Risk Factors For Pancreatic Fistula Research Articles

Dorsal Subcutaneous Fat Thickness as a Risk Factor for Pancreatic Fistula After Gastric Cancer Surgery.

Recently, there have been many reports on the use of preoperative body composition analysis to predict postoperative complications in gastric cancer surgery, most of which used 3D image analysis software for the measurements. This study aimed to evaluate the risk of postoperative infectious complications (PICs), especially pancreatic fistulas, using a simple measurement method incorporating only preoperative computed tomography images. A total of 265 patients with gastric cancer underwent laparoscopic or robot-assisted gastrectomy with lymph node dissection at Osaka Metropolitan University Hospital between 2016 and 2020. To simplify the measurement method, we measured the length of each region of the subcutaneous fat area (SFA). Each area included a) umbilical depth, b) thickness of the longest ventral subcutaneous fat, c) thickness of the longest dorsal subcutaneous fat, and d) thickness of the median dorsal subcutaneous fat (MDSF) measurements. PICs occurred in 27 of 265 cases, of which pancreatic fistula was present in 9. SFA for pancreatic fistulas showed high diagnostic accuracy (area under the curve=0.922). Among the subcutaneous fat lengths, the MDSF was the most useful, and the optimal cut-off value was 16 mm. MDSF and non-expert surgeons were found to be independent risk factors for pancreatic fistula. Since the possibility of developing pancreatic fistula is high in cases with MDSF ≥16 mm, careful surgical strategies, such as having a skilled physician, are necessary.

Anatomical Position of the Pancreas as a Risk Factor for Pancreatic Fistula after Laparoscopic Gastrectomy for Gastric Cancer.

Laparoscopic gastrectomy is more frequently associated with postoperative pancreatic fistula than is open gastrectomy. We assumed that compression of the pancreas with various devices to obtain a proper operative view is associated with the higher incidence of PF in LG and that the extent of the compression differs depending on the anatomical position of the pancreas. The present study aimed to elucidate the correlation between the anatomical position of the pancreas and PF after LG for gastric cancer. Patients who underwent LG for gastric cancer from 2005 to 2019 were retrospectively reviewed. Two anatomical parameters representing the height of the slope looking down the celiac artery from the top of the pancreas (P-A length) and the steepness of the slope (UP-CA angle) were measured in computed tomography sagittal projections. The correlation between PF and (1) P-A length, (2) UP-CA angle, and (3) other clinicopathological factors was analyzed using a logistic regression model. Among 3485 patients, grade ≥ II PF was observed in 140 (4.0%) patients. The UP-CA angle [odds ratio (OR), 2.472; 95% confidence interval (CI), 1.725-3.543; P < 0.001], a high BMI (OR 2.339; 95% CI 1.634-3.348; P < 0.001), and male sex (OR 2.602; 95% CI 1.590-4.257; P < 0.001) were independently correlated with grade ≥ II PF. The present study identified a significant correlation between anatomical position of the pancreas and PF after LG. High BMI and male sex were also significantly correlated with PF after LG.

Chronic Glucocorticoid Use is a Potential Risk Factor for Delayed Pancreatic Fistula after Laparoscopic Distal Pancreatectomy: A Retrospective Analysis.

Pancreatic fistula is a potentially morbid complication after distal pancreatectomy. Chronic glucocorticoid use is one of the risk factors for pancreatic fistula in pancreaticoduodenectomy, though it has not been reported in distal pancreatectomy. We explored whether chronic glucocorticoid use can be a risk factor for pancreatic fistula in distal pancreatectomy. We reviewed 408 consecutive patients who underwent elective distal pancreatectomy from 2011 to 2021. We evaluated two kinds of pancreatic fistula (postoperative pancreatic fistula and delayed pancreatic fistula). We defined delayed pancreatic fistula as a patient who was re-admitted for pancreatic fistula after the first discharge from the hospital. Preoperative characteristics and postoperative outcomes were analyzed. Two hundred sixty-seven patients underwent open distal pancreatectomy, while 141 patients had laparoscopic distal pancreatectomy. A comparison of patient with and without chronic glucocorticoid use showed that only patients with chronic glucocorticoid use developed delayed pancreatic fistula (0% vs. 16.7%; p < 0.001). In addition, delayed pancreatic fistula occurred in only laparoscopic distal pancreatectomy patients with chronic glucocorticoid use (0% vs. 25.0%; p < 0.001). Although sample size is small, it is reasonable to presume that chronic glucocorticoid use is a potential risk factor for delayed pancreatic fistula in laparoscopic distal pancreatectomy.

