture.

Reinforced duct-mucosa anastomosis (REDMA). New alternative after cephalic duodepancreatectomy

IntroductionOf the possible complications after a cephalic duodenopancreatectomy (CPD), the clinically relevant postoperative pancreatic fistula (PPF) is the most important, especially in patients with pancreas of a soft consistency. The main objective of this work is to analyze the different postsurgical complications, with special emphasis on the rate of PPF on soft pancreas with a risk of moderate/high PPF, and its incidence between the two different types of sutures used by our group (classic vs reinforced duct-mucosa anastomosis [REDMA]). MethodsRetrospective observational study, between January 2017 and March 2020, of patients undergoing CPD in our unit after applying the inclusion and exclusion criteria. Analysis of preoperative, intraoperative factors and postoperative complications observed during follow-up. ResultsSample of 34 patients; 67.6% (n = 23) of them under the classic protocol and 32.4% (n = 11) with REDMA. The only post-surgical complication in which we obtained statistical repercussion, without differences between cases and controls in terms of the risk of FPP, in favor of the REDMA anastomosis is that of FPP. Thanks to this surgical innovation, both the complications from stage IIIb, according to the Clavien-Dindo classification, and the mean hospital stay have also been reduced with statistical significance. ConclusionsWhen REDMA reduces the rate of PPF in patients with moderate/high surgical risk of it, we consider it to be a useful alternative to consider in the reconstruction of transit after CPD.

Robotic central pancreatectomy: a systematic review and meta-analysis.

Central pancreatectomy is usually performed to excise lesions of the neck or proximal body of the pancreas. In the last decade, thanks to the advent of novel technologies, surgeons have started to perform this procedure robotically. This review aims to appraise the results and outcomes of robotic central pancreatectomies (RCP) through a systematic review and meta-analysis. A systematic search of MEDLINE, Embase, and Web Of Science identified studies reporting outcomes of RCP. Pooled prevalence rates of postoperative complications and mortality were computed using random-effect modelling. Thirteen series involving 265 patients were included. In all cases but one, RCP was performed to excise benign or low-grade tumours. Clinically relevant post-operative pancreatic fistula (POPF) occurred in 42.3% of patients. While overall complications were reported in 57.5% of patients, only 9.4% had a Clavien-Dindo score≥III. Re-operation was necessary in 0.7% of the patients. New-onset diabetes occurred postoperatively in 0.3% of patients and negligible mortality and open conversion rates were observed. RCP is safe and associated with low perioperative mortality and well preserved postoperative pancreatic function, although burdened by high overall morbidity and POPF rates.

Correlation between Fistula Risk Score with Post Operative Pancreatic Fistula - A Single Centre Indian Study

Introduction: Post operative pancreatic fistula (POPF) is a major cause of morbidity and mortality of pancreatic surgeries done for management of malignancy or chronic pancreatitis. This study was undertaken in our centre as an introspective into the rate of POPF and its predictability assessment. Aims and Objectives: To look for the incidence of POPF in Medical College, Kolkata, India and its correlation with the existing Fistula Risk Score (FRS). Methods: This was a retrospective single centre study. All the existing records of patients undergoing Pylorus preserving pancreaticoduodenectomy(PPPD) and pancreatic drainage or resection procedures were evaluated. POPF and FRS were defined as per the latest International Study Group on Pancreatic Fistula (ISGPF) 2016 guideline. Results: From 2016 to 2021, 31 patients underwent PPPD and 45 patients underwent pancreatic drainage or resection procedures. Of these, seven patients developed POPF. Three patients had only biochemical leak and 2 had Grade B and 1 had Grade C leak. All were from PPPD group. The mean FRS was 2. Three patients had soft pancreatic parenchyma. The mean Main Pancreatic Duct(MPD) diameter was 3.5mm. Conclusion: This study reflects an encouraging data carrying cumulative incidence of POPF of 9.21% comparable with the world data (3%-45%). It carries a mortality risk of nearly 1%. In our centre one patient succumbed. No statistically significant correlation found (correlation coefficient 0.022) between rate of POPF and FRS. Post operative hospital stay was found to be significantly prolonged with POPF,17.62 days with POPF vs 13.36 days without POPF(p- value: 0.045 ).

