Severe Pancreatic Fistula Research Articles

Feasibility, safety and oncological short-term outcome of laparoscopic pancreaticoduodenectomy for periampullary cancer: Findings from a large sample from Vietnam.

Laparoscopic pancreaticoduodenectomy (LPD) is an alternative to open pancreaticoduodenectomy (OPD) for treatment of periampullary cancer in selected patients. However, this is a difficult procedure with a high complication rate. We conducted a prospective cohort study of 85 patients with suspected periampullary cancer who underwent LPD from February 2017 to January 2022 at University Medical Center at Ho Chi Minh City, Vietnam. Among these, 15 patients were excluded from the data analysis because of benign disease confirmed by postoperative pathological examination. Among 70 patients, the mean age was 58.9 ± 8.9 years old and 51.4% were female. The conversion rate to open surgery was 7.1% (n = 5). Among those underwent LPD, the mean operating time and estimated blood loss were 509 ± 94 minutes and 267 ± 102 mL, respectively. The median length of hospital stay was 8 days, interquartile range (IQR) 7-12 days. The percentage of cumulative morbidity, pancreatic fistula and major complication was 35.4%, 12.3%, and 13.8%, respectively. The median of comprehensive complication index (CCI) was 26.2 (IQR 20.9-29.6). Three patients required reoperation due to severe pancreatic fistula (n = 2) and necrotizing pancreatitis (n = 1). There was no death after ninety-day. The average number of harvested lymph nodes was 16.6 ± 5.1. The percentage of R0 resection was 100%. With properly selected patients, LPD can be a feasible, safe and effective approach with acceptable short-term outcomes.

Observational retrospective study on amylase dosage and severity of pancreatic fistula

Background: Pancreatic fistula is a complication in pancreatic surgery. It is important to predict its occurrence to guide postoperative management. There are few studies on the correlation between amylase levels in the drainage fluid and the risk of pancreatic fistula. The aim of the study was to determine whether the amylase level on postoperative day 3 can predict the severity of pancreatic fistula. Material and methods: A retrospective study was performed in patients who underwent duodenopancreatectomy to evaluate the relationship between the amylase value in intra-abdominal drainage on postoperative day 3 and the severity of pancreatic fistula. The relationship between surgical and conventional biochemical results was analyzed. Student's t-test was used for statistical analysis with a value of p<0.05 considered significant. Results: No significant differences or statistically significant correlations were found between the groups evaluated. Conclusion: Isolated measurement of amylase in draining fluid in the early postoperative period is not sufficient but is very useful in predicting the occurrence of FP associated with complications and prolonged hospital stay. Further research is required to reduce its incidence.

Preoperative pancreatic CT value is related to pancreatic fistula after pancreaticoduodenectomy: a retrospective study.

Pancreatic fistula (PF) is the main complication in patients undergoing pancreaticoduodenectomy. Computed tomography (CT) value can reflect pancreatic tissue characteristics which is related to PF. This study was designed to study the relationship between the preoperative CT value and pancreatic fistula. We retrospectively reviewed the clinical and medical data of patients undergoing pancreaticoduodenectomy from 2017 to 2021. The pancreatic CT value and the CT value ratios of the pancreas and abdominal aorta (PCT/ACT) were measured and compared between the PF group and non-PF group. The values in different PF severity groups were compared using variance analysis. A cut-off value was selected by receiver operating characteristic (ROC) curve. Single-factor and multiple-factor analysis were performed to evaluate Correlation between PF and CT. One hundred and twenty-seven cases were included in this study. The PCT/ACT in the PF group was significantly lower than that in the non-PF group (P<0.001), and the PCT/ACT value was correlatively lower in the severe PF group than in the mild PF group (P=0.008). A cutoff value of 0.99 was selected by ROC curves analysis. Further multifactor analysis identified PCT/ACT <0.99 to be an independent preoperative predictor [odds ratio (OR): 11.3, P<0.01]. The preoperative pancreatic CT value can indirectly reflect the histological condition of the pancreas and thus may related to postoperative PF after pancreaticoduodenectomy and provide useful information for surgeons in deciding upon the pancreaticojejunostomy method.

