Soft Pancreatic Texture Research Articles

Risk Factors of Postoperative Clinically Relevant Pancreatic Fistula following Distal Pancreatectomy with Stapler Closure.

To analyse clinicopathological variables to determine risk factors of postoperative pancreatic fistula in patients having distal pancreatectomy with stapler closure. Observational study. Adana City Training and Research Hospital, Adana, Turkey, from January 2015 to May 2020. Medical files of 38 cases having distal pancreatectomy with stapler closure of the pancreatic remnant for conditions emerging from the pancreas or other organs were analysed. Data about demographics, perioperative and pathological findings, postoperative outcomes were gathered. Univariate analysis was utilised for comparisons of categorical data. The possible risk factors found to be significant in the univariate analysis were included into the logistic regression analysis. Based on the description reported by the International Study Group of Pancreatic Surgery, 23.7% and 31.6% of the patients had biochemical leakage and clinically relevant postoperative pancreatic fistula (POPF) respectively. Univariate and multivariate analyses made to determine risk factors of POPF showed a relation between stapler closure alone (p = 0.018) and soft parenchymal texture (p = 0.002) and clinically relevant POPF. Multivariate analyses revealed that parenchymal texture was the sole independent predictor of clinically relevant POPF (OR, 0.016, p = 0.039). Soft pancreatic texture is independently predictive of clinically relevant POPF following distal pancreatectomy with stapler closure. However, reinforcement of the stapler line with extra sutures decreases the risk of clinically relevant POPF. Key Words: Distal pancreatectomy, Pancreatic fistula, Stapler closure, Suture reinforcement.

Total laparoscopic versus robotic-assisted laparoscopic pancreaticoduodenectomy; which one is better?

Minimally invasive pancreaticoduodenectomy is a difficult and complex operation. Since the development of the robotic platform, the number of reports on robotic-assisted pancreatic surgery has been on the rise. This study aimed to compare the technical feasibility and safety between the LPD and the robotic-assisted laparoscopic pancreaticoduodenectomy (RALPD). From September 2012 to August 2020, this study enrolled 257 patients who underwent minimally invasive pancreaticoduodenectomy for periampullary tumor. Of these patients, 207 underwent the LPD, and 50 underwent RALPD. We performed a 1:1 propensity score-matched (PSM) analysis. There was no difference in demographics, including the size of the pancreatic duct, pancreatic texture, and vascular resection. Operation time and estimated blood loss were similar, as was the incidence of complications, such as POPF, delayed gastric emptying, and postoperative hemorrhage. When comparing LPD and RALPD in only patients with a pancreatic duct size of 2 mm or less, there was no difference between the two groups in short-term surgical outcomes, including clinically relevant POPF (CR-POPF). In multivariable analysis, robotic reconstruction was not a predictive factor for CR-POPF, and the only soft pancreatic texture was a predictive factor for CR-POPF (HR 3.887, 95% confidence interval 1.121 to 13.480, p = 0.032). RALPD and LPD are one of the approaches for safe and effective PD, and they are technically equivalent regardless of the size of the pancreatic duct. Considering the high cost of robotic surgery, surgeons need to prepare not only robotic but also the pure laparoscopic technique for PD to fulfill the goal of MIS.

Preoperative and intraoperative risk factors of postoperative pancreatic fistula after pancreaticoduodenectomy – systematic review and meta-analysis

Postoperative pancreatic fistula (POPF) is a potentially life-threatening complication after pancreaticoduodenectomy (PD). It is observed when the amylase activity in the drain fluid exceeds three times the normal upper value. Grades B and C of POPF are considered as clinically relevant. Fistula might originate due to failure of healing of a pancreatic anastomosis or from raw pancreatic surface. 18 retrospective and prospective studies published between 2015 and 2020 were included in this meta-analysis. Total number of patients was 5836. To investigate potential risk factors associated with the occurrence of POPF, odds ratios (OR) with 95% confidence intervals (CI) were calculated. To compare discontinuous data, mean differences (MD) were calculated. 13 factors were divided into preoperative and intraoperative groups. Male sex, higher BMI, soft pancreatic texture and small pancreatic duct were considered as significant risk factors while vascular resection lowered the risk of development pancreatic fistula. It is considered that the development of POPF is associated with intrapancreatic fat. More severe infiltration with fat tissue is responsible for soft texture of the gland, while higher BMI is one of the risk factors of increased pancreatic fat. On the contrary, diabetes is associated with fibrotic pancreas which could lower the risk of developing POPF.

