Severity Of Postoperative Pancreatic Fistula Research Articles

How I do it. Pancreatojejunostomy: surgical tips to mitigate the severity of postoperative pancreatic fistulas after open or minimally invasive pancreatoduodenectomy.

Pancreatoduodenectomy is the most appropriate technique for the treatment of periampullary tumors. In the past, this procedure was associated with high mortality and morbidity, but with improvements in patient selection, anesthesia, and surgical technique, mortality has decreased to less than 5%. However, morbidity remains increased due to various complications such as delayed gastric emptying, bleeding, abdominal collections, and abscesses, most of which are related to the pancreatojejunostomy leak. Clinically relevant postoperative pancreatic fistula is the most dangerous and is related to other complications including mortality. The incidence of postoperative pancreatic fistula ranges from 5-30%. Various techniques have been developed to reduce the severity of pancreatic fistulas, from the use of an isolated jejunal loop for pancreatojejunostomy to binding and invagination anastomoses. Even total pancreatectomy has been considered to avoid pancreatic fistula, but the late effects of this procedure are unacceptable, especially in relatively young patients. Recent studies on the main techniques of pancreatojejunostomy concluded that duct-to-mucosa anastomosis is advisable, but no technique eliminates the risk of pancreatic fistula. The purpose of this study is to highlight technical details and tips that may reduce the severity of pancreatic fistula after pancreatojejunostomy during open or minimally invasive pancreatoduodenectomy.

Pancreatic duct occlusion with polychloroprene-based glue for the management of postoperative pancreatic fistula after pancreatoduodenectomy-an outdated approach?

Managing postoperative pancreatic fistula (POPF) presents a formidable challenge after pancreatoduodenectomy. Some centers consider pancreatic duct occlusion (PDO) in reoperations following pancreatoduodenectomy as a pancreas-preserving procedure, aiming to control a severe POPF. The aim of the current study was to evaluate the short- and long-term outcomes of employing PDO for the management of the pancreatic stump during relaparotomy for POPF subsequent to pancreatoduodenectomy. Retrospective review of consecutive patients at Oslo University Hospital undergoing pancreatoduodenectomy and PDO during relaparotomy. Pancreatic stump management during relaparotomy consisted of occlusion of the main pancreatic duct with polychloroprene Faxan-Latex, after resecting the dehiscent jejunal loop previously constituting the pancreaticojejunostomy. Between July 2005 and September 2015, 826 pancreatoduodenectomies were performed. Overall reoperation rate was 13.2% (n = 109). POPF grade B/C developed in 113 (13.7%) patients. PDO during relaparotomy was performed in 17 (2.1%) patients, whereas completion pancreatectomy was performed in 22 (2.7%) patients. Thirteen (76%) of the 17 patients had a persistent POPF after PDO, and the time from PDO until removal of the last abdominal drain was median 35 days. Of the PDO patients, 13 (76%) patients required further drainage procedures (n = 12) or an additional reoperation (n = 1). In-hospital mortality occurred in one patient (5.9%). Five (29%) patients developed new-onset diabetes mellitus, and 16 (94%) patients acquired exocrine pancreatic insufficiency. PDO is a safe and feasible approach for managing severe POPF during reoperation following pancreatoduodenectomy. A significant proportion of patients experience persistent POPF post-procedure, necessitating supplementary drainage interventions. The findings suggest that it is advisable to explore alternative pancreas-preserving methods before opting for PDO in the management of POPF subsequent to pancreatoduodenectomy.

Postoperative Hyperamylasemia (POH) is an Early Predictor of Pancreatic Fistula Occurrence and Severity after Distal Pancreatectomy: Results from a European Multicentric Study.

