Risk Factors For Pancreatic Fistula Research Articles

Chronic pancreatitis of the pancreatic remnant is an independent risk factor for pancreatic fistula after distal pancreatectomy.

BackgroundThere is an ongoing debate about the best closure technique after distal pancreatectomy (DP). The aim of the closure is to prevent the formation of a clinically relevant post-operative pancreatic fistula (POPF). Stapler technique seems to be equal compared with hand-sewn closure of the remnant. For both techniques, a fistula rate of approximately 30% has been reported.MethodsWe retrospectively analyzed our DPs between 01/2000 and 12/2010. In all cases, the pancreatic duct was over sewn with a separately stitched ligation of the pancreatic duct (5*0 PDS) followed by a single-stitched hand-sewn closure of the residual pancreatic gland. The POPF was classified according to the criteria of the International Study Group for Pancreatic Fistula (ISGPF). Univariate and multivariate analyses of potential risk factors for the formation of POPF were performed. Indications for operations included cystic tumors (n = 53), neuroendocrine tumors (n = 27), adenocarcinoma (n = 22), chronic pancreatitis (n = 9), metastasis (n = 6), and others (n = 7).ResultsDuring the period, we performed 124 DPs (♀ = 74, ♂ = 50). The mean age was 57.5 years (18–82). The POPF rates according to the ISGPF criteria were: no fistula, 54.8% (n = 68); grade A, 24.2% (n = 30); grade B, 19.3% (n = 24); and grade C, 1.7% (n = 2). Therefore, in 21.0% (n = 26) of the cases, a clinically relevant pancreatic fistula occurred. The mean postoperative stay was significantly higher after grade B/C fistula (26.3 days) compared with no fistula/grade A fistula (13.7 days) (p < 0.05). The uni- and multivariate analyses showed chronic pancreatitis of the pancreatic remnant to be an independent risk factor for the development of POPF (p = 0.004 OR 7.09).ConclusionBy using a standardized hand-sewn closure technique of the pancreatic remnant after DP with separately stitched ligation of the pancreatic duct, a comparably low fistula rate can be achieved. Signs of chronic pancreatitis of the pancreatic remnant may represent a risk factor for the development of a pancreatic fistula after DP and therefore an anastomosis of the remnant to the intestine should be considered.

Risk factors of pancreatic fistula after pancreaticoduodenectomy

Objective To investigate the risk factors of pancreatic fistula after pancreaticoduodenectomy.Methods The clinical data of 310 patients who received pancreaticoduodenectomy at the Ruijin Hospital of Shanghai Jiaotong University from January 2005 to May 2013 were retrospectively analyzed.The risk factors associated with the interoperative pancreatic fistula were analyzed.The univariate and multivariate analysis were done using the Pearson chi-square test and non-conditional Logistic regression model.Results A total of 134 patients had postoperative complications,including 103 (33.23％) with pancreatic fistula,among them 40 patients developed additional complications.The results of univariate analysis showed that preoperative levels of hemoglobin,total bilirubin,diameter of the pancreatic duct and postoperative level of albumin were risk factors of pancreatic fistula after pancreaticoduodenectomy (x2 ＝ 4.543,6.087,6.265,5.311,P ＜ 0.05).The results of multivariate analysis showed that preoperative level of total bilirubin equal to or above 34.2 μmol/L,the diameter of the pancreatic duct under 3 mm and the level of postoperative albumin under 28 g/L were the independent risk factors of pancreatic fistula (OR =1.806,1.936,1.780; 95％ confidence interval:1.107-2.948,1.170-3.206,1.002-3.165,P ＜ 0.05).Conclusion Preoperative jaundice (the level of total bilirubin ≥ 34.2 umol/L),pancreatic duct diameter ＜ 3 mm and postoperative malnutrition (albumin ＜ 28 g/L) indicate a higher incidence of postoperative pancreatic fistula. Key words: Pancreatic neoplasms ; Pancreaticoduodenectomy ; Pancreatic fistula

Application of pancreaticojejunostomy procedures selection strategy in pancreaticoduodenectomy and risk factors analysis of pancreatic fistula after operation