Surgical management of severe pancreatic fistula after pancreatoduodenectomy: a comparison of early versus late rescue pancreatectomy

BackgroundRescue pancreatectomy for postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) is associated with high mortality. However, in-depth literature is scarce and hard to interpret. This study aimed to evaluate the indications, timing and perioperative outcomes of rescue pancreatectomy for severe POPF after PD.MethodsRetrospective single-centre study from all consecutive patients (2008–2020) with POPF-C after PD (ISGPS 2016 definition). Major morbidity and mortality during hospitalization or within 90 days after index surgery were evaluated. Time from index surgery to rescue pancreatectomy was dichotomized in early and late (≤ 11 versus > 11 days).ResultsFrom 1076 PDs performed, POPF-B/C occurred in 190 patients (17.7%) of whom 53 patients (4.9%) with POPF-C were included. Mortality after early rescue pancreatectomy did not differ significantly compared to late rescue pancreatectomy (13.6% versus 35.3%; p = 0.142). Timing of a rescue pancreatectomy did not change significantly during the study period: 11 (IQR, 8–14) (2008–2012) versus 14 (IQR, 7–33) (2013–2016) versus 8 days (IQR, 6–11) (2017–2020) (p = 0.140). Over time, the mortality in patients with POPF grade C decreased from 43.5% in 2008–2012 to 31.6% in 2013–2016 up to 0% in 2017–2020 (p = 0.014). However, mortality rates after rescue pancreatectomy did not differ significantly: 31.3% (2008–2012) versus 28.6% (2013–2016) versus 0% (2017–2020) (p = 0.104).ConclusionsRescue pancreatectomy for severe POPF is associated with high mortality, but an earlier timing might favourably influence the mortality. Hypothetically, this could be of value for pre-existent vulnerable patients. These findings must be carefully interpreted considering the sample sizes and differences among subgroups by patient selection.

Early postoperative risk stratification in patients with pancreatic fistula after pancreaticoduodenectomy

BackgroundEarly stratification of postoperative pancreatic fistula according to severity and/or need for invasive intervention may improve outcomes after pancreaticoduodenectomy. This study aimed to identify the early postoperative variables that may predict postoperative pancreatic fistula severity. MethodsAll patients diagnosed with biochemical leak and clinically relevant-postoperative pancreatic fistula based on drain fluid amylase >300 U/L on the fifth postoperative day after pancreaticoduodenectomy were identified from a consecutive cohort from Birmingham, UK. Demographics, intraoperative parameters, and postoperative laboratory results on postoperative days 1 through 7 were retrospectively extracted. Independent predictors of clinically relevant-postoperative pancreatic fistula were identified using multivariable binary logistic regression and converted into a risk score, which was applied to an external cohort from Verona, Italy. ResultsThe Birmingham cohort had 187 patients diagnosed with postoperative pancreatic fistula (biochemical leak: 99, clinically relevant: 88). In clinically relevant-postoperative pancreatic fistula patients, the leak became clinically relevant at a median of 9 days (interquartile range: 6–13) after pancreaticoduodenectomy. Male sex (P = .002), drain fluid amylase-postoperative day 3 (P < .001), c-reactive protein postoperative day 3 (P < .001), and albumin-postoperative day 3 (P = .028) were found to be significant predictors of clinically relevant-postoperative pancreatic fistula on multivariable analysis. The multivariable model was converted into a risk score with an area under the receiver operating characteristic curve of 0.78 (standard error: 0.038). This score significantly predicted the need for invasive intervention (postoperative pancreatic fistula grades B3 and C) in the Verona cohort (n = 121; area under the receiver operating characteristic curve: 0.68; standard error = 0.06; P = .006) but did not predict clinically relevant-postoperative pancreatic fistula when grades B1 and B2 were included (area under the receiver operating characteristic curve 0.52; standard error = 0.07; P = .802). ConclusionWe developed a novel risk score based on early postoperative laboratory values that can accurately predict higher grades of clinically relevant-postoperative pancreatic fistula requiring invasive intervention. Early identification of severe postoperative pancreatic fistula may allow earlier intervention.

One-half layer pancreaticojejunostomy with the rear wall of the pancreas reinforced: A valuable anastomosis technique.