The aim of this international multicentric study is to characterize postoperative hyperamylasemia (POH) after distal pancreatectomy (DP), with particular focus on its relationship with postoperative pancreatic fistula (POPF) occurrence and severity. The clinical relevance of POH after DP and its relationship with the occurrence and severity of POPF have not been explored yet. All patients undergoing DP for any indication between 2015 and 2021 at three European referral Centers for pancreatic surgery were retrospectively analyzed. Drain fluid amylase (DFA), C-reactive protein (C-RP), and serum amylase were examined from postoperative-day (POD) 1 to 3. Biochemical leak (BL), POPF, POH, and post-pancreatectomy hemorrhage (PPH) were defined and graded according to ISGPS definitions. In total 1192 patients were included. Overall rates of POH and POPF were 18% (n= 210) and 29% (n= 344), respectively. The presence of DFA ≥2000 U/L on POD 1 (OR=2.11, 95% CI 1.68-2.86), C-RP ≥200 mg/L on POD 3 (OR=2.19, 95% CI 1.68-2.86), and POH (OR=1.58, 95% CI 1.14-2.19) were all independent early predictors of POPF (all P< 0.01). The presence of POH almost doubled the rate of POPF (43% vs. 26%, P<0.001), and higher POPF severity presented also higher POH rates (no POPF= 12%; BL= 19%; B POPF= 24%; C POPF= 52%). Among patients developing POPF, patients with POH had higher rates of PPH (22% vs 9%, P= 0.001), sepsis (24% vs 13%; P=0.011), re-operation (21% vs 8%; P< 0.01), and mortality (3% vs 0.3%; P= 0.025). The occurrence of POH is an early predictor of POPF and its severity after DP. The diagnosis of POH might define patients at higher risk for a complicated course, targeting them for prevention / mitigation strategies against pancreas specific complications.

Preemptive wirsungostomy: a safe fistula for avoiding a dreadful fistula in elective or planned pancreatoduodenectomy

BackgroundHigh-risk pancreatic anastomosis can lead to a high mortality rate after PD due to the development of postoperative pancreatic fistula (POPF). Performing a wirsungostomy by externalizing the pancreatic duct is a poorly known alternative to anastomosis which could reduce the risk of POPF and the associated severe morbidity MethodsWe retrospectively evaluated patients who underwent primary wirsungostomy with PD from January 2007 to December 2021 in our tertiary referral center. Rates of morbidity and mortality with long-term pancreatic functions were studied. ResultsSixty patients were included. The median Updated Alternative Fistula Risk Score (ua-FRS) was 52%, with 95% patients in the high-risk ua-FRS category and 88.3% patients with stage D risk of developing POPF according to the classification of the ISGPS. The mortality rate was 3.3%, and overall 90-day postoperative morbidity was 63.7% with 50% of patients developing major complications. Mean follow-up was 29.8 months. Twelve patients (20%) became diabetic and 35 patients (58.3%) had preserved pancreatic endocrine function ConclusionPreemptive wirsungostomy with PD could be an appropriate procedure for patients with high-risk pancreatic anastomosis. The high associated morbidity could be compromised by the low mortality and preservation of endocrine function compared to total pancreatectomy or severe POPF.

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.

Severity of Pancreatic Leak in Relation to Gut Restoration After Pancreaticoduodenectomy: The Role of the Roux-en-Y Configuration.

Pancreatic leak after pancreaticoduodenectomy and gut restoration via a single jejunal loop remains the crucial predictor of patients' outcome. Our reasoning that active pancreatic enzymes may be more disruptive to the pancreatojejunostomy prompted us to explore a Roux-en-Y configuration for the gut restoration, anticipating diversion of bile salts away from the pancreatic stump. Our study aims at comparing two techniques regarding the severity of postoperative pancreatic fistula (POPF) and patients' outcome. The files of 415 pancreaticoduodenectomy patients were retrospectively reviewed. Based on gut restoration, the patients were divided into: cohort A (n = 105), with gut restoration via a single jejunal loop, cohort B (n = 140) via a Roux-en-Y technique assigning the draining of pancreatic stump to the short limb and gastrojejunostomy and bile (hepaticojejunostomy) flow to long limb, and cohort C (n = 170) granting the short limb to the gastric and pancreatic anastomosis, whereas hepaticojejunostomy was performed to the long limp. The POPF-related morbidity and mortality were analyzed. Overall POPF in cohort A versus cohorts B and C was 19% versus 12.1% and 9.4%, respectively (P = 0.01 A vs B + C). POPF-related morbidity in cohort A versus cohorts B and C was 10.5% versus 7.3% and 6.3%, respectively (P = 0.03 A vs B+C). POPF-related total hospital mortality in cohorts A versus B and C was 1.9% versus 0.8% and 0.59%, respectively (P = 0.02 A vs B+C). Roux-en-Y configuration showed lower incidence and severity of POPF. Irrespective of technical skill, creating a gastrojejunostomy close to pancreatojejunostomy renders the pancreatic enzymes less active by leaping the bile salts away from the pancreatic duct and providing a lower pH.