To evaluate the pancreaticojejunostomy procedures selection strategy in pancreaticoduodenectomy and to analyze risk factors of pancreatic fistula. Clinical data of 352 patients who received pancreaticoduodenectomy from September 2009 to September 2012 were retrospectively analyzed. For patients with soft pancreas, binding pancreaticojejunostomy was applied to 153 patients. For patients with hard pancreas, duct-to-mucosa pancreaticojejunostomy (DMPJ) was applied (199 cases). The clinical efficacy and incidence of postoperative complications were compared among 2 groups. Risk factors of pancreatic fistula were screened out from many factors by univariate and multivariate analysis. The overall incidence of pancreatic leakage was 13.9% (49/352). There were no significant difference in incidences of pancreatic leakage (χ(2) = 0.512), peritoneal bleeding (χ(2) = 0.784), abdominal infection (χ(2) = 1.161), digestive dysfunction rate (χ(2) = 4.753) and mean duration of hospital stay (t = 2.13) among 2 groups (all P > 0.05). The results of multivariate analysis showed pancreatic tube diameter < 3 mm (OR = 5.748), preoperative total bilirubin level > 171 µmol/L (OR = 5.112), duration of preoperative jaundice > 8 weeks (OR = 5.090), preoperative albumin level < 30 g/L (OR = 4.464) were independent risk factors of pancreatic fistula (all P < 0.05). Bunding pancreatojejunostomy was as good as soft pancreatic; for duct diameter ≥ 3 mm suggested using duct-to-mucosa pancreaticojejunostomy. For the risk factors for pancreatic leakage actively cooperate with preoperative nutritional support and timely treatment of jaundice, the incidence of postoperative pancreatic leakage will be further reduced.

Pancreatic fistula after a pancreaticoduodenectomy for ductal adenocarcinoma and its association with morbidity: a multicentre study of the French Surgical Association

BackgroundsA pancreatic fistula (PF) is the most relevant complication after a pancreaticoduodenectomy (PD). This retrospective multicentric study attempts to elucidate the risk factors and complications of a PF in a large cohort of patients undergoing a PD for ductal adenocarcinoma. MethodsUsing a survey tool, clinical data of 1325 patients undergoing a PD for ductal adenocarcinoma at 37 institutions, between January 2004 and December 2009, were collected. Peri-operative risk factors associated with PF and its association with morbidity and mortality were assessed. Morbidity and PF were graded according to the ISGPF (International Study group for pancreatic fistula) definition and the Dindo–Clavien classification. ResultsOverall PF, mortality, morbidity and relaparotomy rates were 14.3%, 3.8%, 54.4% and 11.7%, respectively. PF occurred more frequently after a pancreaticojejunostomy (PJ) compared with a pancreaticogastrostomy (PG) (16.8% vs. 10.4%; P = 0.0012). Independent risk factors for PF by multivariate analysis were absence of pre-operative diabetes (P = 0.0014), PJ reconstruction (P = 0.0035), soft pancreatic parenchyma (P < 0.0001) and low-volume centre (P = 0.0286). Clinically relevant PF (grade B and C) and severe complications (Dindo–Clavien grade IIIB, IV, V) were significantly more frequent after PJ than PG (71.6% vs. 28.3%; P = 0.030 and 24.8% vs. 19.1%; P = 0.015, respectively). Overall mortality and relaparotomy rates were similar after PG and PJ. ConclusionsA soft pancreatic parenchyma, the absence of pre-operative diabetes, PJ and low-volume centre are independent risk factors for PF after PD for ductal adenocarcinoma. A significantly higher incidence and clinical severity of PF are associated with PJ.