The effect of high intraoperative blood loss on pancreatic fistula development after pancreatoduodenectomy: An international, multi-institutional propensity score matched analysis

BackgroundThe association between intraoperative estimated blood loss and outcomes after pancreatoduodenectomy has, thus far, been rarely explored. MethodsIn total, 7,706 pancreatoduodenectomies performed at 18 international institutions composing the Pancreas Fistula Study Group were examined (2003–2020). High estimated blood loss (>700 mL) was defined as twice the median. Propensity score matching (1:1 exact-match) was employed to adjust for variables associated with high estimated blood loss and clinically relevant pancreatic fistula occurrence. The study was powered to detect a 33% clinically relevant pancreatic fistula increase in the high estimated blood loss group, with α = 0.05 and β = 0.2. ResultsThe propensity score model included 966 patients with high estimated blood loss and 966 patients with lower estimated blood loss; all covariate imbalantces were solved. Patients with high estimated blood loss patients experienced higher clinically relevant pancreatic fistula rates (19.4 vs 12.6%, odds ratio 1.66; P < .001), as well as higher severe complication rates (27.8 vs 15.6%), transfusions (50.1 vs 14.3%), reoperations (9.2 vs 4.0%), intensive care unit transfers (9.9 vs 4.8%) and 90-day mortality (4.7 vs 2.0%, all P < .001). High estimated blood loss was an independent predictor for clinically relevant pancreatic fistula (odds ratio 1.78, 95% confidence interval 1.37–2.32), as were prophylactic Octreotide administration (odds ratio 1.95, 95% confidence interval 1.46–2.61) and soft pancreatic texture (odds ratio 5.32, 95% confidence interval 3.74–5.57; all P < .001). Moreover, a second model including 1,126 pancreatoduodenectomies was derived including vascular resections as additional confounder (14.0% vascular resections performed in each group). On multivariable regression, high estimated blood loss was confirmed an independent predictor for clinically relevant pancreatic fistula reduction (odds ratio 1.80, 95% confidence interval 1.32–2.44; P < .001), whereas vascular resection was not (odds ratio 0.64, 95% confidence interval 0.34–1.88; P = .156). ConclusionThis study better establishes the relationship between estimated blood loss and outcomes after pancreatoduodenectomy. Despite inherent contributions to blood loss, its minimization is an actionable opportunity for clinically relevant pancreatic fistula reduction and performance optimization in pancreatoduodenectomy. Accordingly, practical insights are offered to achieve this goal.

Wrapping double-mattress anastomosis for pancreaticojejunostomy in minimally invasive pancreaticoduodenectomy can significantly reduce postoperative pancreatic fistula rate compared with conventional pancreaticojejunostomy in open surgery: An analysis of a propensity score-matched sample

BackgroundMinimally invasive pancreaticoduodenectomy (MIPD), including laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD), is technically demanding because of pancreaticojejunostomy (PJ). Postoperative pancreatic fistula (POPF) is the most serious complication of MIPD and open pancreaticoduodenectomy (OPD). Contrary to expectations, conventional PJ in MIPD did not improve POPF rate and length of hospital stay. High POPF rates are attributed to technical issues encountered during MIPD, which include motion restriction and insufficient water tightness. Therefore, we developed wrapping double-mattress anastomosis, the Kiguchi method, which is a novel PJ technique that can improve MIPD. Herein, we describe the Kiguchi method for PJ in MIPD and compare the outcomes between this technique and conventional PJ in OPD. MethodsThe current retrospective study included 83 patients in whom the complete obstruction of the main pancreatic duct by pancreatic tumors was absent on preoperative imaging. This research was performed from September 2016 to August 2020 at Fujita Health University Hospital. All patients were evaluated as having a soft pancreatic texture, which is the most important factor associated with POPF development. Briefly, 50 patients underwent OPD with conventional PJ (OPD group). Meanwhile, 33 patients, including 15 and 18 who had LPD and RPD, respectively, underwent MIPD using the Kiguchi method (MIPD group). After a 1:1 propensity score matching, 30 patients in the OPD group were matched to 30 patients in the MIPD group. ResultsThe patients’ preoperative data did not differ. The grade B/C POPF rate was significantly lower in the MIPD group than in the OPD group (6.7% vs 40.0%, p = 0.002). The MIPD group had a significantly shorter median length of hospital stay than the OPD group (24 vs 30 days, p = 0.004). ConclusionThe novel Kiguchi method in MIPD significantly reduced the POPF rate in patients without complete obstruction of the main pancreatic duct.