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.

Postoperative acute pancreatitis after pancreatic resection in patients with pancreatic ductal adenocarcinoma.

Postoperative pancreatic fistula (POPF) is one of the major critical complications after pancreatic resection. Recently, postoperative acute pancreatitis (POAP), a new concept for a pancreatic-specific complication following pancreatic resection, has been advocated, and its association with POPF has been reported. The present study examined the clinical features of POAP and identified the associations of POAP with POPF and other postoperative morbidities in pancreatic ductal adenocarcinoma (PDAC) patients undergoing pancreatic resection. A total of 312 consecutive patients who underwent pancreatic resection for PDAC at our institution from 2013 to 2019 were enrolled in this study. POAP was defined as an elevated serum amylase level above the upper limit normal on postoperative day (POD) 0 or 1, based on Connor's definition. The severity of POPF was assessed by the International Study Group on Pancreatic Surgery definition. A total of 184 patients (58.9%) had POAP. POAP occurred in 58.5% of subtotal stomach-preserving pancreatoduodenectomy patients and 60% of distal pancreatectomy combined with splenectomy patients. The presence of POAP was significantly associated with the development of clinically relevant POPF, higher rates of severe morbidity, and a prolonged hospital stay after pancreatic resection. A multivariate analysis showed that the presence of POAP and elevated C-reactive protein levels on POD 3 were independent predictors of clinically relevant POPF after subtotal stomach-preserving pancreatoduodenectomy. POAP is associated with the development of POPF, higher rates of severe morbidity, and a prolonged hospital stay after pancreatic resection and is an independent risk factor for clinically relevant POPF after pancreatoduodenectomy. POAP represents an important indicator for planning treatment strategies to prevent serious complications, including POPF.

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.

A further modification of the blumgart pancreatojejunostomy: results of a propensity score-matched analysis versus cattel-warren pancreatojejunostomy in open and robotic pancreatoduodenectomy

Introduction: Appropriate surgical technique is key to reduce incidence and severity of post-operative pancreatic fistula (POPF). Method: Blumgart pancreatojejunostomy was further modified (m-BPJ), by reducing to 2 the number of transparenchimal sutures and by adding two two “half purse-string sutures” at the corners. m-BPJ was compared to Cattell-Warren pancreatojejunostomy (C-WPJ) before and after propensity score matching in both open (OPD) and robotic (RPD) pancreatoduodenectomy. The primary study endpoint was incidence of clinically relevant POPF (CR-POPF). Results: mBPJ was used in 190 patients (124 OPD; 66 RPD). C-WPJ was employed in 225 patients (143 OPD and 82 RPD). The incidence of CR-POPF was 13.7% and 29.8% (p< 0.0001; OR=0.37) in mBPJ and C-WPJ, respectively. Equivalent figures in OPD and RPD subgroups were 13.7% and 28.8% (p< 0.003; OR= 0.40) and 13.6% and 31.7% (p< 0.01; OR= 0.34), respectively. Grade C POPF occurred in 9 patients after C-WPJ (4.0%) and in 1 patient after mBPJ (0.5%) (p=0.02). Predictors of CR-POPF are reported in table 1. The matching process identified 107 pairs (78 OPD and 29 RPD). In the global population the adjusted OR decreased to 0.40 (p=0.0007). CR-POPF occurred in 12.8% and 28.2% (p=0.01) OPDs, and in 6.9% and 41.4% (p=0.002) RPDs using mBPJ and C-WPJ, respectively. In propensity score matched analysis OR for CR-POPF of mBPJ decreased to 0.36 (p=0.18) and to 0.09 (p=0.01) in OPDs and RPDs, respectively. Conclusion: In our analysis mBPJ decreased incidence of CR-POPF as compared to C-WPJ in the general population, in OPD and RPD.Tabled 1[Table 1 - Predictive factors of CR-POPF].