Outcomes Following Pancreatoduodenectomy in Octogenarians in Scotland

Background: The benefit of pancreatoduodenectomy (PD) in patients over 80 is not well established. The outcomes of patients undergoing PD in Scotland over a ten year period were evaluated to determine efficacy of this procedure in elderly patients. Methods: Data from all patients who had undergone PD in Scotland from 2007-2017 were collated. Primary outcome was overall survival and secondary outcomes included post-operative morbidity, mortality rates and rates of procedure specific morbidity – post-operative pancreatic fistula (POPF), delayed gastric emptying (DGE) and post-procedure haemorrhage (PPH). Outcomes for those over 80 years were compared with patients under 80. Results: 1102 patients underwent PD during the study period of which 30 (2.7%) were over 80. Overall survival for over 80s was 18.7 months compared with 33 months for under 80s (p=0.002). For patients over 80 with pancreatic adenocarcinoma, median survival was 12.5 months compared with 21 months for those under 80 (p=0.06). There was no significant difference in length of stay - 15 days (over 80s) versus 14 days (under 80s) p=0.85; major morbidity - 10% (over 80s) versus 16.4% (under 80s) p=0.2; and 90 day mortality - 10% (over 80s) versus 6.4% (under 80s) p=0.44. No significant difference was observed in rates of POPF, PPH or DGE. Conclusions: Low numbers of patients over 80 in Scotland undergo PD and overall survival is reduced in this group. Short term outcomes in patients over 80 are comparable to younger patients however, and access to surgery in this group could potentially be improved by prehabilitation.

High-risk Pancreatic Anastomosis vs. Total Pancreatectomy after Pancreatoduodenectomy: Postoperative Outcomes and Quality of Life Analysis

Introduction: Outcomes of high-risk pancreatoduodenectomy (HR-PD) and TP have never been compared. We sought to evaluate total pancreatectomy (TP) as an alternative to pancreatoduodenectomy (PD) in patients at high-risk for postoperative pancreatic fistula (POPF). Methods: All patients who underwent PD or TP between July 2017 and December 2019 were identified. HR-PD was defined according to the alternative Fistula Risk Score. Postoperative outcomes (primary endpoint), pancreatic insufficiency and quality of life after 12 months of follow-up (QoL) were compared between HR-PD or planned PD intraoperatively converted to TP (C-TP). Results: A total of 566 patients underwent PD and 136 underwent TP during the study period. One hundred one (18%) PD patients underwent HR-PD, while 86 (63%) TP patients underwent C-TP. Postoperatively, the patients in the C-TP group exhibited lower rates of post-pancreatectomy hemorrhage (15% vs 28%), delayed gastric emptying (16% vs 34%), sepsis (10% vs 31%), and Clavien-Dindo ≥3 morbidity (19% vs 31%) and had shorter median lengths of hospital stay (10 vs 21 days) (all p< 0.05). The rate of POPF in the HR-PD group was 39%. Mortality was comparable between the two groups (3% vs 4%). Although general, cancer- and pancreas-specific QoL were comparable between the HR-PD and C-TP groups, endocrine and exocrine insufficiency occurred in all the C-TP patients, compared to only 13% and 63% of the HR-PD patients respectively, and C-TP patients had worse diabetes-specific QoL. Conclusions: C-TP may be considered rather than HR-PD only in few selected cases and after adequate counselling.Tabled 1CharacteristicsTotal, No. (%) (N= 187)HR-PD= 101C-TP= 86P-valuePostoperativePOPF, No. (%)39 (39)Abscess, No. (%)39 (21)28 (28)11 (13)0.01PPH, No. (%)41 (22)28 (28)13 (15)0.03DGE, No. (%)48 (26)34 (34)14 (16)<0.01Sepsis, No. (%)40 (21)31 (31)9 (10)<0.01LOS, median (range), days16 (5-289)21 (6-289)10 (5-62)<0.01Clavien-Dindo ≥3, No (%)47 (25)31 (31)16 (19)0.05Mortality, No. (%)7 (4)4 (4)3 (3)0.6 Open table in a new tab

The Modified Blumgart Anastomosis for Pancreaticojejunostomy Reduces the Occurrence of Post-Operative Hemorrhage and Sever Postoperative Pancreatic Fistula: A Case Control Study

Introduction: The modified Blumgart anastomosis (m-BA) for pancreaticojejunostomy is assumed to decrease the rate of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) and has been widely introduced to clinical practice. The aim of this study was to evaluate whether the m-BA method improved the short-term outcomes of pancreaticojejunostomy in patients who underwent PD.