A Simple Classification of Pancreatic Duct Size and Texture Predicts Postoperative Pancreatic Fistula: A classification of the International Study Group of Pancreatic Surgery.

The aim of this study was to develop a classification system for pancreas-associated risk factors in pancreatoduodenectomy (PD). Postoperative pancreatic fistula (POPF) is the most relevant PD-associated complication. A simple standardized surgical reporting system based on pancreas-associated risk factors is lacking. A systematic literature search was conducted to identify studies investigating clinically relevant (CR) POPF (CR-POPF) and pancreas-associated risk factors after PD. A meta-analysis of CR-POPF rate for texture of the pancreas (soft vs not-soft) and main pancreatic duct (MPD) diameter was performed using the Mantel-Haenszel method. Based on the results, the International Study Group of Pancreatic Surgery (ISGPS) proposes the following classification: A, not-soft (hard) texture and MPD >3 mm; B, not-soft (hard) texture and MPD ≤3 mm; C, soft texture and MPD >3 mm; D, soft texture and MPD ≤3 mm. The classification was evaluated in a multi-institutional, international cohort. Of the 2917 articles identified, 108 studies were included in the analyses. Soft pancreatic texture was significantly associated with the development of CR-POPF [odds ratio (OR) 4.24, 95% confidence interval (CI) 3.67-4.89, P < 0.01) following PD. Similarly, MPD diameter ≤3 mm significantly increased CR-POPF risk compared with >3 mm diameter MPDs (OR 3.66, 95% CI 2.62-5.12, P < 0.01). The proposed 4-stage system was confirmed in an independent cohort of 5533 patients with CR-POPF rates of 3.5%, 6.2%, 16.6%, and 23.2% for type A-D, respectively ( P < 0.001). For future pancreatic surgical outcomes studies, the ISGPS recommends reporting these risk factors according to the proposed classification system for better comparability of results.

Is primary total pancreatectomy in patients with high-risk pancreatic remnant justified and preferable to pancreaticoduodenectomy? -a matched-pairs analysis of 200 patients.

Total pancreatectomy (TP) eliminates the risk of postoperative pancreatic fistula (POPF) and its associated secondary complications. Hence, it may theoretically offer advantages over pancreaticoduodenectomy (PD) regarding early postoperative outcome of patients with high-risk pancreatic remnant. Ninety-day mortality and morbidity of 100 TP vs. 100 PD for pancreatic head lesions were retrospectively compared. Groups were matched for pancreatic texture, pancreatic duct size, final histology, age, gender and surgeon. Only patients at high risk for POPF due to soft pancreatic texture and small pancreatic duct <3 mm were included. Preoperatively, the TP-group was characterized by poorer general condition, more comorbidities and more pronounced obesity than the PD-group. Postoperatively, overall morbidity was lower after TP (63% vs. 88%, P<0.001) due to less mild complications. Postpancreatectomy hemorrhage rate was lower after TP than after PD (2% vs. 12%, P=0.014). Duration of surgery, hospital stay, major morbidity (30%) and mortality (7% vs. 5%) were the same. POPF was the most common complication after PD with 32%. Emergency completion pancreatectomy was necessary in 10% of PD with a significantly higher mortality compared to elective TP (50% vs. 7%, P=0.001). TP may reduce severe POPF-associated complications and prevent mortality related to emergency completion pancreatectomy in some elderly, obese and polymorbid patients with high-risk pancreatic remnant. Careful individual selection by an experienced pancreatic surgeon is mandatory.