Pancreatic fistula and biliary fistula after laparoscopic pancreatoduodenectomy: 500 patients at a single institution.

Pancreatic fistula (PF) and biliary fistula (BF) are two major leakage complications after pancreatoduodenectomy (PD). The aim of this study is to investigate the risk factors of PF and BF after laparoscopic PD (LPD). We conducted a retrospective analysis of 500 patients who underwent LPD from 1 April 2015 to 31 March 2020. Clinical data from patients were analysed using multivariate logistic regression analysis. PF occurred in 86 (17.2%) patients. Univariate and multivariate analysis indicated that the soft texture of the pancreas (P = 0.001) was the independent risk factor for PF. BF occurred in 32 (6.4%) patients. Univariate and multivariate analysis indicated that history of cardiovascular disease (P < 0.001), surgical time (P = 0.005), pre-operative CA125 (P = 0.036) and pre-operative total bilirubin (P = 0.044) were independent risk factors for BF. The texture of the pancreas was an independent risk factor for PF after LPD, which was consistent with the literatures. In addition, history of cardiovascular disease, surgical time, pre-operative CA125 and pre-operative total bilirubin were new independent risk factors for BF after LPD. Therefore, patients with high-risk factors of BF should be informed that they are at a high risk for this complication.

Effect of overtime pancreaticoduodenectomy on the short-term prognosis of patients.

BACKGROUNDDue to the large number of operations, surgeons sometimes need to work overtime or even stay up late to perform pancreaticoduodenectomy. Fatigue and sleep deprivation can result in an increased error rate at work. There have been numerous studies about the effect of overtime surgery on the prognosis of patients. However, the effect of overtime work for pancreaticoduodenectomy on the prognosis of patients is unclear. This study explores the impact of overtime work for pancreaticoduodenectomy on the prognosis of patients.AIMTo explore the impact of overtime work for pancreaticoduodenectomy on the short-term prognosis of patients.METHODSThis was a single-center, retrospective cohort study. The patients who underwent pancreaticoduodenectomy between January 2017 and December 2019 were included. Patients were stratified by operative start time into the control group (surgery that started between 8:00 and 16:49) and the overtime group (surgery that started between 17:00 and 22:00) and compared intraoperative and postoperative parameters. The following parameters were compared between the overtime group and the control group: Operative time, blood loss, number of lymph nodes removed, duration of treatment in the Intensive Care Unit (ICU), and incidence of complications. RESULTSFrom January 2017 to December 2019, a total of 239 patients underwent pancreaticoduodenectomy in the Department of Hepatobiliary Surgery of our institution. Four patients were excluded from this study due to lack of clinical data. A total of 235 patients were included, with 177 in the control group and 58 in the overtime group. There was no difference between the two groups in operative time, blood loss, number of lymph nodes removed, ICU length of stay, hospital length of stay, mortality during hospitalization. Compared with the control group, the overtime group had a higher incidence of pancreatic fistula (32.8% vs 15.8%, P < 0.05). Multivariate analysis showed that overtime work, higher Body Mass Index were independent risk factors for pancreatic fistula (P < 0.05). CONCLUSIONOvertime work for pancreaticoduodenectomy increases the incidence of pancreatic fistula. The effect of overtime surgery on the long-term prognosis of patients’ needs to be further studied.

Application analysis of omental flap isolation and modified pancreaticojejunostomy in pancreaticoduodenectomy (175 cases)