BACKGROUNDPostoperative pancreatic fistula (POPF) is one of the most common and serious complications after pancreaticoduodenectomy (PD). To effectively reduce the incidence of POPF, we designed a new type of pancreaticojejunostomy (PJ), which was termed one-half layer PJ with the rear wall of the pancreas reinforced.AIMTo explore the clinical application value of this new technique.METHODSWe compared 62 patients who had undergone PD by either the traditional duct-to-mucosa anastomoses or the new one-half layer PJ with the rear wall of the pancreas reinforced method at our hospital from May 2015 to September 2019. All 62 patients were operated by the same surgeon experienced in both procedures. We retrospectively analyzed patient characteristics, perioperative outcomes, and surgical results.RESULTSThere was no significant difference between the two groups in basic information except the postoperative hospital stays, 14.7 ± 5.4 d in the traditional duct-to-mucosa anastomoses group and 12.0 ± 4.2 d in the one-half layer PJ group (P = 0.042). In terms of postoperative complications, the one-half layer PJ group had a lower rate of POPF than the traditional group. The overall number of cases with POPF was 8 (24.2%) in the traditional group and 2 (6.9%) in the one-half layer group (P = 0.017). Additionally, the rate of grades B and C POPF was lower in the one-half layer group (3.4%) compared with that (12.1%) in the traditional group (P = 0.010). One patient died due to hemorrhage caused by severe pancreatic fistula in the traditional group.CONCLUSIONOne-half layer PJ with the rear wall of the pancreas reinforced is a safe and feasible procedure that can successfully reduce the rate of POPF. It may be a promising technique for PJ after PD.

Preliminary results of laparoscopic versus open pancreaticoduodenectomy in Vietnam: A retrospective analysis from a multi-center research

IntroductionThe goal of this study was to compare the results of LPD with those of open pancreaticoduodenectomy (OPD). MethodData were retrospectively collected from a database of patients who underwent PD from January 2010 to May 2020. Intraoperative, postoperative, and follow-up assessment studies were conducted. ResultsA total of 149 patients were selected. Compared with OPD, LPD was fewer intraoperative blood transfusions (p = 0.015), a longer median operative time (p < 0.001), hospital stay (p = 0.034), a higher rate of bile leakage (p = 0.02), overall morbidity (p = 0.045), and re-operation (p = 0.044). There was no difference between the two groups in severe pancreatic fistula, postoperative bleeding, delayed gastric emptying, Clavien-Dindo classification ≥ III, or 30-day mortality. LPD had a similar number of excised lymph nodes, R0 resection rate, and long-term survival cases involving malignant tumors, ampulla of Vater cancer, and pancreatic ductal adenocarcinoma. ConclusionIn the early period, the benefit of LPD has not been found as there was a high rate of conversion to laparotomy, morbidity, and re-operation. Despite that, LPD is a feasible oncological approach with long-term survival comparable to OPD.

Impact of parenchyma-preserving surgical methods on treating patients with solid pseudopapillary neoplasms: A retrospective study with a large sample size.

BACKGROUNDSolid pseudopapillary neoplasm (SPN) of the pancreas is a rare neoplasm that mainly affects young women.AIMTo evaluate the impact of parenchyma-preserving surgical methods (PPMs, including enucleation and central pancreatectomy) in the treatment of SPN patients.METHODSFrom 2013 to 2019, patients who underwent pancreatectomy for SPNs were retrospectively reviewed. The baseline characteristics, intraoperative index, pathological outcomes, short-term complications and long-term follow-up data were compared between the PPM group and the conventional method (CM) group.RESULTSIn total, 166 patients were included in this study. Of them, 33 patients (19.9%) underwent PPM. Most of the tumors (104/166, 62.7%) were found accidentally. Comparing the parameters between groups, the hospital stay d (12.35 vs 13.5 d, P = 0.49), total expense (44213 vs 54084 yuan, P = 0.21), operation duration (135 vs 120 min, P = 0.71), and intraoperative bleeding volume (200 vs 100 mL, P = 0.49) did not differ between groups. Regarding pathological outcomes, tumor size (45 vs 32 mm, P = 0.07), Ki67 index (P = 0.53), peripheral tissue invasion (11.3% vs 9.1%, P = 0.43) and positive margin status (7.5% vs 6%, P = 0.28) also did not differ between groups. Moreover, PPM did not increase the risk of severe postoperative pancreatic fistula (3.8% vs 3.0%, P = 0.85) or tumor recurrence (3.0% vs 6.0%, P = 0.39). However, the number of patients who had exocrine insufficiency during follow-up was significantly lower in the PPM group (21.8% vs 3%, P = 0.024). CM was identified as an independent risk factor for pancreatic exocrine insufficiency (odds ratio = 8.195, 95% confident interval: 1.067-62.93).CONCLUSIONPPM for SPN appears to be feasible and safe for preserving the exocrine function of the pancreas.