Intraoperative Shear Wave Elastography as a Quantitative Predictor of Pancreatic Fibrosis and Exocrine Function.

Soft pancreatic texture is a risk factor for postoperative pancreatic fistula (POPF). However, conventional evaluation of pancreatic texture is largely dependent on subjective assessment and lacks quantitative parameters. The study aimed to use ultrasonic shear wave elastography (SWE) to evaluate pancreatic stiffness to determine if the intraoperative SWE measurement could be a quantitative predictor for POPF. Fifteen patients scheduled for pancreaticoduodenectomy were included. Both pre- and intra-operative measurement of the pancreatic SWE index (SWEI) were evaluated. Relationships between intraoperative and preoperative SWEI, pathological fibrosis of the resected pancreatic specimen, postoperative exocrine function of the remnant pancreas, and the incidence of POPF were evaluated. The intraoperative SWEI was correlated with the preoperative SWEI, pathological fibrosis of pancreatic tissue, and pancreatic exocrine function. Intraoperative SWE measurement of pancreatic elasticity may be useful as a quantitative method for evaluating pancreatic fibrosis and exocrine function.

Predictive factors of postoperative pancreatic fistula after laparoscopic pancreatoduodenectomy.

BackgroundClinically relevant postoperative pancreatic fistula (CR-POPF) continues to be a major contributor to morbidity after pancreaticoduodenectomy (PD), but it remains unclear what risk factors can precisely predict the development of CR-POPF after laparoscopic pancreatoduodenectomy (LPD). We thus aimed to identify the risk factors for predicting CR-POPF after LPD.MethodsA total of 388 consecutive patients who underwent LPD at our institution between July 2014 and December 2018 were identified. All data, including pre-, intra-, and postoperative risk factors associated with CR-POPF defined by the International Study Group of Pancreatic Fistula, were collected retrospectively. To evaluate the predictive performance of the risk factor models, areas under the receiver operating characteristic curve (ROC) were determined.ResultsCR-POPF was observed in 31 patients (8.0%) with significant association observed with body mass index (BMI), visceral fat area (VFA), subcutaneous fat area (SFA), total fat area (TFA), intra-abdominal fat thickness, main pancreatic duct width, soft pancreatic texture, operative time, underlying pathology, and albumin (Alb) on postoperative days (POD) 1­–3. Multivariate analyses revealed that VFA >82 cm2 [odds ratio (OR) =11.088; P=0.029], main pancreatic duct width <3 mm (OR =7.701; P=0.001), soft pancreatic texture (OR =12.543; P=0.022), and operative time >320 min (OR =6.061; P<0.001) were independent risk factors for CR-POPF after LPD. Areas under the ROC curve (AUC) analysis revealed the pancreatic texture was the strongest single predictor (AUC =0.854) of CR-POPF, and pancreatic texture + pancreatic duct width was the best two-predictor model (AUC =0.904). Meanwhile, our findings indicated an association between the TFA >221 cm2 (OR =8.637; P=0.001) and VFA >82 cm2 (OR =7.009; P<0.001) with soft pancreatic texture.ConclusionsSoft pancreatic texture, VFA >82 cm2, main pancreatic duct width <3 mm, and operative time >320 min were independent predictive risk factors of CR-POPF for LPD.

Pancreaticoduodenectomy performed by surgeons in training and the risk of post-operative fistula: a systematic review and meta-analysis