BackgroundTo explore the application value of free omental wrapping and modified pancreaticojejunostomy in pancreaticoduodenectomy (PD).MethodsThe clinical data of 175 patients who underwent pancreaticoduodenectomy from January 2015 to December 2020 were retrospectively analysed. In total, 86 cases were divided into Group A (omental wrapping and modified pancreaticojejunostomy) and 89 cases were divided into Group B (control group). The incidences of postoperative pancreatic fistula and other complications were compared between the two groups, and univariate and multivariate logistic regression analyses were used to determine the potential risk factors for postoperative pancreatic fistula. Risk factors associated with postoperative overall survival were identified using Cox regression.ResultsThe incidences of grade B/C pancreatic fistula, bile leakage, delayed bleeding, and reoperation in Group A were lower than those in Group B, and the differences were statistically significant (P < 0.05). Group A had an earlier drainage tube extubation time, earlier return to normal diet time and shorter postoperative hospital stay than the control group (P < 0.05). The levels of C-reactive protein (CRP), interleukin-6 (IL-6), and procalcitonin (PCT) inflammatory factors 1, 3 and 7 days after surgery also showed significant. Univariate and multivariate logistic regression analyses showed that a body mass index (BMI) ≥ 24, pancreatic duct diameter less than 3 mm, no isolation of the greater omental flap and modified pancreaticojejunostomy were independent risk factors for pancreatic fistula (P < 0.05). Cox regression analysis showed that age ≥ 65 years old, body mass index ≥ 24, pancreatic duct diameter less than 3 mm, no isolation of the greater omental flap isolation and modified pancreaticojejunostomy, and malignant postoperative pathology were independent risk factors associated with postoperative overall survival (P < 0.05).ConclusionsWrapping and isolating the modified pancreaticojejunostomy with free greater omentum can significantly reduce the incidence of postoperative pancreatic fistula and related complications, inhibit the development of inflammation, and favourably affect prognosis.

Expert consensus on the use of human serum albumin in critically ill patients.

Expert consensus on the use of human serum albumin in critically ill patients.

Preoperative body mass index and amylase level predict postoperative pancreatic fistula independently

Postoperative pancreatic fistula (POPF) is one of the difficult complications after distal pancreatectomy (DP), resulting increased postoperative morbidity and mortality. It is still a hotspot to prevent the occurrence of POPF in recent researches. Our study aimed to investigate the risk factors of pancreatic fistula in patients following DP. We retrospectively analyzed 206 patients with DP in Tongji Hospital, China, from January 2014 to March 2019. Univariate and multivariate logistic regressions were performed to assess the risk factors of POPF. A total of 206 eligible patients were enrolled into this study, including 123 females and 83 males. The overall morbidity was 30.1%. Postoperative complications included postoperative biliary fistula (0.5%), delayed gastric emptying (1%), grade B pancreatic fistula (4.9%), grade C pancreatic fistula (1.9%), postoperative abdominal abscess (2.4%), wound infection (3.4%), percutaneous drainage (18.4%) and reoperation (0.5%). The first hospitalization time was 24 days. There were 21 patients re-hospitalized within 30 days and 8 patients within 90 days. No postoperative death was observed.Univariate analysis indicated that the occurrence of POPF was related to preoperative BMI > 25 kg/m2 (p = 0.034), serum pancreatic amylase > 53 U/L (p = 0.049), splenic preservation (p = 0.069) and splenic vessel preservation (p = 0.036). Multivariate analysis showed that preoperative BMI > 25 kg/m2 (OR = 2.637, p < 0.05) and serum pancreatic amylase > 53 U/L (OR = 2.658, p < 0.05) were independent risk factors of clinical related-postoperative pancreatic fistula. Preoperative BMI > 25 kg/m2 and serum amylase > 53 U/L are independent risk factors of POPF. It is necessary to monitor BMI and amylase level preoperatively in patients undergoing DP.

Risk Factors for Clinically Relevant Postoperative Pancreatic Fistula (CR-POPF) after Distal Pancreatectomy: A Single Center Retrospective Study.

Objectives Clinically relevant postoperative pancreatic fistula (CR-POPF) is the considerable contributor to major complications after pancreatectomy. The purpose of this study was to evaluate the potential risk factor contributing to CR-POPF following distal pancreatectomy (DP) and discuss the risk factors of pancreatic fistula in order to interpret the clinical importance. Methods In this retrospective study, 263 patients who underwent DP at Ningbo Medical Center Li Huili Hospital between January 2011 and January 2020 were reviewed in accordance with relevant guidelines and regulations. Patients' demographics and clinical parameters were evaluated using univariate and multivariate analyses to identify the risk factors contributing to CR-POPF. P < 0.05 was considered statistically significant. Results In all of the 263 patients with DP, pancreatic fistula was the most common surgical complication (19.0%). The univariate analysis of 18 factors showed that the patients with a malignant tumor, soft pancreas, and patient without ligation of the main pancreatic duct were more likely to develop pancreatic fistula. However, on multivariate analysis, the soft texture of the pancreas (OR = 2.381, 95% CI = 1.271–4.460, P=0.001) and the ligation of the main pancreatic duct (OR = 0.388, 95% CI = 0.207–0.726, P=0.002) were only an independent influencing factor for CR-POPF. Conclusions As a conclusion, pancreatic fistula was the most common surgical complication after DP. The soft texture of the pancreas and the absence of ligation of the main pancreatic duct can increase the risk of CR-POPF.