Peripancreatic Bacterial Contamination Can Lead to the Development of Postoperative Pancreatic Fistula after Pancreaticoduodenectomy

Introduction: The aim of this study was to analyze the relationship between Peripancreatic bacterial contamination (PPBC) and postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) and to investigate the bacterial species in the peripancreatic fluid and identify useful antibiotics to prevent POPF. Methods: Three hundred twenty consecutive patients underwent PD between May 2012 and December 2019. Amylase (D-AMY) and microbial culture have been routinely obtained from the peripancreatic drain on postoperative day (POD) 1, 3, and 6 since May 2012 and Modified Blumgart pancreaticojejunostomy (MBPJ) (N=158) has been adopted since May 2016. POPF was defined as grade B/C according to the international definition. Results: POPF occurred in 26 (16.5%) of 158 patients with MBPJ. In univariate analysis, non-pancreatic disease (P=0.026), body mass index (BMI) >25 kg/m2 (P=0.016), soft pancreas (P=0.009), D-AMY on POD1 >5000 U/L (P< 0.001), and PPBC on POD1 or 3 (P< 0.001) were significantly associated with POPF. In multivariate analysis, BMI >25kg/m2 (Odds ratio [OR]=3.61; P=0.022), D-AMY on POD1 >5000 U/L (OR=5.28; P=0.004) and PPBC on POD1 or 3 (OR=4.96; P=0.003) were independent risk factors of POPF. Of all 320 patients, PPBC gradually increased from POD1 to 6. The most commonly isolated bacteria on POD1 or 3 were Enterococcus sp. (10.9%), Pseudomonas sp. (2.5%), and Enterobacter sp. (1.9%) which were sensitive to piperacillin, imipenem, meropenem, and levofloxacin. Conclusions: Early PPBC after PD can cause the development of POPF. The patients suspected of PPBC should receive more sensitive antibiotics in the early postoperative period to prevent severe POPF.

Management of postoperative drainage after pancreaticoduodenectomy: review from the location of perianastomotic fluid collection during the early postoperative period

Introduction: To assess the association between perianastomotic fluid collection (PFC) during the early postoperative period and postoperative pancreatic fistula (POPF) related complications, and to investigate the optical drain location. Methods: Medical records of 148 patients who had undergone PD and computed tomography (CT) on postoperative day 4 were retrospectively reviewed. The location—superior, inferior, ventral, dorsal, or splenic hilum—and volume of PFC were determined using CT. Postoperative complications were compared between the PFC and non-PFC groups. Association between volume and postoperative complications was assessed. Results: The PFC group included 102 patients (69%). POPF and organ/space surgical site infection (SSI) were more frequent in the PFC group (p < 0.001 and p=0.020, respectively). According to the location of PFC, superior and ventral PFCs were associated with pseudoaneurysm (p=0.006 and p=0.002, respectively), while inferior and dorsal PFCs were associated with deep incisional SSI (p=0.027 and p=0.034, respectively). In 5 of 9 patients with inferior PFC and deep incisional SSI, the PFC had reached the abdominal wall via the surface of the transverse mesocolon. All of these patients showed a dorsal PFC connected to the inferior PFC on CT performed on POD 4. Therefore, we added drainage tube at the inferior part of PJ for soft pancreas cases after January 2019. We encountered clinically relevant POPF in 3 cases of 10 soft pancreas cases, however we did not experience deep incisional SSI. Conclusion: The prevention of PFC during the early postoperative period may prevent more severe POPF related complications.