Surgery Indeed has an Important Role in Long‐Term Outcome in Patients with Pancreatic Head Cancer

We read with interest the article by Petermann et al. [1] in the August 2013 issue of World Journal of Surgery. First of all, we would like to congratulate the authors for their very interesting article. In this retrospective study 101 pancreatic head resections due to pancreatic ductal adenocarcinoma were analyzed. The authors wanted to assess the impact of postoperative complications, stratified by severity, on long-term survival of patients after pancreatic head resection for ductal adenocarcinoma. However, we have several concerns about their conclusions. First, the authors concluded that surgery is not associated with severe postoperative complications. Surgery is the cornestone in the treatment of pancreatic cancer. Pancreaticoduodenectomy (PD) is the standard surgical treatment of pancreas head cancer. Using an optimal pancreatic reconstruction technique is thought to be a major prophylactic measure to minimize the risk of PD-related complications. Also, there are many possibilities of type of reconstruction as well as many possibilities for pancreaticojejunostomies (PJA): (1) layer with or without telescope, (2) layer, end-to-end, end-to-side, ‘‘duct to mucosa,’’ ‘‘Blumgart‘s’’ anastomosis, etc. [2]. Further, we don’t agree with authors’ conclusion that surgery is not associated with severe postoperative complications. They did not mention what kind of reconstructions were performed In accordance with this we could state following facts. Delayed gastric emptying (DGE) occurs dominantly after pylorus-preserving pancreaticoduodenectomy (PPPD) and remains a leading cause of PPPD postoperative complications. Delayed gastric emptying was probably exacerbated by some intra-abdominal complications, such as an anastomotic leak or an abscess. Problems could also be caused by the surgical procedure itself, namely injury to the nerve of Latarjet. In one study the incidence of DGE was significantly reduced in the pyloric ring resection group compared to controls, without an increase in dumping syndrome [3]. Most pancreatic fistulas (PF) can be managed nonoperatively, but a significant number of grade C PF do require reoperative surgical intervention. Risk factors for pancreatic fistula are well recognized and include a soft pancreatic parenchyma, small main pancreatic duct caliber, and a distal pancreatic resection (vs PD) [4]. Type of anastomosis is also very important regarding this problem. For example, there is a statistically significant decrease in fistula rate in the invagination group—PJA with invagination compared to other types of anastomoses [5]. Patients with postoperative hemorrhage often have underlying complications such as pancreatic fistula that require urgent surgical treatment. Pancreatic enzymes in combination with infection can cause erosion of the gastroduodenal artery or splenic artery stump, resulting in significant bleeding requiring immediate treatment. D. Zdravkovic (&) D. Bilanovic T. Randjelovic S. Dikic Surgery, Faculty of Medicine, University of Belgrade, Belgrade, Serbia e-mail: drdarkozdravkovic@gmail.com

Surgical outcomes of distal pancreatectomy.

Most efforts to minimize pancreatic fistula after distal pancreatectomy (DP) have been focused on techniques of pancreatic transection and management of the pancreatic remnant. However, an ideal method of handling remnant pancreas after resection does not exist. This study evaluates surgical outcome of DP and describes how to reduce pancreatic fistula (PF) after DP. From March 1999 to May 2011, 142 DPs were performed at Ajou University Medical Center. The rate of pancreatic leak was 23.2% (33/142); grade A (n=18), grade B (n=15), and grade C (n=0). The remnant pancreas was managed by stapler in 44 patients (31.0%), suture in 45 (31.7%), and stapler with suture in 53 (37.3%). The morbidity and mortality rates were 38.0% and 0%. In patients who underwent surgery for extrapancreatic disease, the rate of PF was 50% (25/50). It was significantly higher than that (11.9%) in those with pancreatic disease (p = 0.003). Among closure methods for the remnant pancreas, the stapler with suture method reduced postoperative PF. In those with pancreatic disease, the PF rate after stapler with suture was significantly lower than that with stapler or suture alone. Surgery for extrapancreatic disease is an independent risk factor for PF after DP. Of the methods of handling pancreatic remnants, the stapler with suture method by an experienced hepatobiliary surgeon decreased the risk of PF.