Main Risk Factors of Development of Postoperative Pancreatic Fistula Development after Pancreatoduodenectomy.

Purpose: To study the main risk factors of pancreatic fistula (POPF) after pancreatoduodenectomy (PD), in order to determine the degree of possible influence on them and reduce the development of early postoperative complications. Method: The results of examination and PD of 108 patients were studied from the period from 2016 to 2020. The criteria influencing the formation of POPF involved in the study: the consistency of the pancreas (determined subjectively according to the soft / hard), the diameter of the pancreatic duct, intraoperative blood loss, presence of biliary decompression (BD) before PD. Results: BD for the obstructive jaundice before PD were performed in 71 patients (65.7%), among them POPF developed in 17 patients (23.9%). In the group without BD (37 patients) in 9 (24.3 %) (p ˃ 0.05) .In patients with soft pancreas (50 patients), POPF developed in 21 patients (42.0%), among patients with hard pancreas - in 5 (5.8%) (p < 0.01). It was proposed to consider a diameter of up to 3 mm inclusively as «narrow» and «wide» from 4 or more. In 45 (41.7%) patients with a narrow duct POPF occured in 17 patients (37.8%), in 63 patients with a wide Wirsung duct (58.3%) POPF developed in 9 patients (14.3%) (p < 0.01). The volume of intraoperative blood loss less than 400 ml was regarded as physiological, this volume of blood loss was observed in 90 patients (83.3%), POPF occurred in 24 patients (26.7%), in 18 patients (17.7%) intraoperative blood loss exceeded 400 ml, POPF developed in 2 patients (11.1%) (p ˃ 0.05). All 100% of patients underwent pancreatojejunostomy at the reconstructive stage of the operation. 89 patients underwent duct-to-mucosa anastomosis, in the standard version without transanastomotic catheter, POPF occurred in 18 patients (20.0%), the rest included different options with transanastomotic catheter with or without invagination component , in this group (19 patients) PF developed in 8 people (44.4%). A statistically significant difference (p < 0.05) was obtained, however, due to the fact that a departure from the standard in the group of patients with combination of a narrow duct and soft pancreas, objectification of such a risk factor is impossible. Conclusion: In our study, the factors that significantly increase the frequency of POPF formation were the degree of pancreas density and the diameter of the pancreatic duct.

Possibility of computer tomography with contrast enhancement in evaluation of the structure of the pancreas and prediction of pancreatic fistula in pancreas resection

One of the most common complications after pancreatic resections is an external pancreatic fistula. The main risk factor for pancreatic fistula is the “soft” structure of the pancreas. The aim of the study is to determine the possibility of computed tomography with contrast enhancement at the preoperative period in an objective assessment of the structure of the pancreas with pancreatoduodenal resections and prediction of pancreatic fistula in the postoperative period. Retrospectively, 102 patients were selected. Patients were divided into 2 groups depending on the structure of the pancreas according to computed tomography at the preoperative period. According to the data of preoperative CT with contrast enhancement, the structure of the pancreas was evaluated; density characteristics in native, arterial, venous, delayed phases (HU); pancreatic duct diameter. Group 1 included 37 patients with a “soft” pancreas. 65 patients with a “solid” pancreas were in group 2. In group 1, in 16 cases (43%), a clinically significant PF was formed in the postoperative period; in 21 cases (57%), the postoperative period proceeded uncomplicated. In group 2, in 5 cases (8%), the postoperative period was complicated by clinically significant PF; in 60 cases (92%), the postoperative period was uncomplicated. The development of clinically significant PF positively correlates with the “soft” pancreas (r = 0.374, p&lt;0.001), the density of pancreas of the native phase (r = 0.179, p = 0.099), the density of pancreas in the arterial phase (r = 0.208, p =0.054). Negatively correlates with the “solid” pancreas (r = -0.274, p&lt;0.001) and the pancreatic duct diameter (r = -0.339, p = 0.001). The “soft” pancreas positively correlates with the density pancreas in the native phase (r = 0,559, p&lt;0,001) and the density pancreas in the arterial phase (r = 0,710, p&lt;0,001) and negatively correlates with the pancreatic duct diameter (r = - 0,534, p&lt;0,001) and the density pancreas in the excretory phase (r = -0,409, p&lt;0,001). Using computed tomography with contrast enhancement at the preoperative period, an objective assessment of the pancreatic structure is possible due to its density characteristics in the native and arterial phases of the scan to highlight a high-risk group for the development of clinically significant PF.