Pancreatic neck transection using a harmonic scalpel increases risk of biochemical leak but not postoperative pancreatic fistula after pancreaticoduodenectomy

BackgroundThe effect of a harmonic scalpel on postoperative pancreatic fistula (POPF) has not been addressed. This study assessed the effect of pancreatic neck transection using a harmonic scalpel on rate and severity of POPF after pancreaticoduodenectomy (PD). MethodsThis retrospective analysis included patients who underwent PD at National Taiwan University Hospital between July 2015 and March 2019. We compared rate and severity of POPF between patients who underwent pancreatic neck transection using a harmonic scalpel versus electrosurgical unit. ResultsOf 422 consecutive PDs, the pancreatic neck was transected using a harmonic scalpel or electrosurgical unit in 144 and 278 patients, respectively. Use of a harmonic scalpel significantly increased risk of biochemical leak (25.7% versus [vs] 10.8%; P < 0.05) but not clinically relevant POPF (CR-POPF; 30.2% vs 26.4%; P = 0.41). Harmonic transection was an independent predictor of biochemical leak (odds ratio [OR] = 2.93; P < 0.05) but not CR-POPF (OR = 0.83; P = 0.41) or other major complications (OR = 0.72; P = 0.27). There was no significant intergroup difference in postoperative hospital stay. ConclusionPancreatic neck transection using a harmonic scalpel increased risk of biochemical leak but not CR-POPF or other major complications.

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.

Feasibility, Morbidity and Mortality in Two Hundred Consecutive Cases of Pancreaticogastrostomy After Pancreaticoduodenectomy

BackgroundPostoperative mortality associated with pancreaticoduodenectomy (PD) in high-volume hospitals is below 5%, yet morbidity rates range between 45% and 60%. Recent studies show a lower incidence of complications and postoperative pancreatic fistula (POPF) in pancreaticogastrostomy (PG). The primary objective was to assess the incidence and predictive factors for complications: POPF, post-pancreatectomy hemorrhage (PPH) and delayed gastric emptying (DGE) following the criteria of the ISGPS and Clavien-Dindo classifications. MethodsA prospective observational study that included all patients who underwent PD between 2008 and 2016. PG was the surgical procedure of choice for PD reconstruction. ResultsTwo hundred forty-nine (249) patients underwent surgery with intention of performing a PD. The feasibility of PG was 90.5%. One hundred and six (53%) patients had complications, 36 (18%) were severe (Clavien-Dindo grade ≥ III). Death within 90 postoperative days was 4%. DGE was the most frequent complication (22.5%), followed by PPH (21%). The clinical POPF rate was 15% (6% Clavien-Dindo grade ≥ III). The primary risk factors associated with complications were age >70 years (1.9 [1–3.55]), being male (1.89 (1; 3.6]) and soft pancreatic texture (3.38 [1.5; 7.37]). ConclusionsIn this paper, we report a feasibility study for PG (90.5%). The primary risk factors associated with complications are age >70 years, being male and soft pancreatic texture. Soft pancreatic texture is also associated with the development and severity of POPF.

Neoadjuvant Chemotherapy Enhances Local Postoperative Histopathological Tumour Stage in Borderline Resectable Pancreatic Cancer - A Matched-Pair Analysis.

Neoadjuvant chemotherapy (NAC) is established in the treatment of ductal pancreatic adenocarcinoma for downsizing borderline-resectable pancreatic cancer (BRPC) and may affect nodal positivity and rates of R0 resection. This study aimed to identify the impact of NAC on postoperative histopathological parameters with a prognostic relevance. A one-to-three matched-pair analysis, including an overall total of 132 patients (25% treated with NAC and subsequent resection and 75% undergoing upfront surgery) was performed. Influence of NAC on nodal positivity, lymphatic, vascular and perineural invasion, as well as resection stage and grading, was examined. Furthermore, perioperative complications, in-hospital stay, re-admission rates, mortality, as well as preoperative body mass index and American Association of Anesthesiologist classification scores, were evaluated. Patients treated with NAC significantly less frequently had lymphatic tissue invasion (lymph node invasion: 51.5% vs. 72.7%; p=0.032, and lymphatic vessel invasion 9.4% vs. 55.3%; p=0.0004), whereas vascular and perineural invasion, as well as grading and resection state were not significantly different. Carbohydrate antigen 19-9 regression in correlation with nodal positivity also did not differ, and both groups showed comparable perioperative complication rates. Occurrence and severity of postoperative pancreatic fistula (18.2% vs. 24.3%; p=0.034) were significantly lower in patients who had undergone NAC. NAC significantly affects postoperative histopathological tumour stage in BRPC and appears to be a safe treatment option without increased perioperative complications, re-admission, in-hospital stay, or mortality. Further studies are mandatory to underline the suitability of NAC for ductal pancreatic adenocarcinoma subgroups in order to guide clinicians in their daily decision-making comprehensively.