Is Central Pancreatectomy an Effective Alternative for Distal Pancreatectomy for Low-grade Pancreatic Body Tumors: A 20-Year Single-Center Propensity Score-Matched Case-Control Study

Introduction: Central pancreatectomy (CP) is associated with a higher rate of postoperative pancreatic fistula (POPF) rate and is less preferred to distal pancreatectomy (DP). The study was done to compare the short and long-term outcomes between the CP and DP in low-grade pancreatic body tumors.

Reinforced Duct-Mucosa Anastomosis (REDMA). New Technique after Cephalic Duodepancreatectomy

Introduction: Of the possible complications after a cephalic duodenopancreatectomy (CPD), the clinically relevant postoperative pancreatic fistula (PPF) is the most important, especially in patients with pancreas of a soft consistency. The main objective of this work is to analyze the different postsurgical complications, with special emphasis on the rate of PPF on soft pancreas with a risk of moderate/high PPF, and its incidence between the two different types of sutures used by our group (classic vs reinforced duct-mucosa anastomosis [REDMA]).

The Influence of Procedural Volume on Short-Term Outcomes for Robotic Pancreaticoduodenectomy

Introduction: An increasing number of robotic pancreaticoduodenectomies (RPD) are reported, with benefits in reduced complications and shortened postoperative stay. However, questions remain on the number of procedures needed for gaining technical proficiency in RPD and the impact of procedure volume on outcomes. Therefore, we aimed to assess the influence of procedure volume on short-term RPD morbidity and operative variables. Methods: A retrospective review of consecutive RPD cases performed by a single surgeon was undertaken. Cumulative sum (CUSUM) analysis was performed to identify the procedure volume threshold, following which before-threshold and after-threshold outcomes were compared. Results: Since May 2017, 57 patients underwent an RPD at our institution. The median operative time was 360 min (IQR 300 – 445 min). The overall morbidity (Clavien-Dindo grade ≥3) in the cohort was 27.1%. The postoperative pancreatic fistula rate was 8.3% (all grade A), while the re-operation rate was 6.3%. CUSUM analysis has identified 20 cases as proficiency threshold, indicated by curve inflexion (Figure 1). Median operative time was significantly shorter after the threshold of 20 cases (470 min vs 320 min, p<0.001). However, no significant difference between before- and after-threshold groups in median Clavien-Dindo complication grade (0.5 vs 1.5, p=0.675) was found. Conclusion: A decrease in operative time after 20 RPD cases suggests a threshold of technical proficiency potentially associated with an initial adjustment to new instrumentation, port placement and standardisation of operative step sequence. Nonetheless, no clinically meaningful decrease in short-term morbidity was found during the initial learning phase, suggesting its safety.

The Impact of Preoperative Biliary Stenting on Postoperative Pancreatic Fistula Rates