Risk factors for pancreatic fistula after distal pancreatectomy

Risk factors for pancreatic fistula after distal pancreatectomy

The Impact of Stump Closure Techniques on Pancreatic Fistula Stratified by the Thickness of the Pancreas in Distal Pancreatectomy

Background: The purpose of this retrospective study was to evaluate the impact of stump closure techniques on pancreatic fistula (PF) focusing on pancreatic thickness after distal pancreatectomy (DP). Methods: A total of 213 patients who underwent DP between 2007 and 2017 were retrospectively reviewed. The risk factors of PF were investigated. Results: In all patients, age ≥65 years (odds ratio [OR]: 3.60, p = 0.012), operation time ≥300 min (OR: 3.05, p = 0.013) and thickness of transected pancreas (OR: 1.37, p < 0.001) were identified as independent risk factors for clinically relevant PF. A receiver operating curve analysis revealed the optimum cut-off values of thickness to be 14 mm with stapler closure and 17 mm with the clamp-crushing method. There were no significant differences regarding PF between the stapler closure and clamp-crushing methods in the thin (<14 mm) and very thick pancreas (≥17 mm) groups (p = 0.822, p = 0.072). In contrast, stapler closure was the only independent risk factor for developing PF in the moderately thick (≥14, <17 mm) pancreas group (OR: 6.75 and p = 0.004, respectively). Conclusion: The clamp-crushing method was superior to stapler closure for pancreatic transection, especially in patients with moderately thick pancreas.

Risk Factors and Management of Postoperative Pancreatic Fistula Following Pancreaticoduodenectomy: Single-center Experience.

Pancreatic fistula (PF) remains the most frequent complication after pancreaticoduodenectomy (PD). This study was undertaken to explore the risk factors of postoperative PF following PD and discuss the management of PF in our center. A single-center respective study, involving 241 patients who underwent PD between September 2015 and June 2018, was conducted. Differences in the demographic data, preoperative, intraoperative and postoperative variables between the group with PF [International Study Group on Pancreatic Surgery (ISGPS) grade B/C] and the group without PF (no PF and ISGPS grade BL) were evaluated. The diagnosis and grading of PF were in strict accordance with ISGPS. Risk factors were analyzed by univariate analysis and multivariate logistic regression analysis. The results showed that postoperative PF occurred in 50 (20.7%) of the patients; 25 (10.4%) patients had a PF type BL, 46 (19.1%) patients developed a PF type B and 4 (1.6%) had a PF type C. Univariate analysis showed that fasting blood glucose (P=0.02), pancreatic texture (P&lt; 0.001) and pancreatic duct diameter (P=0.01) were correlated with PF. Multivariate logistic regression analysis identified one independent risk factor for postoperative PF: soft pancreatic texture (OR=3.251, P=0.002). Among the cases, there were three postoperative deaths, giving a 60-day hospital mortality rate of 1.2% (3/241), and the mortality related to PF was 4.0% (2/50). One of the patients died from multiple organ failure caused by postoperative abdominal hemorrhage. In conclusion, soft pancreatic texture is an independent risk factor for PF. Surgeons should be well aware of this risk factor when performing a PD.

