Predictors of surgical site infection after pancreaticoduodenectomy.

BACKGROUND: Surgical site infection (SSI) is one of the most common complications after pancreaticoduodenectomy (PD). Thus, it is beneficial to preoperatively identify patients at high risk of developing SSI. The primary aim of the present study was to identify the factors associated with SSI after PD, and the secondary aim was to identify the adverse outcomes associated with the occurrence of SSI. METHODS: A single-centre retrospective study was conducted. All 280 patients who underwent PD at our institution from January 2008 to December 2018 were enrolled. Demographic and perioperative data were reviewed, and the potential risk factors for developing SSI and the adverse outcomes related to SSI were analysed. RESULTS: A total of 90 patients (32%) developed SSI. Fifty-one patients developed incisional SSI, and 39 developed organ/space SSI. Multivariate logistic analysis revealed that the significant risk factors for developing incisional SSI were preoperative biliary drainage (odds ratio, 3.04; 95% confidence interval, 1.36-6.79; p < 0.05) and postoperative pancreatic fistula (odds ratio, 2.78; 95% confidence interval, 1.43-5.38; p < 0.05), and the risk factors for developing organ/space SSI were preoperative cholangitis (odds ratio, 10.07; 95% confidence interval, 2.31-49.75; p < 0.05) and pancreatic fistula (odds ratio, 6.531; 95% confidence interval, 2.30-18.51; p < 0.05). Enterococcus spp., Escherichia coli and Klebsiella pneumoniae were the common bacterial pathogens that caused preoperative cholangitis as well as SSI after PD. The patients in the SSI group had a longer hospital stay and a higher rate of delayed gastric emptying than patients in the non-SSI group. CONCLUSIONS: The presence of postoperative pancreatic fistula was a significant risk factor for both incisional and organ/space SSI. Any efforts to reduce postoperative pancreatic fistula would decrease the incidence of incisional SSI as well as organ/space SSI after pancreaticoduodenectomy. Preoperative biliary drainage should be performed in selected patients to reduce the incidence of incisional SSI. Minimizing the occurrence of preoperative cholangitis would decrease the incidence of developing organ/space SSI.

Comparative outcomes of extended distal pancreatectomy and distal pancreatectomy.

PURPOSE: Patients with locally advanced pancreatic body/tail tumors, gastric cancer, or colon cancer often have contiguous organ involvement requiring extensive pancreatic resection. This study was performed to compare surgical complications and the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) between distal pancreatectomy (DP) with extended organ resection and standard DP. METHODS: In total, 128 patients who underwent DP from January 2012 to January 2021 were retrospectively reviewed. Extended DP was defined according to the International Study Group of Pancreatic Surgery definition. RESULTS: Of the 128 patients, 62 (48.4%) underwent extended DP and 66 (51.6%) underwent DP. Blood loss was greater (p < 0.001), the incidence of major complications was higher (p = 0.032), and the hospital stay was longer (p = 0.002) in the extended DP group than in the DP group. There were no differences in the incidence of CR-POPF, the readmission rate, or the need for postoperative intervention drainage. Univariate and multivariate analyses showed that extended DP was not a risk factor for CR-POPF or major complications. CONCLUSION: Extended DP can be performed with comparable CR-POPF occurrence and mortality but increased morbidity when compared with standard DP.

Timing of laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreatography in cholelithiasis patients: A systematic review and meta-analysis.

There are many variations and unclear definitions of the appropriate timing of laparoscopic cholecystectomy (LC) after endoscopic retrograde cholangiopancreatography (ERCP), and there is still a lack of consistency about the appropriate timing. Inappropriate timing can be associated with serious comorbidity and can affect the patients. This meta-analysis was conducted to assess the operative outcomes and morbidity to provide a benefit to the patients based on the best timing of LC after ERCP. Randomized controlled trials (RCTs) and retrospective studies were identified from the PubMed and Scopus databases from inception to July 2021. A meta-analysis was performed to estimate the treatment effects on operative outcomes and morbidity. Four RCTs and four retrospective studies met our inclusion criteria. A meta-analysis indicated that patients who received LC after ERCP on the same day or within 72 hours had about 0.354 days shorter length of hospital stay with a shorter operative time of about 0.111-1.835 minutes and a lower risk of complications around 37%-73%. Our evidence suggests that the appropriate timing of LC after ERCP is either the same day or within 72 hours for treating cholelithiasis patients based on the severity of disease.