Selective Policy of No Drain after Pancreaticoduodenectomy Is a Valid Option in Patients at Low Risk of Pancreatic Fistula: A Case‐Control Analysis

Abdominal drainage is routinely performed after pancreaticoduodenectomy (PD), but this policy has recently been challenged. The aim of the present study was to assess whether abdominal drainage could be omitted after PD in patients at low risk of pancreatic fistula (PF). From 2009 to 2011, 27 consecutive patients underwent PD without abdominal drainage. Their preoperative characteristics and postoperative outcomes were compared to those of 27 matched patients undergoing PD with prophylactic drainage. Patients were matched 1:1 in terms of demographic data, preoperative weight loss, preoperative biliary drainage, surgical indication, and main risk factors of PF (pancreatic texture, main duct size, and body mass index). Overall morbidity rates (no drainage, 56 % vs. drainage, 70 %; p < 0.4) and operative mortality (1 patient in each group) were similar in both groups. The two groups did not differ significantly in terms of delayed gastric emptying (15 vs. 11 %; p = 0.68), and chylous ascites (4 vs. 15 %; p = 0.35). Radiological or surgical interventions for surgical complications were required in 2 patients (1 in each group). Pancreatic fistula rate (0 vs. 22 %; p = 0.009) and hospital stay (10 vs. 15 days; p = 0.004) were significantly reduced in the no drainage group as compared to the drainage group. The hospital readmission rate was similar in the two groups (no drainage, 3.7 vs. 0 %; p = 0.31). This study suggests that abdominal drainage should not be considered routinely after PD in patients at low risk of PF. A no drain policy may reduce hospital stay after PD.

Risk factors of pancreatic fistula after pancreaticoduodenectomy

Objective To investigate the risk factors of pancreatic fistula after pancreaticoduodenectomy (PD).Methods The clinical data of 186 patients who received PD at the Second Affiliated Hospital of Kunming Medical College from May 2000 to May 2010 were retrospectively analyzed.All patients were divided into pancreatic fistula group (39 patients) and non-pancreatic fistula group ( 147 patients).Risk factors of pancreatic fistula after PD were screened out from 20 factors by univariate and multivariate analysis.The univariate analysis was carried out by chi-square test or Fisher exact test,and the muhivariate analysis was done by Logistic regression.Results Thirty-nine patients were complicated with pancreatic fistula,including 26 in grade A,10 in grade B and 3 in grade C.The results of univariate analysis showed that duration of preoperative jaundicc,loss of body weight at 6 months before operation,preoperative total bilirubin level,preoperative albumin level,postoperative albumin level,length of pancreas dissected,pancreatic tube diameter,pancreatic texture and time of abdominal drainage tube pull out were high risk factors of pancreatic fistula ( x2 =34.990,20.480,8.212,10.890,13.561,11.505,13.820,4.539,36.590,P ＜ 0.05).The results of multivariate analysis showed that duration of preoperative jaundice ＞ 8 weeks,loss of body weight at 6 months before operation ≥ 10％,pancreatic tube diameter ＜ 3 mm,soft pancreatic texture and time of abdominal drainage tube pull out ＞ 5 days were the independent risk factors of pancreatic fistula ( OR =2.229,3.383,1.437,1.273,11.939,P ＜ 0.05).Conclusion Duration of preoperative jaundice ＞ 8 weeks,unconscious loss of body weight ≥ 10％ within 6 months before operation,pancreatic tube diameter ＜ 3 mm,soft pancreatic texture,time of abdominal drainage tube pull out ＞ 5 days would increase the risk of pancreatic fistula after PD. Key words: Pancreatic diseases ; Pancreaticoduodenectomy ; Pancreatic fistula

Analysis of complications after pancreaticoduodenectomy

Objective To investigate the complications and the risk factors of pancreatic fistula after pancreaticoduodenectomy.Methods The clinical data of 339 patients who underwent pancreaticoduodenectomy at the First Affiliated Hospital of Sun Yat-Sen University from January 2000 to Decembcr 2009 were retrospectively analyzed.The risk factors of pancreatic fistula were analyzed.The incidences of complications accured from 2000 to 2004 and from 2005 to 2009 were compared.All data were analyzed by the t test,chi-square test,Fisher exact probability or Logistic regression model.Results The incidence of complications of all patients was 33.0％ ( 112/339),and the incidence of pancreatic fistula was 8.6％ (29/339).Of the 29 patients complicated with pancreatic fistula,6 patients were in grade A,8 in grade B and 15 in grade C.Soft texture of remnant pancreas and the diameter of pancreatic duct smaller than 3 mm were the independent risk factors of pancreatic fistula( OR =1.75,3.75,P ＜ 0.05 ).The number of hospital death was 12,including 1 patient died during the first period (2000-2004) and 11 patients died during the second period (2005-2009).Three patients died of pancreatic fistula and abdominal hemorrhage,3 died of postoperative upper gastrointesitnal bleeding,2 died of cardiac insufficiency,1 died of respiratory failure,1 died of pancreatic fistula,abdominal infection and necrotic pancreatitis,1 died of abdominal hemorrhage and hepatic and renal failure,1 died of bililary fistula,abdominal infection and multiple organ dysfunction syndrome.Conclusions Soft texture of remnant pancreas and the diameter of the pancreatic duct smaller than 3 mm are important risk factors of postoperative pancreatic fistula.Pancreatic fistula is the main factor causing death after pancreaticoduodenectomy. Key words: Pancreatic diseases ; Pancreaticoduodenectomy ; Pancreatic leakage