Effect of non-diabetic postoperative hyperglycemia on complications after pancreaticoduodenectomy

Objective: To examine the association of hyperglycemia and postoperative complications in non-diabetic patients underwent pancreaticoduodenectomy(PD). Methods: The clinical data of 209 non-diabetic patients who underwent PD from January 2012 to June 2018 at Department of Pancreatic and Biliary Surgery, the First Affiliated Hospital of Harbin Medical University and met the inclusion criteria were retrospectively analyzed. According to the diagnostic criteria of postoperative hyperglycemia, the patients were divided into postoperative hyperglycemia group (167 cases, 79.9%) and control group(42 cases, 20.1%). The propensity score matching(PSM) method was used to eliminate the difference between groups(caliper value=0.02; 38 cases in control group including 30 males and 8 females with age of 59.0 years;38 cases in postoperative hyperglycemia group including 32 males and 6 females with age of 61.0 years;37 cases of pancreatic head carcinoma,30 cases of periampullary carcinoma and 9 cases of benign diseases). A comparative analysis was applied for preoperative data, surgical related indicators and postoperative complication rates.The receiver operating characteristic(ROC) curve was used to calculate the area under the curve(AUC) of blood glucose values on postoperative day 1,3 and 5(POD1, POD3, POD5), to determine the high-risk blood glucose cutoff value of complications and to evaluate its sensitivity and specificity for the prediction of postoperative complications. Results: Univariate analysis showed that the differences in gender, body mass index, preoperative blood glucose, and serum urea nitrogen levels were statistically significant before PSM.There was no significant difference in the preoperative data between the two groups after PSM. Compared with the control group, the incidence of postoperative pancreatic fistula (31.6% vs. 5.3%), abdominal infection(29.0% vs. 7.9%) and Clavien-Dindo Ⅲ-Ⅴ complications(31.6% vs.7.9%) were statistically different(χ(2)=7.092,P=0.008; χ(2)=4.290,P=0.038; χ(2)=5.316,P=0.021), respectively. According to the AUC on POD3,the blood glucose value ≥8.860 mmol/L was an independent risk factor for pancreatic fistula with sensitivity of 58.3% and specificity of 76.9%,the blood glucose value ≥9.130 mmol/L was an independent risk factor for abdominal infection with sensitivity of 54.5% and specificity of 81.5% and the blood glucose value ≥7.685 mmol/L was independent risk factor of Clavien-Dindo Ⅲ-Ⅴ complications with sensitivity of 75.0% and specificity of 57.7%. Conclusions: Postoperative hyperglycemia in non-diabetic patients is associated with postoperative pancreatic fistula, abdominal infection, and Clavien-Dindo Ⅲ-Ⅴ complications.According to the early postoperative blood glucose value,the occurrence of postoperative pancreatic fistula, abdominal infection and Clavien-Dindo Ⅲ- Ⅴ complications can be effectively predicted.

Blame it on the injury: Trauma is a risk factor for pancreatic fistula following distal pancreatectomy compared with elective resection.

Postoperative pancreatic fistula (POPF) remains a significant source of morbidity following distal pancreatectomy (DP). There is a lack of information regarding the impact of trauma on POPF rates when compared with elective resection. We hypothesize that trauma will be a significant risk factor for the development of POPF following DP. A retrospective, single-institution review of all patients undergoing DP from 1999 to 2017 was performed. Outcomes were compared between patients undergoing DP for traumatic injury to those undergoing elective resection. Univariate and multivariable analyses were performed using SAS (version 9.4). Of the 372 patients who underwent DP during the study period, 298 met inclusion criteria: 38 DPs for trauma (TDP), 260 elective DPs (EDP). Clinically significant grade B or C POPFs occurred in 17 (44.7%) of 38 TDPs compared with 41 (15.8%) of 260 EDPs (p < 0.0001). On multivariable analysis, traumatic injury was found to be independently predictive of developing a grade B or C POPF (odds ratio, 4.3; 95% confidence interval, 2.10-8.89). Age, sex, and wound infection were highly correlated with traumatic etiology and therefore were not retained in the multivariable model. When analyzing risk factors for each group (trauma vs. elective) separately, we found that TDP patients who developed POPFs had less sutured closure of their duct, higher infectious complications, and longer hospital stays, while EDP patients that suffered POPFs were more likely to be male, younger in age, and at a greater risk for infectious complications. Lastly, in a subgroup analysis involving only patients with drains left postoperatively, trauma was an independent predictor of any grade of fistula (A, B, or C) compared with elective DP (odds ratio, 8.6; 95% confidence interval, 3.09-24.15), suggesting that traumatic injury is risk factor for pancreatic stump closure disruption following DP. To our knowledge, this study represents the largest cohort of patients comparing pancreatic leak rates in traumatic versus elective DP, and demonstrates that traumatic injury is an independent risk factor for developing an ISGPF grade B or C pancreatic fistula following DP. Prognostic study, Therapeutic, level III.