Surgical Management of Severe Pancreatic Fistula after Pancreatoduodenectomy: Indications, Timing, and Perioperative Outcomes of Rescue Pancreatectomy

Introduction: Rescue pancreatectomy for postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) is associated with high mortality. In-depth literature is scarce and hard to interpret. Method: Retrospective single-center study from all consecutive patients (2008-2020) with POPF-C after PD (ISGPS 2016 definition). Major morbidity (i.e. Clavien-Dindo grade ≥IIIa) and mortality during hospitalization or within 90 days after index surgery were evaluated. Time from index surgery to rescue pancreatectomy was dichotomized in early and late (≤11 versus >11 days). Results: From 1076 PDs performed, POPF-B/C occurred in 190 patients (17.7%) of whom 53 patients (4.9%) with POPF-C were included. Postpancreatectomy hemorrhage (PPH) grade B or C occurred in 21% (11/53) and 62% (33/53). Percutaneous drainage for intra-abdominal collection, minimally invasive PPH management, and relaparotomy was performed in 66%, 30%, and 49%. Most patients developed single- (19/53, 36%) or multi- (17/53, 32%) organ failure. Rescue pancreatectomy was performed in 39 patients (74%), preceded by minimally invasive intervention(s) or relaparotomy in 21/39 (54%) and 11/39 (28%). Mortality in the overall population and after rescue pancreatectomy was 30% and 23%. Timing for rescue pancreatectomy did not change over time: 11 days (IQR 8-14) [2008-2012] versus 14 days (IQR 7-33) [2013-2016] versus 8 days (IQR 6-11) [2017-2020] (p=0.140). Mortality after early rescue pancreatectomy (3/22, 14%) was lower compared to late rescue pancreatectomy (6/17, 35%), although not significant (p=0.142). Conclusions: Rescue pancreatectomy for severe POPF is associated with high mortality, but may be more favourable in an early stage to avoid further clinical deterioration in vulnerable patients.

Postoperative pancreatitis after pancreatoduodenectomy

Retrospective assessment of the influence of postoperative pancreatitis in development of pancreatic fistula. The study included 173 patients after pancreatoduodenectomy performed between 2016 and 2019. Postoperative pancreatitis within the 1st postoperative day was verified considering blood amylase > 125 U/L. Patients with postoperative pancreatitis (n=36) were included in the main group, the control group consisted of 137 patients without pancreatitis. Postoperative pancreatic fistula was determined according to the ISGPS 2016 classification. Statistical analysis of the effect of postoperative pancreatitis on development of pancreatic fistula was carried out using relative risk and odds ratio with 95% confidence interval in both groups. Postoperative pancreatitis occurred in 36 (20.8%) out of 173 patients after pancreatoduodenectomy. Pancreatic fistula occurred in 18 (50%) cases. Among 137 patients without postoperative pancreatitis, only 18 (13.1%) patients developed severe pancreatic fistula. Relative risk was 3.8 (95% CI 2.22-6.51, p<0.0001), odds ratio - 6.6 (95% CI 2.91-15.01, p<0.0001). Postoperative pancreatitis significantly influences development of severe pancreatic fistula.

Fatal pancreatic fistula after laparoscopic distal pancreatectomy for intraductal papillary mucinous carcinoma with pancreaticobiliary maljunction and sphincterotomized papilla: a case report

BackgroundPancreatic juice is constantly activated by contaminated bile in patients with pancreaticobiliary maljunction (PBM). Here, we report a case of laparoscopic distal pancreatectomy for a patient with PBM and sphincterotomized papilla, resulting in fatal pancreatic fistula.Case presentationA 79-year-old man was diagnosed with pancreatic intraductal papillary mucinous neoplasm and common bile duct stones. Endoscopic sphincterotomy was performed prior to surgery. The pancreatic duct was simultaneously visualized when the contrast agent was injected into the common bile duct. Sudden bleeding was observed from the abdominal drain on postoperative day (POD) 6. Emergent stent graft placement and coil embolization were performed for bleeding from the splenic artery. On POD 9, the drainage fluid changed to yellowish in color with bile contamination. For internal drainage of the digestive fluid, endoscopic retrograde biliary tube and pancreatic drainage tube were placed. On POD 24, second emergent coil embolization was performed for bleeding from the left gastric artery. On POD 25, open abdominal drainage was performed. On POD 32, third emergent coil embolization was performed for bleeding from the gastroduodenal artery. Subsequently, remnant pancreatic resection was performed. On POD 39, massive bleeding was again observed from the abdominal drain. Emergency arterial portography revealed bleeding in the right wall of the superior mesenteric vein. The patient died of hemorrhagic shock on the same day.ConclusionsThe extreme risk of severe pancreatic fistula after distal pancreatectomy should be considered in patients with PBM and sphincterotomized papilla. In this extraordinary situation, surgeons should promptly decide whether to resect the remnant pancreas to prevent losing the patient.