Introduction: The complexity of pancreaticoduodenectomy (PD) and fear of morbidity, particularly post-operative pancreatic fistula (POPF), can be a barrier to surgical trainees gaining vital experience. This meta-analysis sought to establish the POPF rate following PD by trainees or established surgeons. Methods: A systematic review of the literature was performed using PRISMA guidelines and meta-analysis compared complication rates using RevMan software. Results: 3 of 53 studies were included for meta-analysis, all defining POPF using ISGPS 2005 criteria. Some 309 PD (16%) were performed by trainees. The rate of POPF after surgery performed by those who had completed training was not different when surgery was performed by trainees (19.6 vs 23.0%; OR: 0.65; 95%CI 0.36-1.18; p=0.07) or mortality (OR: 1.08; 95%CI 0.30-3.97; p=0.60). Neither soft pancreatic texture (OR: 0.62; 95%CI: 0.19-1.99; p=0.042) nor pancreatic duct width significantly differed between the two groups. Gastrointestinal bleeding, blood loss and operative time were greater when operations were performed by trainees but there was no difference in delayed gastric emptying, intra-abdominal collection or mortality. Conclusions: PD, when performed by trainees, is associated with acceptable outcomes. Evidence of heterogeneity in key variables indicates a need for further studies and it is unclear whether outcomes are similar when trainees perform surgery among patients stratified as low or high risk for POPF using established risk scores. The use of risk adjusted CUSUM as reported recently could be a useful tool to assess trainees performance.

Blumgart anastomosis reduces the incidence of pancreatic fistula after pancreaticoduodenectomy: a systematic review and meta-analysis

Postoperative pancreatic fistula (POPF) is the most serious complication after pancreaticoduodenectomy (PD). Recently, Blumgart anastomosis (BA) has been found to have some advantages in terms of decreasing POPF compared with other pancreaticojejunostomy (PJ) using either the duct-to-mucosa or invagination approach. Therefore, the aim of this study was to examine the safety and effectiveness of BA versus non-Blumgart anastomosis after PD. The PubMed, EMBASE, Web of Science and the Cochrane Central Library were systematically searched for studies published from January 2000 to March 2020. One RCT and ten retrospective comparative studies were included with 2412 patients, of whom 1155 (47.9%) underwent BA and 1257 (52.1%) underwent non-Blumgart anastomosis. BA was associated with significantly lower rates of grade B/C POPF (OR 0.38, 0.22 to 0.65; P = 0.004) than non-Blumgart anastomosis. Additionally, in the subgroup analysis, the grade B/C POPF was also reduced in BA group than the Kakita anastomosis group. There was no significant difference regarding grade B/C POPF in terms of soft pancreatic texture between the BA and non-Blumgart anastomosis groups. In conclusion, BA after PD was associated with a decreased risk of grade B/C POPF. Therefore, BA seems to be a valuable PJ to reduce POPF comparing with non-Blumgart anastomosis.

Robotic pancreaticoduodenectomy decreases the risk of clinically relevant post-operative pancreatic fistula: a propensity score matched NSQIP analysis

BackgroundA single-institution study demonstrated robotic pancreaticoduodenectomy (RPD) was protective against clinically-relevant postoperative pancreatic fistula (CR-POPF) compared to open pancreaticoduodenectomy (OPD). We sought to compare the national rate of CR-POPF by approach. MethodsProcedure-targeted pancreatectomy Participant User Data File was queried from 2014 to 2017 for all patients undergoing pancreaticoduodenectomy. A modified fistula risk score was calculated and patients were stratified into risk categories. Multivariate logistic regression and propensity score matching was used. ResultsThe rate of CR-POPF (15.6% vs. 11.9%; p = 0.026) was higher in OPD compared to RPD. On subgroup analysis, OPD had higher CR-POPF in high risk patients (32.9% vs. 19.4%; p = 0.007). On multivariable analysis OPD was a predictor of increased CR-POPF (Odds Ratio [OR] = 1.61 [1.15–2.25]; p = 0.005). Other operative factors associated with increased CR-POPF included soft pancreatic texture (OR = 2.65 [2.27–3.09]; p < 0.001) and concomitant visceral resection (OR = 1.41 [1.03–1.93]; p = 0.031). Increased duct size (reference <3 mm) was predictive of decreased CR-POPF: 3–6 mm (OR = 0.70 [0.61–0.81]; p < 0.001) and ≥6 mm (OR = 0.47 [0.37–0.60]; p < 0.001). Following propensity score matching, RPD continued to be protective against the occurrence of CR-POPF (OR = 1.54 [1.09–2.17]; p = 0.013). ConclusionsThis is the largest multicenter study to evaluate the impact of RPD on POPF. It suggests that RPD can be protective against POPF, especially for high risk patients.