CP-673451, a Selective Platelet-Derived Growth Factor Receptor Tyrosine Kinase Inhibitor, Induces Apoptosis in Opisthorchis viverrini-Associated Cholangiocarcinoma via Nrf2 Suppression and Enhanced ROS.

Platelet-derived growth factors (PDGFs) and PDGF receptors (PDGFRs) play essential roles in promoting cholangiocarcinoma (CCA) cell survival by mediating paracrine crosstalk between tumor and cancer-associated fibroblasts (CAFs), indicating the potential of PDGFR as a target for CCA treatment. Clinical trials evaluating PDGFR inhibitors for CCA treatment have shown limited efficacy. Furthermore, little is known about the role of PDGF/PDGFR expression and the mechanism underlying PDGFR inhibitors in CCA related to Opisthorchis viverrini (OV). Therefore, we examined the effect of PDGFR inhibitors in OV-related CCA cells and investigated the molecular mechanism involved. We found that the PDGF and PDGFR mRNAs were overexpressed in CCA tissues compared to resection margins. Notably, PDGFR-α showed high expression in CCA cells, while PDGFR-ß was predominantly expressed in CAFs. The selective inhibitor CP-673451 induced CCA cell death by suppressing the PI3K/Akt/Nrf2 pathway, leading to a decreased expression of Nrf2-targeted antioxidant genes. Consequently, this led to an increase in ROS levels and the promotion of CCA apoptosis. CP-673451 is a promising PDGFR-targeted drug for CCA and supports the further clinical investigation of CP-673451 for CCA treatment, particularly in the context of OV-related cases.

Early postoperative serum aspartate aminotransferase for prediction of post-hepatectomy liver failure.

BACKGROUND: Post-hepatectomy liver failure (PHLF) is a serious complication of hepatectomy. The current criteria for PHLF diagnosis (ISGLS consensus) require laboratory data on or after postoperative day (POD) 5, which may delay treatment for patients at risk. The present study aimed to determine the associations between early postoperative (POD1) serum aminotransferase levels and PHLF. METHODS: The medical records of patients who underwent hepatectomy at Ramathibodi Hospital from January 2008 to December 2019 were retrospectively examined. Patients were classified into PHLF and non-PHLF groups. Preoperative characteristics, intraoperative findings, and early postoperative laboratory data (serum AST, ALT, bilirubin, and international normalized ratio (INR) on POD0 to POD5) were analyzed. RESULTS: A total of 890 patients were included, of whom 31 (3.4%) had PHLF. Cut-off points for AST of 260 U/L and ALT of 270 U/L on POD1 were predictive of PHLF. In multivariate analysis, AST > 260 U/L on POD1, ICG-R15, major hepatectomy, blood loss, and INR were independently associated with PHLF. CONCLUSIONS: Early warning from elevated serum AST on POD1, before a definitive diagnosis of PHLF is made on POD5, can help alert physicians that a patient is at risk, meaning that active management and vigilant monitoring can be initiated as soon as possible.

Effect of local anaesthetic infiltration on postoperative pain after laparoscopic cholecystectomy: randomized clinical trial.

BACKGROUND: Local anaesthetic infiltration is widely used to reduce pain after laparoscopic cholecystectomy (LC). This trial evaluated the effect of depth of local anaesthetic infiltration on postoperative pain reduction after LC. METHODS: Patients undergoing elective LC between March 2018 and February 2019 were randomized into no infiltration, subcutaneous infiltration, and rectus sheath infiltration using bupivacaine. The primary outcome was 24-h postoperative cumulative morphine use, and the secondary outcomes were mean 24-h Numerical Rating Scale (NRS) for pain, and nausea, and vomiting. Subgroups were compared and multivariable analyses were performed. RESULTS: Out of 170 eligible patients, 162 were selected and 150 patients were analysed: 48 in the no-infiltration group, 50 in the subcutaneous infiltration group, and 52 in the rectus sheath infiltration group. The groups had similar clinical features, although mean BMI was higher in the subcutaneous infiltration group (P = 0.001). The 24-h cumulative morphine use in the rectus sheath infiltration group was significantly lower than in the no-infiltration group (P = 0.043), but no difference was observed between the subcutaneous infiltration and no-infiltration groups (P = 0.999). One hour after surgery, the rectus sheath infiltration group had a significantly lower NRS score than the no-infiltration and subcutaneous infiltration groups respectively (P = 0.006 and P = 0.031); however, the score did not differ among the three groups at any of the time points from 2 h after the surgery. The incidence of nausea or vomiting was comparable among the three groups. Multivariable analysis documented that a lower dose of morphine use was associated with rectus sheath infiltration (P = 0.004) and diabetes (P = 0.001); whereas, increased morphine use was associate with age (P = 0.040) and a longer duration of surgery (P = 0.007). CONCLUSIONS: Local anaesthetic infiltration into the rectus sheath reduced postoperative cumulative morphine use and the immediate NRS score in patients undergoing LC; however, the pain scores were comparable 2 h after surgery. REGISTRATION NUMBER: TCTR20201103002 (http://www.thaiclinicaltrials.org).