Day of surgery and mortality after pancreatoduodenectomy: A retrospective analysis of 29270 surgical cases of pancreatic head cancer from Japan.

The day of the week can impact medical treatment outcomes; however, few large-scale, disease-specific studies have focused on the association between the day of the week and mortality in patients after pancreatoduodenectomy for pancreatic head cancer. Data were obtained from the National Clinical Database. Twenty-two clinical variables were adopted for hierarchal logistic regression modeling to determine adjusted odds ratios (ORs) for surgical mortality after elective pancreatoduodenectomy. The 30-day mortality and surgical mortality rates were 1.0% and 1.7%, respectively (n=29720). Surgeries were performed the least on Fridays (13.4%) compared with other weekdays. Crude rates of severe postoperative complications (mean, 14.1%; range, 13.5%-14.8%) and pancreatic fistulas (mean, 10.0%; range, 9.6%-10.3%) remained stable throughout the week. Unadjusted/adjusted ORs did not significantly differ between Friday and Monday (0.868, 95% CI: 0.636-1.173, P=.365, and 0.928, 95% CI: 0.668-1.287, P=.653, respectively), and results were similar for the remaining weekdays. Nineteen independent factors were associated with surgical mortality. The rate of perioperative mortality for elective pancreatoduodenectomy is low in Japan, with no evidence of disparities in surgical mortality rates between weekdays.

Outcomes of early reoperation in severe pancreatic fistula and/or haemorrhage after pancreaticoduodenectomy

Although advances in multidisciplinary management reduce the mortality after pancreaticoduodenectomy (PD) from medical complications, postoperative pancreatic fistula (POPF) and/or postpancreatectomy haemorrhage (PPH) still remain as common morbidities and main causes of mortality. The morbidity of POPF and/or PPH after PD in our centre, Yangon Specialty Hospital, is 18-30% per year. And there are still ongoing disputes regarding management of POPF and/or PPH after PD. It is a hospital based prospective descriptive study carried out between 2018 January and 2020 April in surgical units at Yangon General Hospital, New Yangon General Hospital and our centre. Total 28 reoperated patients with POPF and/or PPH patients after PD were included in the study. The indications for reoperation in this study were patients with SIRS together with drain amount more than 300 ml/day and/or blood in drain/ NGT with Hb drop ≥ 3 g% or sentinel bleed. Preoperative CECT scan was done if condition was favorable. In this study, demographic distribution, proportion of reoperation, timing of reoperation, types of procedure were also recorded while outcomes of reoperation was emphasized in this eposter. There were 56 patients who suffered from POPF and/or PPH after PD for periampullary carcinoma during this study period. Although reoperation was advised to 34 patients, who met the indications for reoperation, six of them declined operation for various reasons. Therefore, total 28 patients were reoperated (50%). Fig. 1 showed the intraoperative findings of POPF and PPH patient. Median timing of reoperation was 9 days (2-25 days) and 71% were reoperated within 10 days. While external tube wirsungosotmy (Fig. 2) was performed in majority of POPF cases as a damage control surgery, PPH patients ended up with mainly laparotomy and GDA ligation for arrest of haemorrhage because of lack of interventional radiology (IR) support at present. Among reoperated patients, 14 patients (50%) survived and 14 patients (50%) expired. Therefore, overall in-hospital mortality was 50% in reoperated cases. The main cause was multi-organ failure due to severe sepsis. According to the Fig. 3, in-hospital mortality rate of POPF was 16% and that of PPH was 66% while that of POPF and PPH was 80% in this study. Gangl et al. (2011) [1] reported that the combination of pancreatic fistula and severe hemorrhage was a strong predictor of postoperative mortality (relative risk (RR), 22.75). And Tamijmarane et al. (2006) [2] pointed out that patients themselves are in such a moribund condition that their associated mortality rate ranges between 38 and 50%. In addition, it was surprisingly found that all six patients, who needed reoperation, died with conservative management in this study. It is found that reoperation is necessary in patients when it is indicated i.e. mainly clinical based. Early reoperation and damage control surgery is found to have better outcomes in especially POPF patients before organ failure or haemorrhage supervenes. And it is hard to say the accurate timing of reoperation and optimal procedures because this study has some limitations like small sample size, and limited resources for multidisciplinary management. Therefore, further study with larger sample size and optimal resources and management will be necessary for better and more significant results. Showing intraoperative findings of POPF and PPH. Showing method of external tube Wirsungostomy insertion. Outcomes of reoperative management.