Intraoperative Ultrasound Elastography Is Useful for Determining the Pancreatic Texture and Predicting Pancreatic Fistula After Pancreaticoduodenectomy.

Pancreatic fistula (PF) is one of the most common complications after pancreaticoduodenectomy (PD). The soft pancreatic texture is known to be an important predictive factor for PF after PD. However, its evaluation is dependent on the sense of touch by the operator during operation, thus not objective. The aim of this study was to investigate the relationship between mean elasticity via intraoperative ultrasound elastography and histological pancreatic hardness, as well as predictive factor of PF after PD. Forty-eight patients who underwent ultrasound elastography during PD and had pancreatic parenchyma histologically evaluated were included. Pancreatic fistula was noted in 20 patients. There were significant differences in the histological pancreatic fibrosis rate between soft pancreas group (8.2%) and hard pancreas group (28.4%, P < 0.05) and in the mean elasticity between soft pancreas group (1.94 m/s) and hard pancreas group (3.17 m/s, P < 0.05). The mean elasticity was significantly correlated with pancreatic fibrosis rate (P < 0.05). A multivariate analysis revealed that the mean elasticity of less than 2.2 m/s was a significant predictor of PF after PD (P = 0.003). Intraoperative ultrasound elastography could predict pancreatic texture objectively. The mean elasticity of less than 2.2 m/s was a significant predictor of PF after PD.

Implications of increased serum amylase after pancreaticoduodenectomy: toward a better definition of clinically relevant postoperative acute pancreatitis

BackgroundPostoperative acute pancreatitis (POAP) can be a possible cause of postoperative pancreatic fistula (POPF). The present study aimed to evaluate the role of clinically-relevant POAP (CR-POAP), defined according to different cut-offs of postoperative amylase (AMS) values and C-reactive protein (CRP), in the development of clinically relevant POPF (CR-POPF) after pancreaticoduodenectomy (PD). MethodsData from 610 patients who underwent PD (2015–2018) were analyzed. Patients were divided according to the upper limit (100 U/l) and 3-fold the upper limit (300 U/l) of serum POD1 AMS. Univariate and multivariable analysis of possible predictors of CR-POPF were performed. ResultsOverall, 360 patients (59%) had POD1 serum AMS ≤100 U/l, 142 patients (23%) had POD1 serum AMS >100 U/l and ≤300 U/l, and 108 patients (18%) had POD1 serum AMS >300 U/l. Patients with POD1 serum AMS >300 had a higher frequency of soft pancreatic texture, complications, main pancreatic duct diameter ≤3 mm, and CR-POPF. POD1 serum AMS >100 U/l associated to POD2 CRP ≥180 mg/l (OR: 4.3, p < 0.001) was an independent predictor of CR-POPF. ConclusionThese results confirm that CR-POAP, defined as POD1 serum AMS >100 U/l and POD2 CRP ≥ 180 mg/l, is associated with an increased risk of CR-POPF.

A Novel Way of Preventing Postoperative Pancreatic Fistula by Directly Injecting Profibrogenic Materials into the Pancreatic Parenchyma.

This paper aims to validate if intrapancreatic injection of penicillin G can enhance hardness and suture holding capacity (SHC) of the pancreas through prompting the fibrosis process. Soft pancreatic texture is constantly mentioned as one of the most contributory predictors of postoperative pancreatic fistula (POPF). Soft pancreas has poor SHC and higher incidence of parenchymal tearing, frequently leading to POPF. From a library of 114 antibiotic compounds, we identified that penicillin G substantially enhanced pancreatic hardness and SHC in experimental mice. Specifically, we injected penicillin G directly into the pancreas. On determined dates, we measured the pancreatic hardness and SHC, respectively, and performed molecular and histological examinations for estimation of the degree of fibrosis. The intrapancreatic injection of penicillin G activated human pancreatic stellate cells (HPSCs) to produce various fibrotic materials such as transforming growth factor-β1 (TGF-β1) and metalloproteinases-2. The pancreatic hardness and SHC were increased to the maximum at the second day after injection and then it gradually subsided demonstrating its reversibility. Pretreatment of mice with SB431542, an inhibitor of the TGF-β1 receptor, before injecting penicillin G intrapancreatically, significantly abrogated the increase of both pancreatic hardness and SHC caused by penicillin G. This suggested that penicillin G promotes pancreatic fibrosis through the TGF-β1 signaling pathway. Intrapancreatic injection of penicillin G promotes pancreatic hardness and SHC by enhancing pancreatic fibrosis. We thus think that penicillin G could be utilized to prevent and minimize POPF, after validating its actual effectiveness and safety by further studies.