Pancreatic thickness as a predictive factor for postoperative pancreatic fistula after distal pancreatectomy using an endopath stapler

No consistent risk factor has yet been established for the development of pancreatic fistula (PF) after distal pancreatectomy (DP) with a stapler. A total of 31 consecutive patients underwent DP with an endopath stapler between June 2006 and December 2010 using a slow parenchymal flattening technique. The risk factors for PF after DP with an endopath stapler were identified based on univariate and multivariate analyses. Clinical PF developed in 7 of 31 (22 %) patients who underwent DP with a stapler. The pancreata were significantly thicker at the transection line in patients with PF (19.4 ± 1.47 mm) in comparison to patients without PF (12.6 ± 0.79 mm; p = 0.0003). A 16-mm cut-off for pancreatic thickness was established based on the receiver operating characteristic (ROC) curve; the area under the ROC curve was 0.875 (p = 0.0215). Pancreatic thickness (p = 0.0006) and blood transfusion (p = 0.028) were associated with postoperative PF in a univariate analysis. Pancreatic thickness was the only significant independent factor (odds ratio 9.99; p = 0.036) according to a multivariate analysis with a specificity of 72 %, and a sensitivity of 85 %. Pancreatic thickness is a significant independent risk factor for PF development after DP with an endopath stapler. The stapler technique is thus considered to be an appropriate modality in patients with a pancreatic thicknesses of <16 mm.

Risk Factors of Pancreatic Fistula after Pancreaticoduodenectomy – Patients with Low Drain Amylase Level on Postoperative Day 1 are Safe from Developing Pancreatic Fistula

Based on the criteria of International Study Group on Pancreatic Fistula (ISGPF), the risk factors for grade B/C pancreatic fistula (PF) after pancreaticoduodenectomy (PD) were analyzed in this study. Between October 2006 and August 2010, 114 consecutive patients underwent PD at National Hospital Organization Osaka National Hospital. We compared the clinicopathological features between patients with grade B/C PF and those with PF-free/grade A PF. We also examined the relationship between PF formation and the drain amylase level on post-operative day (POD) 1 and POD 3. Eighteen patients (15.8%) developed grade B/C P. Of these patients, four patients underwent reoperation. The mortality rate in patients with grade B/C PF was 5.6%(1/18). The non-dilated pancreatic duct (≤ 3mm) was the only independent risk factor for grade B/C PF by a multivariate analysis (p=0.026). There were 45 patients who showed low (≤ three times serum amylase level)drain amylase level on POD 1 and none of them developed PF. Although our study demonstrated that the non-dilated pancreatic duct is significantly correlated with the increased incidence of grade B/CPE patients with low amylase level of drainage fluid on POD 1 are thought to be safe from developing PE.

Body Mass Index is a Risk Factor of Pancreatic Fistula after Pancreaticoduodenectomy

Pancreatic fistula (PF) after pancreaticoduodenectomy (PD) is still a severe complication and a challenging problem. The common risk factors are the soft pancreas and small pancreatic duct of the remnant pancreas. Those two risk factors were recognized during surgery. On the other hand, a preoperatively determined risk factor of PF is unclarified. We conducted a retrospective analysis of 203 patients consecutively treated by PD from April 2000 to October 2010. PF was defined according to the criteria of the International Study Group of Pancreatic Fistula. Clinical and pre- and intraoperative data were compared between PF and non-PF patients. The recommended cutoff value of body mass index (BMI) as 20 kg/m(2) was defined by receiver operating characteristic curve analysis. PF occurred in 53 (26.1%) of 203 patients. In univariate analysis, BMI and soft remnant pancreas were found to be risk factors of PF (P = 0.027, P = 0.005). In multivariate analysis, BMI and soft pancreas were also risk factors of PF (P = 0.040, P = 0.005). Patients with PF had a significantly longer hospital stay than non-PF patients (P = 0.005). High BMI and soft pancreas were significant risk factors for PF.