Acute Pancreatitis as the Initial Presentation of Pancreatic Adenocarcinoma does not Impact Short- and Long-term Outcomes of Curative Intent Surgery: A Study of the French Surgical Association.

Acute pancreatitis (AP) can be one of the earliest clinical presentation of pancreatic ductal adenocarcinoma (PDAC). Information about the impact of AP on postoperative outcomes as well as its influences on PDAC survival is scarce. This study aimed to determine whether AP as initial clinical presentation of PDAC impact the short- and long-term outcomes of curative intent pancreatic resection. From 2004 to 2009, 1449 patients with PDAC underwent pancreatic resection in 37 institutions (France, Belgium and Switzerland). We used univariate and multivariate analysis to identify factors associated with severe complications and pancreatic fistula as well as overall and disease-free survivals. There were 764 males (52,7%), and the median age was 64years. A total of 781 patients (53.9%) developed at least one complication, among whom 317 (21.8%) were classified as Clavien-Dindo ≥ 3. A total of 114 (8.5%) patients had AP as the initial clinical manifestation of PDAC. This situation was not associated with any increase in the rates of postoperative fistula (21.2% vs 16.4%, P = 0.19), postoperative complications (57% vs 54.2%, P = 0.56), and 30day mortality (2.6% vs 3.4%, P = 1). In multivariate analysis, AP did not correlate with postoperative complications or pancreatic fistula. The median length of follow-up was 22.4months. The median overall survival after surgery was 29.9months in the AP group and 30.5months in the control group. Overall recurrence rate and local recurrence rate did not differ between groups. AP before PDAC resection did not impact postoperative morbidity and mortality, as well as recurrence rate and survival.

Endoscopic ultrasound-guided hepaticogastrostomy vs. ERCP for preoperative biliary drainage in patients undergoing pancreatic resection

Abstract Objective Preoperative bile drainage in patients with obstructive jaundice due to pancreatic head malignancy is needed, if pancreatic head resection cannot be performed in a timely fashion. The safety and efficacy of ultrasound-guided hepaticogastrostomy (HGS) as an alternative to the established endoscopic retrograde cholangio-pancreatography (ERCP) with stent placement needs further investigation. Methods Clinicopathological data of patients who underwent partial or total pancreaticoduodenectomy between January 2017 and December 2019 in a major swiss hepatopancreatobiliary center were assessed. We compared the HGS with ERCP/stent regarding the kinetics of bilirubin decrease, the procedure-related morbidity, and the postoperative surgical outcomes. Results During the study period, 102 patients underwent pancreaticoduodenectomy or total pancreatectomy for pancreatic malignancy. Preoperative bile drainage was performed in 65 patients (20 HGS, 45 ERCP). HGS was associated with a faster (6 vs. 10 days, P = 0.042) and more effective (133 µmol/L vs. 101 µmol/L, P = 0.037) reduction of the serum bilirubin levels. HGS was safe and did not differ from ERCP with stent placement concerning post-interventional complications (P = 0.565), postoperative mortality (P = 0.996) and postoperative morbidity (P = 0.896), including infectious complications (wound infection, P = 0.662/ intra-abdominal abscess, P = 0.587), severe pancreatic fistula (P = 0.587), bile leak (P = 0.131), and postoperative hemorrhage (P = 0.886). Conclusion HGS performed in a specialized multidisciplinary hepatopancreatobiliary center is feasible and safe and may result in more accelerated and effective bile drainage compared to the established ERCP. In patients with obstructive jaundice related to pancreatic malignancy unable to undergo adequate bile drainage by ERCP, HGS may be an effective alternative method enabling surgery in a timely manner.

A comprehensive strategy for perioperative care of pancreaticoduodenectomy according to the risk stratification by pancreatic fistula and delayed gastric emptying