Facing the surgeon's nightmare: Incidence and management of postoperative pancreatic fistulas grade C after pancreaticoduodenectomy based on the updated definition of the International Study Group of Pancreatic Surgery(ISGPS).

Postoperative pancreatic fistulas (POPF) grade C represent a rare but feared complication following pancreaticoduodenectomy (PD). They can contribute significantly to postoperative morbidity and mortality. We performed a retrospective chart review for all patients who had undergone pancreatic head resection between 2007 and 2016 to identify those who suffered from POPF grade C according to the updated definition of the International Study Group of Pancreatic Surgery (ISGPS). A total of 722 patients underwent PD. Twenty-three patients (3.19%) developed a POPF grade C. Cardiovascular diseases, soft pancreatic texture and main pancreatic duct diameter were identified as risk factors (P<.05). Reoperation was necessary in all affected patients on postoperative day 12±9 on average. Mortality was significantly associated with POPF grade C (P<.05) being present in 39.1% (9/23). POPF grade C after PD remains a serious complication with a high level of morbidity and mortality. Surgical treatment is the sole curative therapy and thus the treatment of choice.

Preoperative adiposity at bioimpedance vector analysis improves the ability of Fistula Risk Score (FRS) in predicting pancreatic fistula after pancreatoduodenectomy

BackgroundAnthropometric parameters have been associated with increased risk of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD). Nonetheless, conventional metrics to predict POPF do not include the assessment of body composition. We aimed to validate the most used Fistula Risk Score (FRS), and to assess whether the appraisal of adipose compartment at bioimpedance vector analysis (BIVA) improves the accuracy of FRS in CR-POPF prediction. MethodPD patients from 3 Italian academic institutions were prospectively included over a 2-year period. Patients with ASA score ≥3, heart failure, chronic kidney disease, or compartmentalized fluid collections were excluded. BIVA was performed on the day prior to surgery. CR-POPF occurrence and severity were classified per the ISGPS classification. ResultsOut of 148 PDs, 84 patients (56.8%) had pancreatic cancer, and 29 (19.6%) experienced CR-POPF. FRS elements, namely soft pancreatic texture (p = 0.009), small pancreatic duct diameter (p = 0.029), but not blood loss (p = 0.450), as well as high BMI (p = 0.004) were associated with CR-POPF. Also, the preoperative fat mass (FM) amount measured at BIVA was significantly higher in patients who developed CR-POPF, compared to those who did not (median FM = 19.4 kg/m2 vs. 14.4 kg/m2, respectively; p = 0.005). The predictive ability of a multivariate model adding FM to the FRS, assessed at the receiver operating characteristics curve showed a higher accuracy than the FRS alone (AUC = 0.774 and AUC = 0.738, respectively). ConclusionsAssessment of preoperative FM at BIVA can improve the accuracy of FRS in predicting CR-POPF following pancreatoduodenectomy.

Predictors of prolonged pancreatic fistula in patients undergoing pancreatoduodenectomy (whipple procedure)