Introduction: Preoperative biliary stenting (PBS) prior to pancreatoduodenectomy (PD) remains controversial and has been associated with bile contamination, microbiome changes and increased risk of postoperative pancreatic fistula (POPF). This study evaluates the impact of PBS on the risk of clinically relevant (CR)-POPF after PD in a national cohort of patients. Methods: Patients with biliary obstruction (total bilirubin >1.2 mg/dl) that underwent elective PD were identified in the American College of Surgeons-NSQIP dataset (2014-2019). A validated modified Fistula Risk Score (FRS) was used to stratify this cohort into two groups (low FRS ≤6, high FRS >6). Within each group, patient factors, PBS use, CR-POPF and postoperative outcomes were analyzed. Multivariate regression model was used to assess factors associated with CR-POPF. Results: Out of 3864 patients that underwent PD, 3109 (80%) received PBS, 1579 (41%) had a high-FRS and 2285 (59%) had a low-FRS. The rate of CR-POPF was 15%, 24.5%, and 8.5% for the entire cohort, high-FRS and low-FRS groups, respectively. The rate of CR-POPF was similar with (15.1%) and without PBS (14.7%) In both low- and high-FRS groups, PBS was not associated with increased risk for CR-POPF (8.3% vs 9.2% and 25% vs 23%). However, in the low-FRS group, PBS was associated with a reduced LOS (OR 0.7, 95% CI=0.51-0.92, p=0.012) and increased infectious complications (OR 1.6, 95% CI=1.19-2.24, p=0.003). Conclusion: In this retrospective study of a national cohort of PD patients, PBS was not associated with an increased risk of CR-POPF in both low- and high-FRS groups.Tabled 1EP02D-062 Table 1. Multivariable Model*VariablesLow FRSHigh FRSOdds RatioCI (95%)P-ValueOdds RatioCI (95%)P-ValueCR-POPFPBS0.9420.652-1.3630.7531.2590.926-1.7120.142Prolonged LOSPBS0.6820.506-0.9190.0120.9160.659-1.2730.601Infectious ComplicationsPBS1.631.186-2.2410.0031.2170.889-1.6650.221*Adjusted for Mortality, CR-POPF, Prolonged (LOS >14 days), Discharge-not-to-home Open table in a new tab *Adjusted for Mortality, CR-POPF, Prolonged (LOS >14 days), Discharge-not-to-home

Outcomes of Surgical Resection of Pancreatic Cystic Neoplasms Based on the European Expert Consensus Statement: A Prospective Observational Study

Background: The most common types of true epithelial exocrine pancreatic cystic neoplasms are serous cystic neoplasms (SCNs), mucinous cystic neoplasms (MCNs), intra-ductal papillary mucinous neoplasms (IPMNs), and solid pseudo-papillary neoplasms (SPPNs). Both open and laparoscopic pancreatic surgeries are major procedures with significant morbidity and mortality rates. This study aimed to determine the outcomes of laparoscopic pancreatic surgery in managing true exocrine epithelial pancreatic cystic neoplasms in terms of postoperative pancreatic fistula and recurrence rate and to identify associated risk factors.

Comparison of Postoperative Pancreatic Fistula Rates of Laparoscopic Versus Robotic Pancreaticojejunostomy after Pancreaticoduodenectomy in Soft Pancreas with Small Pancreatic Duct; a Multi-Center Study with a Propensity Score Matching Analysis

Introduction: Soft pancreatic texture and small pancreatic duct were well known risk factors of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD). This study aims to compare the POPF rates and other surgical outcomes of laparoscopic versus robotic pancreaticojejunostomy(PJ) in risky pancreas. Method: Between October 2012 to June 2020, total of 429 cases of minimally invasive PD were performed by three surgeons in three different institutions. Among those patients, 201 patients with soft pancreas and small pancreatic duct less than 3 mm were included based on preoperative image study and the operative record. Propensity score matching analysis was performed. Results: 118 totally laparoscopic PD, 49 totally robotic PD, and 34 hybrid PD (laparoscopic resection and robotic anastomosis) were performed. 69 patients underwent laparoscopic PJ and 69 patients underwent robotic PJ were selected after propensity score matching. Demographics of the patients were comparable. Pancreatic duct diameter was similar in both groups (1.8±0.4 mm vs 1.8±0.5 mm, p=1.00). Operative time was shorter in RPJ group (456.1±83.2 vs 405.1±75.4, p=<0.01). Incidence of clinically relevant POPF greater than grade B was comparable in laparoscopic and robotic PJ group (14.5 % vs 11.6 %, p=0.80). Biochemical leakage, grade B, and grade C pancreatic fistulas were 46.4%, 14.5% and 0.0% in laparoscopic PJ group, respectively, and 31.9%, 11.6% and 0.0% in robotic PJ group. Conclusions: Risk of POPF of laparoscopic or robotic PJ in soft texture and small duct was comparable by experienced surgeons. Robotic approach may be beneficial saving operative time.