Background/ObjectivePancreaticoduodenectomy (PD) is highly invasive with unsatisfactory postoperative complication rates. Nutritional and fluid management after major surgery attracts much attention with regard to the reduction in severe postoperative complications. We retrospectively analyzed PD cases and proposed a novel strategy for perioperative fluid and nutritional therapy according to the risk stratification by pancreatic fistula (PF) and delayed gastric emptying (DGE). MethodsBetween 2003 and 2018, 140 patients underwent PD at our institute of which 134 patients were enrolled. We evaluated the clinicopathological factors affecting severe (≥10%) body weight loss (BWL), factors affecting the incidence of PF and intraabdominal complications (IAC), and factors related to DGE. ResultsMultivariate analysis indicated that male sex, severe PF, and DGE are significant risk factors for BWL ≥10%. PF and IAC were predominantly observed in male patients and those with non-pancreatic cancer. A fluid balance ≥6000 ml on postoperative day 2 was the sole risk factor for primary DGE. Secondary DGE significantly correlated with stomach preserving PD. Importantly, the average BWL was around 15% in grade B or C secondary DGE. ConclusionSevere postoperative complications resulted in significant BWL. Enteral feeding is unnecessary in cases with a hard pancreas and dilated pancreatic duct if appropriate perioperative fluid management is performed. Secondary DGE followed by PF or IAC is unavoidable to some extent, especially in the case of soft pancreas with a fine pancreatic duct. In such cases, enteral feeding with tube ileostomy should be considered, and stomach preserving PD is likely to be harmful.

Immediate outcomes of pancreatoduodenectomy after different digestive reconstruction procedures

To study the immediate results of pancreatoduodenectomy depending on digestive reconstruction procedure. We analyzed 242 patients who underwent pancreatoduodenectomy for the period from January 2013 to December 2019. There were 32 combined procedures: 28 (11.6%) with portal vein resection and 8 (3.3%) simultaneous operations (right-sided hemicolectomy - 4, right-sided adrenalectomy - 2, gastrectomy with splenectomy - 2). Pancreatic stump was inserted into the jejunum in 156 (64.5%) patients, into the stomach - in 86 (35.5%) cases. Postoperative period was uneventful in 180 (74.4%) patients. Eighty postoperative complications were observed in 62 (25.6%) patients; 221 (91.3%) patients were discharged, 21 (8.7%) patients died. Pancreatic necrosis was the most common postoperative event and provoked 65 (82.5%) various complications (38 (72.1%) in patients with pancreaticojejunostomy and 20 (71.5%) in those with pancreaticogastrostomy). Incidence of complications was similar in both groups. However, pancreaticojejunostomy was followed by severe pancreatic fistula type C in 12 (23.1%) patients, type B in 24 (46.1%) cases. In case of pancreaticogastrostomy, pancreatic fistula type C occurred in 4 (14.3%) cases, type B - in 8 (28.6%) patients. Pancreatic necrosis was the most common postoperative event after pancreatoduodenectomy. Fewer severe pancreatic fistulae (type C) were recorded after pancreaticogastrostomy although these patients had lower density of the pancreas and unclear pancreatic duct. Choice of pancreatic-digestive anastomosis should be determined by features of pancreatic parenchyma, pancreatic duct diameter. Nevertheless, final decision is a prerogative of surgeon. Pancreaticogastrostomy is especially advisable in minimally invasive PDEs that will simplify inclusion of the pancreas into digestive system and reduce the incidence of complications and mortality.

Inability to manage non-severe complications on an outpatient basis increases non-white patient readmission rates after pancreaticoduodenectomy: a large metropolitan tertiary care center experience