Prospective randomized controlled trial of omental roll-up technique on pancreatojejunostomy anastomosis for reducing perioperative complication in patients undergoing pancreatoduodenectomy.

BACKGROUND: Wrapping pancreatojejunal anastomosis with omentum to prevent postoperative pancreatic fistula (POPF) has only been reported in non-randomized, controlled trials. Therefore, this study aimed to conduct a randomized, controlled trial to compare outcomes between omental roll-up and non-omental roll-up in pancreatojejunal anastomosis. METHODS: This single-center, randomized, two-arm trail (Clinical Trials Register: NCT03083938) was conducted between February 2017 and February 2019. We studied 34 patients in the omental roll-up group and 34 patients in the non-omental roll-up group. The primary endpoint was the incidence of clinically relevant POPF. Thirty-day mortality and morbidity were recorded. RESULTS: Patients' demographic data were not significantly different between the two groups, except for histological diagnosis, with a significantly higher incidence of pancreatic cancer in the omental roll-up group (n = 15, 44.1%) than in the non-omental roll-up group (n = 9, 26.4%) (P = 0.042). There was one death in the non-omental roll-up group due to myocardial infarction. The incidence of POPF was not different between the omental roll-up group (n = 5, 14.7%) and non-omental roll-up group (n = 7, 20.6%) (P = 0.525). No differences were found in postoperative hemorrhage after pancreatectomy, delayed gastric emptying, and chyle leakage between the groups. CONCLUSION: This study shows that omental roll-up does not decrease the incidence of POPF after pancreatoduodenectomy.

Association of the rate of bilirubin decrease with major morbidity in patients undergoing preoperative biliary drainage before pancreaticoduodenectomy.

OBJECTIVE: The objective of this study was to examine the relationship between the rate of bilirubin decrease following preoperative biliary drainage before pancreaticoduodenectomy and postoperative morbidity. METHODS: Records of patients who underwent pancreaticoduodenectomy at the Department of Surgery in Ramathibodi Hospital between January 2008 and December 2019 were retrospectively reviewed. The patients were classified into either an adequate or inadequate drainage rate groups according to the bilirubin decrease rate. Major morbidity was defined as higher than grade II in the Clavien-Dindo classification. Risk factors for major morbidity were analyzed by logistic regression analysis. RESULTS: In total, 166 patients were included in the study. Major morbidity was observed in 36 patients (21.6%). Adequate biliary drainage rate was observed in 39 patients (23.4%). Patients who had major morbidity were less likely to have come from the adequate biliary drainage rate group than the inadequate group (38.9% vs. 61.1%). However, through multivariate logistic analysis, only body mass index, operative time, and pancreatic duct diameter were independent factors associated with major morbidity, whereas the bilirubin decrease rate was not. CONCLUSIONS: Bilirubin decrease rate following preoperative biliary drainage has no significant association with major postoperative morbidity after pancreaticoduodenectomy.

Outcomes of delayed endoscopic retrograde cholangiopancreatography in patients with acute biliary pancreatitis with cholangitis.