Risk Factors of Pancreatic Fistula in Distal Pancreatectomy Patients.

Introduction Benign and malignant lesions of the pancreas located at the body and tail of the pancreas are managed by the standard procedure of distal pancreatectomy (DP). The mortality associated with this procedure is reported as less than 5% in high-volume centers. The major proportion of morbidity is comprised of pancreatic fistula with a reported incidence of 5% to 60%. The most considered risk factors associated with pancreatic fistula formation are soft pancreatic texture, diameter of the pancreatic duct <3 mm, intraoperative blood loss >1000 ml and surgical techniques. Among all these factors, the modifiable factor is the surgical technique. Several surgical techniques have been developed and modified for closure of the pancreatic remnant in the recent past in order to minimize the risk of pancreatic fistula and other complications. The main objective of the study is to analyze the factors associated with formation of pancreatic fistula after distal pancreatectomy. Patients and Methods We performed a single-center retrospective study at Aga Khan University Hospital from January 2004 till December 2015. The perioperative and postoperative data of 131 patients who underwent pancreatic resection were recorded by using ICD 9 coding. 45 patients underwent distal pancreatectomy, out of which 38 were included in the study based on inclusion criteria. Variables were grouped into demographics, indications, operative details, and postoperative course. Statistical analysis software (SPSS) was used for analysis. Quantitative variables were presented as mean with standard deviation or median with interquartile range depending on the distribution of data. Study endpoints for the risk factor analysis were surgical morbidity and development of pancreatic fistula. Univariate logistic regressions were performed associated with study endpoints. P value less than 0.05 was considered significant. Results Postoperative pancreatic fistula was the most common perioperative morbidity. The significant associated risk factor for pancreatic fistula was multivisceral resection as compared to spleen-preserving distal pancreatectomy (P value 0.039). However, the technique of stump closure when opted for suture techniques was seen to be associated with a higher occurrence of postoperative pancreatic fistula. The mortality rate was 2.6%. Conclusion Postoperative pancreatic fistula is the most common complication seen after distal pancreatectomy in our series. Multivisceral resection is associated with a high incidence of pancreatic fistula and is a statistical significant predictor of pancreatic fistula.

Pancreatic attenuation on computed tomography predicts pancreatic fistula after pancreaticoduodenectomy

BackgroundSome parameters using preoperative computed tomography (CT) have been evaluated to predict the development of pancreatic fistula (PF) after pancreaticoduodenectomy (PD). The present retrospective study evaluated the predictive value of pancreatic attenuation for PF after PD. MethodsA retrospective review was conducted of the patients who underwent PD between January 2010 and December 2014. The pancreatic attenuation was measured in unenhanced preoperative CT images. Pre- and intraoperative variables were analyzed for the risk of PF after PD. ResultsOf the 346 consecutive patients, PF occurred in 116 (34%). The pancreatic attenuation was significantly greater in patients with PF than in those without PF (median, 40.0 vs. 33.3 Hounsfield units [HU], P < 0.001). A multivariate analysis showed that a pancreatic attenuation ≥30.0 HU (odds ratio [OR], 3.72; P < 0.001), a body mass index ≥25.0 kg/m2 (OR, 3.67; P < 0.001) and a diameter of the main pancreatic duct <3.0 mm (OR, 1.84; P = 0.034) were independent risk factors for PF after PD. ConclusionThe degree of pancreatic attenuation on preoperative CT images was significantly associated with PF, and a pancreatic attenuation ≥30.0 HU was an independent risk factor of PF after PD.