Presenter: May Tee MD, MPH | Mercy Medical Center Background: Postoperative pancreatic fistula (POPF) contributes to substantial morbidity associated with pancreatoduodenectomy (PD). Risk stratification for development of POPF, based on factors such as pancreatic duct size, pancreatic texture, and intraoperative blood loss, may mitigate severity of POPF by treatment with antibiotics, additional drains, or feeding tubes. We aimed to examine predictors of prolonged POPF (POPF at 30 days or greater) in patients undergoing PD to provide further stratification of patients at risk. Methods: The American College of Surgeons National Surgical Quality Improvement Program pancreatectomy procedure targeted participant use file was queried from 2015-2017, when persistent POPF at postoperative day 30 was captured. All PD procedures were extracted with emergent cases excluded. Univariable and multivariable analyses were conducted to examine the association between persistent POPF and 30-day surgical outcomes. Results: N = 12,014 patients undergoing open and minimally invasive PD were evaluated. On univariate analyses, persistent POPF was associated with the following outcomes: surgical site infection (SSI) superficial (11.0% vs. 7.4%, P < 0.001), deep SSI (3.1% vs. 1.2%, P < 0.001), organ space SSI (44.1% vs. 13.1%, P < 0.001), wound dehiscence (2.3% vs. 1.0%, P < 0.001), pneumonia (6.7% vs. 3.5%, P < 0.001), reintubation (9.2% vs. 3.2%, P < 0.001), pulmonary embolus (2.9% vs. 1.1%, P < 0.001), failure to wean off mechanical ventilation (9.2% vs. 2.4%, P < 0.001), renal insufficiency (1.6% vs. 0.6%, P < 0.001), renal failure (2.4% vs. 0.8%, P < 0.001), myocardial infarction (2.3% vs. 1.1%, P=0.001), deep vein thrombosis (6.8% vs. 2.6%, P < 0.001), sepsis (19.2% vs. 8.5%, P < 0.001), septic shock (9.9% vs. 2.4%, P < 0.001), length of stay greater than 12 days (58.9% vs. 23.7%, P < 0.001), discharge to destination other than home (28.9 vs. 12.8%, P < 0.001), return to operating room (13.5% vs. 4.9%, P < 0.001), readmission to hospital (23.8% vs. 15.8%, P < 0.001), delayed gastric emptying (35.2% vs. 15.4%, P < 0.001), percutaneous drain placement (33.3% vs. 10.9%, P < 0.001), and postoperative C. difficile colitis (3.3% vs. 1.8%, P=0.003). On multivariable analyses, independent predictors of prolonged POPF include: male sex (OR=1.6, P < 0.001), obesity (OR=1.5, P < 0.001), operative time greater than 420 minutes (OR=1.2, P=0.03), preoperative chemotherapy (OR=0.6, P=0.002), postoperative blood transfusion (OR=1.7, P < 0.001), pancreatic duct < 3mm (OR=1.7, P=0.002), soft pancreatic texture (OR=2.4, P < 0.001), and drain to suction (OR=1.4, P=0.015). Conclusion: Prolonged POPF is a major source of morbidity following PD but not mortality. Further risk stratification for POPF may be considered for male patients with increased body mass index undergoing prolonged PD procedures. Significant perioperative blood loss requiring transfusion, small pancreatic duct, and soft pancreas remain important predictors of prolonged POPF. Interestingly, drain placed to suction was associated with increased odds of prolonged POPF but neoadjuvant chemotherapy appeared to be protective against prolonged POPF.

Predictors of external pancreatic fistulae after pancreatic resection

Despite a significant decrease in postoperative mortality after pancreatic resections in recent years (5.2-15% after pancreatoduodenectomy and about 5% after distal pancreatectomy), incidence of postoperative complications remains high (30-50% and 22-50%, respectively). Postoperative pancreatic fistula is one of the most common and formidable complications. Currently, most authors use the classification proposed by the International Study Group for Pancreatic Fistula (biochemical failure, fistula type B and C). Prediction of the risk of postoperative fistula is still a complex and unresolved problem of modern surgical pancreatology. According to the literature, the main risk factors of postoperative pancreatic fistulae are obesity and high body mass index, concomitant cardiovascular diseases, no neoadjuvant chemo- and radiotherapy, soft pancreatic texture, narrow pancreatic duct, no fibrotic changes in parenchyma, adipose infiltration of the pancreas, advanced intraoperative blood loss, as well as center experience. Most often, magnetic resonance imaging, computed tomography, ultrasound elastography and various multivariate risk assessment systems are used to estimate the risk of pancreatic fistulae. However, a generally accepted technique does not exist. This manuscript is devoted to analysis of risk factors of postoperative pancreatic fistulae and diagnostic methods for assessment of this risk.

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

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