Risk factors for postoperative pancreatic fstula in patients with insulinomas: analysis of 292 consecutive cases

Pancreatic fistula (PF) remains the most challenging complication in pancreatic surgery, yet few published studies have focused on the risk factors for postoperative PF in patients undergoing surgery for insulinomas. From January 1990 to February 2010, a total of 292 patients with insulinomas underwent surgery at Peking Union Medical College Hospital. Demographic data, intraoperative procedures, and postoperative data were collected. Particular attention was paid to variables associated with PF as defined by the International Study Group of Pancreatic Fistula (ISGPF). Univariate and multivariate analyses were used to identify possible risk factors for PF. PF was found in 132 (45.2%) patients, of whom 90 were classified into ISGPF grade A, 33 grade B, and 9 grade C. Multivariate analysis showed that male patients (OR=2.56; P=0.007) and operative time >180 minutes (OR=3.756; P<0.0001) were independent risk factors for clinical PF. Pancreatic resection with stapler was a protective factor for both total PF (OR=0.022; P=0.010) and clinical PF (OR=0.097; P=0.007). Male gender and operative time >180 minutes were independent risk factors for clinical PF, while pancreatic resection with a stapler was a protective factor. Whether body mass index (BMI) and other variables during operation are risk factors of PF needs further study.

Diabetes Mellitus: A Risk or Protective Factor for Pancreatic Fistula after Pancreatic Resection?

A recent report by Chu et al. [6] showed that patients with diabetes had a higher likelihood of developing pancreatic fistula (with diabetes 10.3% vs. without diabetes 3.7%, p=0.04), and diabetes was an independent risk factor for pancreatic fistula [Odds Ratio (OR) 4.3, 95% CI 1.18-15.8, p=0.027] when adjusted for age, co-morbidities, BMI, preoperative albumin level, type of operation, surgery time, and pancreatic quality. While in the subgroup analysis, the authors found that the frequency of clinically significant pancreatic fistula (grades B or C) did not differ in patients with and without diabetes (5.2% vs. 4.4%, p=0.8). When stratified by type of operation, diabetic patients had a higher pancreatic fistula rate only after left pancreatectomy (33% vs. 0%, p=0.02). Comparison of preoperative variables in diabetic and non-diabetic patients showed that patients with diabetes were older, more likely to have additional co-morbidities, and had lower serum albumin and higher BMI, although of no statistical significance. All these factors more or less influence the formation of pancreatic fistula. This study includes a large number of patients, while there are still some limitations. First, the number of patients developing postoperative pancreatic fistula is so small that the statistical

Arguments for an individualized closure of the pancreatic remnant after distal pancreatic resection

To analyze risk factors for postoperative pancreatic fistula (POPF) rate after distal pancreatic resection (DPR). We performed a retrospective analysis of 126 DPRs during 16 years. The primary endpoint was clinically relevant pancreatic fistula. Over the years, there was an increasing rate of operations in patients with a high-risk pancreas and a significant change in operative techniques. POPF was the most prominent factor for perioperative morbidity. Significant risk factors for pancreatic fistula were high body mass index (BMI) [odds ratio (OR) = 1.2 (CI: 1.1-1.3), P = 0.001], high-risk pancreatic pathology [OR = 3.0 (CI: 1.3-7.0), P = 0.011] and direct closure of the pancreas by hand suture [OR = 2.9 (CI: 1.2-6.7), P = 0.014]. Of these, BMI and hand suture closure were independent risk factors in multivariate analysis. While hand suture closure was a risk factor in the low-risk pancreas subgroup, high BMI further increased the fistula rate for a high-risk pancreas. We propose a risk-adapted and indication-adapted choice of the closure method for the pancreatic remnant to reduce pancreatic fistula rate.