Postoperative Outcomes Analysis After Pancreatic Duct Occlusion: A Safe Option to Treat the Pancreatic Stump After Pancreaticoduodenectomy in Low-Volume Centers

Background: Surgical resection is the only possible choice of treatment in several pancreatic disorders that included periampullar neoplasms. The development of a postoperative pancreatic fistula (POPF) is the main complication. Despite three different surgical strategies that have been proposed–pancreatojejunostomy (PJ), pancreatogastrostomy (PG), and pancreatic duct occlusion (DO)–none of them has been clearly validated to be superior. The aim of this study was to analyse the postoperative outcomes after DO.Methods: We retrospectively reviewed 56 consecutive patients who underwent Whipple's procedure from January 2007 to December 2014 in a tertiary Hepatobiliary Surgery and Liver Transplant Unit. After pancreatic resection in open surgery, we performed DO of the Wirsung duct with Cyanoacrylate glue independently from the stump characteristics. The mean follow-up was 24.5 months.Results: In total, 29 (60.4%) were men and 19 were (39.6%) women with a mean age of 62.79 (SD ± 10.02) years. Surgical indications were in 95% of cases malignant diseases. The incidence of POPF after DO was 31 (64.5%): 10 (20.8%) patients had a Grade A fistula, 18 (37.5%) Grade B fistula, and 3 (6.2%) Grade C fistula. No statistical differences were demonstrated in the development of POPF according to pancreatic duct diameter groups (p = 0.2145). Nevertheless, the POPF rate was significantly higher in the soft pancreatic group (p = 0.0164). The mean operative time was 358.12 min (SD ± 77.03, range: 221–480 min). Hospital stay was significantly longer in patients who developed POPF (p < 0.001). According to the Clavien-Dindo (CD) classification, seven of 48 (14.58%) patients were classified as CD III–IV. At the last follow-up, 27 of the 31 (87%) patients were alive.Conclusions: Duct occlusion could be proposed as a safe alternative to pancreatic anastomosis especially in low-/medium-volume centers in selected cases at higher risk of clinically relevant POPF.

P-P29 The glycated haemoglobin (HbA1c) test is not a predictor of pancreatectomy specific complications or survival

Abstract Background The glycated haemoglobin (HbA1c) test is a venous blood test used as a diagnostic test for diabetes mellitus and to monitor glucose control in patients known to have diabetes. The test has been recommended by National Institute for Health Care Excellence (NICE) clinical guidelines in the pre-operative setting since 2016. The purpose of testing is to reduce perioperative morbidity and mortality by optimising management of blood glucose levels in the perioperative period. The aim of this study was to assess the prognostic value of HbA1c in pancreatic cancer patients treated with pancreaticoduodenectomy. Methods This is a retrospective analysis of a prospectively managed database of pancreatic resections at a single institution from January 2016 to December 2020. Included patients had confirmed pancreatic adenocarcinoma and underwent a pancreaticoduodenectomy with preoperative measurement of their HbA1c. Patients who were already prescribed insulin were excluded. Demographic data, survival, operative and perioperative details were collected. Included patient records were assessed for the incidence of postoperative complications in accordance with International Study Group of Pancreatic Surgery guidelines for pancreatic fistula, delayed gastric emptying and post pancreatectomy haemorrhage. An HbA1c greater than 41 was deemed elevated. Results There were 145 patients who met the inclusion criteria. The HbA1c level was normal in 101/145 (70%) and elevated in 44/45 (30%). The postoperative pancreatic fistula rate was 18% in the patients with a normal HbA1c and 23% in those with elevated HbA1c (p = 0.499). The rate of delayed gastric emptying was 21 and 23% in the patients with normal and elevated HbA1c respectively. There were five relaparotomies overall, one of these patients had an elevated preoperative HbA1c. There were no perioperative deaths. Overall survival was 31months (95%CI 27-35) with a normal preoperative HbAlc and 32months (95%CI 27-38) if elevated. Conclusions There is little doubt that the preoperative HbA1c is helpful in the package of preoperative assessment tests to optimise patients for surgery. However, the preoperative HbA1c level in patients planned for pancreaticoduodenectomy is not predictive of pancreaticoduodenectomy specific complications such as postoperative pancreatic fistula, delayed gastric emptying, relaparotomy or mortality. In addition, long-term overall survival is not influenced by an elevated preoperative HbAlc.