Applicational value of modified pancreaticojejunostomy and risk factors of pancreatic fistula following pancreaticoduodenectomy

Objective: To compare the efficacy of modified pancreaticojejunostomy with traditional pancreaticojejunostomy following pancreaticoduodenectomy, and to investigate the risk factors of postoperative pancreatic fistula. Methods: Clinical data of 68 patients who underwent pancreaticoduodenectomy between October 2017 and October 2018 at the Second Department of Biliary Tract Surgery, Eastern Hepatobiliary Surgery Hospital was retrospectively collected and analyzed.According to the method of pancreaticojejunostomy, the patients were divided into two groups: modified pancreaticojejunostomy group (34 patients) and traditional pancreaticojejunostomy group (34 patients). There were 18 males and 16 females, aged (60.4±9.6) years of modified pancreaticojejunostomy groups; there were 17 males and 18 females, aged (58.9±10.9) years of traditional pancreaticojejunostomy group. The major postoperative complications such as pancreatic fistula were compared between the two groups, and the risk factors of postoperative pancreatic fistula were analyzed by univariate and multivariate analyses. Results: All of the 68 operations were successfully completed. The overall incidence of postoperative complications was 51.5% (35/68). The incidence of postoperative pancreatic fistula was 13.2% (9/68), of which all were cases of grade B.There were 16 patients (23.5%) occurred with abdominal infection, and 11 patients (16.2%) occurred with delayed gastric emptying, including 1 case of grade A, 1 case of grade B and 9 cases of grade C.And 9 patients (13.2%) occurred with postoperative bleeding was, including 2 cases of mild bleeding, 5 cases of moderate bleeding, and 2 cases of severe bleeding.Biliary leakage occurred in one patient (1.5%) and chylous leakage occurred in two patients (2.9%). The modified pancreaticojejunostomy could significantly reduce the incidence of postoperative bleeding compared with control group (χ(2)=4.610, P=0.032). And there were no significant differences for other postoperative complications between the two groups (all P>0.05). According to the results of univariate analysis: age, intraoperative bleeding and diameter of pancreatic tube were related factors affecting postoperative pancreatic fistula (P=0.025, 0.019, 0.017, respectively). The results of multivariate analysis showed that intraoperative bleeding>400 ml and diameter of pancreatic tube <3 mm were independent risk factors of pancreatic fistula following pancreaticoduodenectomy (P=0.025, 0.008, respectively). Conclusion: The modified pancreaticojejunostomy is feasible with advantages of reducing postoperative bleeding following pancreaticoduodenectomy.

Impaired immune reaction and increased lactate and C-reactive protein for early prediction of severe morbidity and pancreatic fistula after pancreatoduodenectomy

BackgroundPrediction of complications after pancreatoduodenectomy (PD) remains of interest. Blood parameters and biomarkers during first and second postoperative days (POD1, POD2) may be early indicators of complications. MethodsThis case-control study included 50 patients. Baseline, POD1 and POD2 values of leukocytes, neutrophils, lymphocytes, platelets, hemoglobin, C-reactive protein (CRP), procalcitonin and arterial lactate were compared between individuals presenting Clavien ≥ III morbidity, pancreatic fistula (PF) or clinically relevant PF (CRPF) and those without these morbidities. Common variables reaching significance were further analyzed in order to calculate a predictive score. ResultsSevere morbidity, PF and CRPF rates were 28.0%, 26.0% and 14.0%, respectively. Patients with severe morbidity had lower leukocytes on POD2 (P = 0.04). Patients with PF presented higher CRP on POD2 (P = 0.001), higher lactate on POD1 (P = 0.007) and POD2 (P = 0.008), and lower lymphocytes on POD1 (P = 0.007) and POD2 (P = 0.008). Patients with CRPF had lower leukocytes and neutrophils on POD1 (P = 0.048, P = 0.038), lower lymphocytes on POD1 (P = 0.001) and POD2 (P = 0.003), and higher CRP on POD2 (P = 0.001). Baseline parameters and procalcitonin obtained no statistical associations. Score was defined according to lymphocytes on POD1 < 650/µL and CRP on POD2 ≥ 250 mg/L allocating patients in 3 risk categories. PF and CRPF rates were statistically higher as risk category increased (P<0.001). Receiver operating characteristic curves and Hosmer–Lemeshow tests showed a good accuracy. ConclusionsImpaired immunological reaction during early postoperative period (lower leukocytes and, particularly, lymphocytes) in response to surgical aggression would favor complications after PD. Likewise, acidosis (higher arterial lactate) could behave as risk factor of PF. An elevated CRP on POD2 is also an early biomarker of PF. Our novel score based on postoperative lymphocyte count and CRP seems reliable for early prediction of PF.