Risk Factor for Pancreatic Fistula after Pancreaticoduodenectomy Performed by a Surgeon during a Learning Curve: Analysis of a Single Surgeon’s Experiences of 100 Consecutive Patients

Among several kinds of morbidities, pancreatic fistula (PF) is the most common complication of pancreaticoduodenectomy (PD). However, it has not been clarified what kind of perioperative factors are risk factors of PF after PD is performed by a training surgeon. We evaluated the risk factors of PF after PD in which all procedures for 100 consecutive patients were performed by a single training surgeon, retrospectively. The 100 cases were divided into two groups and the first 50 cases were named Group A and the latter 50 cases were named Group B. Multivariate analysis demonstrated that the absence of main pancreatic duct dilatation was an independent risk factor for grade B and grade C PF (p=0.0080; OR=5.311; 95% CI=1.116-7.025). There was no significant difference of the frequencies of grade B and grade C PF between Group A and Group B (p=0.13361). We demonstrated that the absence of main pancreatic duct dilatation was an independent risk factor for grade B and grade C PF after PD was performed by a training surgeon; for those without pancreatic duct dilatation, PD can be performed by a surgeon in the earlier training period with an acceptable rate of PF.

Clinical Validation of the ISGPF Classification and the Risk Factors of Pancreatic Fistula Formation Following Duct-to-Mucosa Pancreaticojejunostomy by One Surgeon at a Single Center

BackgroundPostoperative pancreatic fistula remains a troublesome complication after pancreatoduodenectomy (PD), and many authors have suggested factors that affect pancreatic leakage after PD. The International Study Group on Pancreatic Fistula (ISGPF) published a classification, but the new criteria adopted have not been substantially validated. The aims of this study were to validate the ISGPF classification and to analyze the risk factors of pancreatic leakage after duct-to-mucosa pancreatojejunostomy by a single surgeon. MethodsAll patient data were entered prospectively into a database. The risk factors for pancreatic fistula were analyzed retrospectively for 247 consecutive patients who underwent conventional pancreatoduodenectomy or pylorus-preserving pancreatoduodenectomy between June 2005 and March 2009 at the Samsung Medical Center by a single surgeon. Duct-to-mucosa pancreatojejunostomy was performed on all patients. The ISGPF criteria were used to define postoperative pancreatic fistula. ResultsConventional pancreatoduodenectomy was performed in 84 patients and pylorus-preserving pancreatoduodenectomy in 163. Postoperative complications occurred in 144 (58.3%) patients, but there was no postoperative in-hospital mortality. Pancreatic fistula occurred in 105 (42.5%) [grade A, 82 (33.2%); grade B, 9 (3.6%); grade C, 14 (5.7%)]. However, no difference was evident between the no fistula group and the grade A fistula group in terms of clinical findings, including postoperative hospital stays (11 versus 12 days, respectively, p = 0.332). Mean durations of hospital stay in the grade B and C fistula groups were significantly longer than in the no fistula group (21 and 28.5 days, respectively; p < 0.001). Multivariate analysis revealed that a soft pancreas and a long operation time (>300 min) were individually associated with pancreatic fistula formation of grades B and C. ConclusionsAlthough the new ISGPF classification appears to be sound in terms of postoperative pancreatic leakage, grade A fistulas lack clinical implications; thus, we are of the opinion that only grade B and C fistulas should be considered in practice. A soft pancreatic texture and an operation time exceeding 300 min were found to be risk factors of grade B and C pancreatic fistulas.