P-P39 Perioperative Interventions to Reduce Pancreatic Fistula following Pancreaticoduodenectomy: A Systematic Review and Meta-Analysis

Abstract Background Many studies evaluate interventions to reduce POPF following PD, but often report conflicting results. Previous meta-analyses have generally included non-randomised trials and not considered novel interventions. Aim To evaluate interventions to reduce postoperative pancreatic fistula (POPF) following pancreatoduodenectomy (PD) with level 1 data. Methods A systematic review and meta-analysis assessed randomised controlled trials (RCTs) evaluating interventions to reduce All-POPF or clinically relevant (CR)-POPF after PD. A post-hoc analysis of negative RCTs assessed whether these had appropriate levels of statistical power. Results Among 22 interventions (n = 7,512 patients, 55 studies), 12 were assessed by multiple studies, and subject to meta-analysis. Of these, external pancreatic duct drainage was the only intervention found to be associated with significantly reduced rates of CR- and all-POPF. In addition, Ulinastatin was associated with significantly reduced rates of CR-POPF, whilst invagination (vs duct to mucosa) pancreatojejunostomy was associated with significantly reduced rates of all-POPF. Review of negative RCTs found the majority to be underpowered, with post-hoc power calculations indicating that interventions would need to reduce the POPF rate to ≤ 1% in order to achieve 80% power in 16/34 (All-POPF) and 19/25 (CR-POPF) studies, respectively. Conclusions Meta-analysis supports a role for several interventions to reduce POPF after PD, although data is often inconsistent and/or based on small trials. Systematic review identifies other interventions which may benefit from further study. However, underpowered trials appear to be a fundamental problem, inherently more so with CR-POPF. Larger trials, or new directions for research are required to further understanding in this field.

Incidence and impact of postoperative pancreatic fistula after minimally invasive and open distal pancreatectomy

BackgroundPrevious studies reported a higher rate of postoperative pancreatic fistula after minimally invasive distal pancreatectomy compared to open distal pancreatectomy. It is unknown whether the clinical impact of postoperative pancreatic fistula after minimally invasive distal pancreatectomy is comparable with that after open distal pancreatectomy. We aimed to compare not only the incidence of postoperative pancreatic fistula, but more importantly, also its clinical impact. MethodsThis is a post hoc analysis of a multicenter randomized trial investigating a possible beneficial impact of a fibrin patch on the rate of clinically relevant postoperative pancreatic fistula (International Study Group for Pancreatic Surgery grade B/C) after distal pancreatectomy. Primary outcomes of the current analysis are the incidence and clinical impact of postoperative pancreatic fistula after both minimally invasive distal pancreatectomy and open distal pancreatectomy. ResultsFrom October 2010 to August 2017, 252 patients undergoing distal pancreatectomy were randomized, and data of 247 patients were available for analysis: 87 minimally invasive distal pancreatectomy and 160 open distal pancreatectomies. The postoperative pancreatic fistula rate after minimally invasive distal pancreatectomy was significantly higher than that after open distal pancreatectomy (28.7% vs 16.9%, P = .029). More patients were discharged with an abdominal surgical drain after minimally invasive distal pancreatectomy compared to open distal pancreatectomy (30/87, 34.5% vs 26/160, 16.5%, P = .001). In patients with postoperative pancreatic fistula, additional percutaneous catheter drainage procedures were performed less often (52% vs 84.6%, P = .012), with fewer drainage procedures (median [range], 2 [1–4] vs 2, [1–7], P = .014) after minimally invasive distal pancreatectomy. ConclusionIn this post hoc analysis, the postoperative pancreatic fistula rate after minimally invasive distal pancreatectomy was higher than that after open distal pancreatectomy, whereas the clinical impact was less.