Modified Single-Loop Reconstruction for Pancreaticoduodenectomy.

Modified single-loop reconstruction in pancreaticoduodenectomy separates pancreatic secretion from bile. It is performed in cases of high-risk pancreatic remnants to reduce the severity of postoperative pancreatic fistulas and moreover the overall postoperative morbidity. This reconstruction technique is characterized by an extra-long jejunal loop for the construction of the pancreaticojejunostomy and hepaticojejunostomy. The longer distance between these anastomoses and an additional jejuno-jejunostomy between the afferent and efferent limb of the hepaticojejunostomy separate the fluids and prevent backflow of bile towards the pancreaticojejunostomy. Thus, the secretions cannot activate each other and aggravate an existing anastomotic leakage. We observed a reduced rate of severe postoperative pancreatic fistulas after modified single-loop reconstruction compared to conventional single loop reconstruction. The technique is easy to perform, safe, and less time-consuming than a traditional double-loop reconstruction.

Combination of postoperative C-reactive protein value and computed tomography imaging can predict severe pancreatic fistula after pancreatoduodenectomy

BackgroundRecent management after pancreatoduodenectomy recommends either omission of prophylactic drainage or early removal. This potentially makes the diagnosis of postoperative pancreatic fistula (POPF) difficult because the diagnosis is based on the amylase value of drain effluent. The aim of this study was to determine if severe POPF could be predicted independent of drainage information. MethodsRecords of consecutive patients who underwent pancreatoduodenectomy between 2012 and 2018 were included for further analysis. The presence of a peripancreatic collection (PC) on routine postoperative (day7) computed tomography (early CT) and perioperative characteristics were analyzed. ResultsPC appeared in 82/211 patients (39%) and was associated with clinically relevant POPF (p < 0.001). The C-reactive protein (CRP) on postoperative day5 was a good predictor of severe POPF (needing interventional therapy or Grade C) (area under the receiver operating characteristics curve, 0.802; 95% confidence interval, 0.702–0.875). Presence of a PC and a high CRP value were independent risk factors for severe POPF following multivariate analysis. The combination of CRP<5.0 mg/dL on postoperative day 5 and the absence of a PC had 98% negative predictive value. ConclusionThe combination of CRP measurement and PC evaluation by early CT was useful in predicting severe POPF after pancreatoduodenectomy.

Postoperative Pancreatic Fistula in Surgery for Perihilar Cholangiocarcinoma.

There are numerous studies on postoperative pancreatic fistula (POPF) in pancreatic surgery but few studies on POPF in extrahepatic bile duct resection with or without hepatectomy for perihilar cholangiocarcinoma (PHCC). The aim of this study is to investigate the incidence of and risk factors for POPF in this challenging surgery. All consecutive patients who underwent surgical resection for presumed PHCC between January 2008 and December 2017 were retrospectively reviewed, with special attention paid to POPF. Among 416 patients, 90 patients showed a drain amylase level of > 3 times the normal limit on day 3 or after. The severity of POPF was biochemical leakage in 46 patients and grade B in 44 patients. No patient had grade C POPF; thus, the incidence of clinically relevant POPF was 10.6% (44/416). The resection line of the common bile duct was closely associated with POPF; 23 (27.7%) of the 83 patients who underwent intrapancreatic resection of the common bile duct developed POPF. The occurrence of intra-abdominal abscess and liver failure was significantly higher in patients with POPF, but the 90-day mortality was similar. The multivariate analysis identified a body mass index of ≥ 22 and intrapancreatic bile duct resection as independent risk factors for POPF. POPF occurs in approximately 10% of patients undergoing resection for PHCC. Careful postoperative management with attention to POPF is required, especially in patients who undergo intrapancreatic resection of the common bile duct and in those with a high body mass index.