Use of omentum or falciform ligament does not decrease complications after pancreaticoduodenectomy: Nationwide survey of the Japanese Society of Pancreatic Surgery

Wrapping is thought to prevent pancreatic fistula and postoperative hemorrhage for pancreaticoduodenectomy (PD), and we analyzed whether omentum/falciform ligament wrapping decreases postoperative complications after PD. This is a retrospective study of wrapping using the omentum/falciform ligament in patients that underwent PD between January 2006 and June 2008 in 139 institutions that were members of the Japanese Society of Pancreatic Surgery. Ninety-one institutions responded to the questionnaires, and data were accumulated from 3,288 patients. The data from 2,597 patients were acceptable for analysis; 918 (35.3%) patients underwent wrapping and 1,679 patients did not. A pancreatic fistula occurred in 623 patients (37.3%) in the nonwrapping group, in comparison to 393 patients (42.8%) in the wrapping group (P = .006). The incidence of a grade B/C pancreatic fistula was lower in the nonwrapping group than the wrapping group (16.7% vs. 21.5%; P = .002). An intra-abdominal hemorrhage occurred in 54 patients (3.2%) in the nonwrapping group, which was similar to the incidence in the wrapping group (32 patients; 3.5%). The mortality was 1.3% and 1.0% in nonwrapping and wrapping groups, respectively. A multivariate analysis revealed 7 independent risk factors for pancreatic fistula; male, hypoalbuminemia, soft pancreas, long operation time, extended resection, pylorus preservation, and omentum wrapping. There were 4 independent risk factors for early intra-abdominal hemorrhage and 2 independent risk factors for late intra-abdominal hemorrhage. This retrospective study revealed that omentum wrapping did not decrease the incidence of pancreatic fistula. An additional validation study is necessary to evaluate the efficacy of wrapping for PD.

Risk Factors for Pancreatic Fistula after Stapled Gland Transection

The objective of this study was to identify risk factors for pancreatic fistula (PF) after stapled transection in distal pancreatectomy (DP). Patients undergoing DP using a stapler for transection between 2005 and 2009 were identified from a pancreatic resection database. Variables examined included patient and tumor characteristics, staple size, and the use of mesh reinforcement. Univariate and multivariate regression analyses were performed to identify risk factors for postoperative PF. One hundred forty-nine had stapled transection, and of these, 25 (17%) had mesh reinforcement. The overall morbidity and mortality rates were 28 per cent and less than 1 per cent; 34 (23%) were diabetic. The rate of clinically significant PF was 14 per cent. On univariate analysis, diabetes (P = 0.04), a firm pancreas (P = 0.03), use of mesh staple line reinforcement (P = 0.02), use of a 4.1-mm staple cartridge (P = 0.01), and blood loss greater than 100 mL (P = 0.01) were associated with higher pancreatic fistula rates. On multivariate analysis, only the presence of diabetes (OR, 4.17; 95% CI, 1.1-15.3; P = 0.03) and the use of a 4.1-mm cartridge (OR, 8.57; 95% CI, 1.2-60.2; P = 0.03) were independently associated with pancreatic fistula formation. Stapled pancreatic transection provides an acceptable PF rate after DP. Diabetes and staple size influence PF rates. In our experience, use of mesh staple line reinforcement did not reduce the incidence of PF after stapled transection.

Neuroendocrine Pancreatic Tumors Are Risk Factors for Pancreatic Fistula after Pancreatic Surgery

Background: Postoperative pancreatic fistula (PF) is still regarded as a major complication in pancreatic surgery. In the present study, we evaluated the risk of PF in a large study population of patients with neuroendocrine pancreatic tumors (NPT), pancreatic cancer (PC), and chronic pancreatitis (CP). Methods: Patients who underwent pancreatic surgery between 1989 and 2008 at our institution were retrospectively evaluated. Patients were analyzed regarding age, gender, BMI, alcohol, smoking, preoperative diabetes, reason for operation, operative procedure, and PF. Three different grades of PF (grades A, B, C) were defined. Results: 133 patients with NPT, 212 patients with PC, 52 patients with CP, and 76 patients with other reasons were evaluated. Patients with a NPT had a significant higher risk of developing a PF than patients with PC, CP, or other reasons (p = 0.0001). Enucleation of the tumor was associated with the highest rate of PF (p = 0.001). In a multivariate analysis, BMI >26, and preoperative diabetes were associated with a higher rate of PF (p = 0.042 and p = 0.02, respectively). Conclusion: We demonstrated that after excluding factors like different definitions of PF, or different peri- or postoperative management, patients with NPT have a significantly higher risk of postoperative PF than patients with other pancreatic diseases.