Presenter: Jorge G Zarate Rodriguez MD | Washington University, St. Louis Background: Racial disparities play an important role in readmissions after surgery. Pancreaticoduodenectomy (PD) is associated with high rates of morbidity and readmission, but not all readmissions are equal in terms of severity. We hypothesize that, secondary to differences in access to care, white patients are managed more successfully as outpatients for non-severe complications compared to non-white patients. This may be a factor contributing to the increased readmission rate for non-white patients after PD. Methods: Patients undergoing PD were prospectively followed, and their complications graded using the Modified Accordion Grading System (MAGS). Complications were categorized as non-severe if MAGS 1-2 and severe if MAGS ≥3. Readmissions were categorized based on complication severity—a non-severe readmission was defined as a patient readmission for a MAGS non-severe complication, and severe readmission was defined as a readmission for a MAGS severe complication. Univariate and multivariate analysis were used to compare patients with MAGS non-severe and MAGS severe readmission to patients without readmission. Results: 837 patients underwent PD, the 90-day readmission rate was 27.5% and 51.3% of readmissions were for non-severe complications. The overall readmission rate was 25.8% for white patients and 39.3% for non-white (p = 0.004). Non-white patients with readmission were 81.0% Black, 11.9% Asian, 4.8% Latinx, and 2.4% other race. Readmitted patients were more likely to be non-white (18.3% vs 10.7%, p = 0.004), obese (34.4% vs 27.5%, p = 0.047) and have soft glands (37.8% vs 28.8%, p = 0.012), and less likely to have pancreatic adenocarcinoma (49.1% vs 57.0%, p = 0.041). Patients with readmission were more likely to have suffered complications during their initial surgical hospitalization (62.7% vs 48.6%, p <0.001), both MAGS non-severe (53.5% vs 44.3%, p = 0.018) and MAGS severe (26.1% vs 12.0%, p < 0.001). More specifically, patients with readmission were more likely to have suffered bleeding complications (15.7% vs 10.5%, p = 0.042), MAGS severe pancreatic fistula (10.0% vs 4.5%, p = 0.003), MAGS severe delayed gastric emptying (7.0% vs 1.3%, p <0.001), and DVT (5.2% vs 1.7%, p = 0.004). Readmitted patients also had longer initial surgical hospitalizations (p = 0.044). Non-white race was independently associated with readmission (OR 1.83, p = 0.007). The MAGS non-severe readmission rate for white patients was 14.7% and 27.8% for nonwhite (p = 0.002), while the MAGS severe readmission rate for white patients was 14.9% vs 20.7% for non-white (p = 0.172). Non-white race was independently associated with MAGS non-severe readmission (OR 2.13, p = 0.006), but not MAGS severe readmission. Non-white patients were more likely to be readmitted without requiring an intervention that met criteria for a MAGS complication compared to white patients (21.4% vs 9.6%, p = 0.031). Conclusion: Non-white patients are more likely to be readmitted, particularly for non-severe complications. Non-complication associated elements, such as patient, provider, and healthcare system related factors, are likely driving the disproportionate frequency of readmissions in non-white patients after PD. Follow up protocols should be tailored to address racial disparities in the rates of readmission for less severe complications, which could potentially be avoidable.

Up-to-date comparison of robotic-assisted versus open distal pancreatectomy: A PRISMA-compliant meta-analysis.

Although robot-assisted distal pancreatectomy (RADP) has been successfully performed since 2003, its advantages over open distal pancreatectomy (ODP) are still uncertain. The objective of this meta-analysis is to compare the clinical and oncologic safety and efficacy of RADP vs ODP. Multiple databases (PubMed, Medline, EMBASE, Web of Science, and Cochrane Library) were searched to identify studies that compare the outcomes of RADP and ODP (up to February, 2020). Fixed and random effects models were applied according to different conditions. A total of 7 studies from high-volume robotic surgery centers comprising 2264 patients were included finally. Compared with ODP, RADP was associated with lower estimated blood loss, lower blood transfusion rate, lower postoperative mortality rate, and shorter length of hospital stay. No significant difference was observed in operating time, the number of lymph nodes harvested, positive margin rate, spleen preservation rate, rate of severe morbidity, incidence of postoperative pancreatic fistula, and severe postoperative pancreatic fistula (grade B and C) between the 2 groups. With regard to perioperative outcomes, RADP is a safe and feasible alternative to ODP in centers with expertise in robotic surgery. However, the evidence is limited and more randomized controlled trials are needed to further clearly define this role.

Meta-analysis of short-term outcomes comparing robot-assisted and laparoscopic distal pancreatectomy.

Aim: To evaluate and compare the short-term outcomes of robotic surgery and laparoscopic approach in distal pancreatectomy (DP). Materials& methods: EMBASE, PubMed, the Cochrane Library, CNKI and Wan Fang database were retrieved from the inception of electronic databases to June 2019. All analyses were performed using Stata/SE 15.1 version (StataCorp). Results: Twenty-two papers were included, four of which were prospective studies and the rest were retrospective studies. There was significant difference in spleen preservation rate (odds ratio: 2.020; 95% CI: 1.085-3.758; p =0.027), operation time (mean difference [MD]: 27.372; 95% CI: 8.236-47.210; p =0.000), the length of hospital stay (MD: -0.911; 95% CI: -1.287 to -0.535; p =0.000), conversion rate (rate difference: -0.090; 95% CI: -1.287 to -0.535; p =0.000), operation cost (MD: 2816.564; 95% CI: 1782.028-3851.064; p =0.000). However, no significant difference was detected in estimated blood loss, total complication, severe complication, lymph nodules harvest, blood transfusion rate, total pancreatic fistula, severe pancreatic fistula, R0 resection rate and mortality. Conclusion: Both robotic and laparoscopic DP are safe and feasible. Although robotic DP increases the operation cost, the spleen-preserving rate is much higher. Robotic surgery may be an alternative approach to DP.