OBJECTIVE: The recommended treatment for acute biliary pancreatitis(ABP) with cholangitis is urgent endoscopic retrograde cholangiopancreatography(ERCP). However, tight schedules in the endoscopy room mean that urgent ERCP may not always be performed. This study aimed to compare the outcomes of early (≤72 h) and delayed(>72 h) ERCP in patients with ABP with cholangitis. METHODS: Ninety-five patients diagnosed with ABP with cholangitis who underwent ERCP between May 2012 and April 2018 were retrospectively reviewed. RESULTS: Sixty-seven patients(70.5%) were classified in the early ERCP and 28(29.5%) in the delayed ERCP groups. There was no significant difference in pancreatitis severity between the groups. Total bilirubin was higher in the early compared with the late ERCP group (5.7 ± 5.2 versus 3.5 ± 2.3 mg/dL, p = 0.03). Fewer patients in the early group had end-stage renal disease (0 versus 3, p = 0.006) and relatively fewer patients in the early group took aspirin (15(22.4%) versus 12(42.9%), p = 0.04). There were no significant differences between the early and delayed ERCP groups in terms of mortality (2(3.0%) versus 0), disease-related complications(11 (16.4%) versus 5(17.9%), p = 0.86), or ERCP-related complications(5(7.5%) versus 3(10.7%), p = 0.60). The total length of stay(LoS) was shorter in the early group(6.3 ± 4.4 versus 9.8 ± 6.1 days, p = 0.002). The rate of complete stone removal was lower in the early compared with the delayed ERCP group(32/42(76.2%) versus 18/18(100%), p = 0.02). CONCLUSION: Delayed ERCP can be performed in selected patients with ABP with cholangitis, with similar complication rates but longer LoS compared with early ERCP.

Is It Reasonable to Use Indocyanine Green Fluorescence Imaging to Determine the Border of Pedicled TRAM Flap Zone IV?

BACKGROUND: The contralateral lateral section (zone IV) of a pedicled transverse rectus abdominis musculocutaneous (TRAM) flap is generally removed intraoperatively. The border of zone IV is usually identified anatomically using the Hartrampf classification. In this study, we used the indocyanine green (ICG) fluorescence method to determine the border of zone IV and find the correlation with clinical flap outcome. METHODS: The study recruited breast cancer patients who underwent a pedicled TRAM flap reconstruction. The border of zone IV was identified using the intraoperative ICG fluorescence imaging. The medial border of the removed specimen was sent for a pathological examination of vascular density. RESULTS: A total of 29 patients underwent a pedicled TRAM reconstruction. In 16 patients, the border of zone IV identified by ICG fluorescent imaging was identical to the anatomical border. The ICG imaging showed distinct perfusion patterns, which we divided into 4 categories: sequential, simultaneous, low midline scar, and delayed pattern. Overall, there were no patient with total flap loss, 1 patient had a partial flap loss and 4 patients had a fat necrosis. Neither the ICG perfusion time nor the pathological vascular density correlates with the clinical flap outcome. The delayed ICG perfusion pattern (category IV) has the highest fat necrosis rate, although it is not statistically significant. CONCLUSIONS: In this study, more than half of the patients have ICG perfusion corresponding with the Hartrampf zone, which reflected the conventional practice of zone IV pedicled TRAM flap removal. Some ICG perfusion patterns could be helpful, especially in low midline and delayed pattern.

Fluorescence cholangiography enhances surgical residents' biliary delineation skill for laparoscopic cholecystectomies.

BACKGROUND: Laparoscopic cholecystectomy (LC) is a minimally invasive procedure, often performed by surgical residents (SRs). Fluorescence cholangiography (FC) enables real-time identification of biliary anatomy. AIM: To investigate the benefit of FC for enhancing SRs' identification skills. METHODS: Prospective data was collected from January 2018 to June 2018 at our hospital. The study cohorts were the SRs (study group, n = 15) and the surgical staff (SS; control group, n = 9). Participants were assigned to watch videos of LCs with FC from five different patients who had gallbladder disease, and identify structures in the video clips (including cystic duct, common bile duct, common hepatic duct, and cystic artery), first without FC, and then with FC. RESULTS: In the without-FC phase, the overall misidentification rate by SRs (21.7%) was greater than that of the SS (11.8%; P = 0.018), However, in the FC phase, the two groups did not significantly differ in misidentification rates (23.3% vs 23.3%, P = 0.99). Paired-structure analysis of the without-FC and with-FC phases for the SR group found a significantly higher misidentification rate in the without-FC phase than the with-FC phase (21.9% vs 10.9%; P < 0.01). However, misidentification rates in the with-FC phase did not significantly differ between SRs and SS. CONCLUSION: FC enhanced identification skills of inexperienced surgeons during LC compared with conventional training. Combined with simulation-based video training, FC is a promising tool for enhancing technical and decision skills of trainees and inexperienced surgeons.

Preoperative serum albumin is associated with intra-abdominal infection following major hepatectomy.

BACKGROUND: Major hepatectomy is a complex surgical procedure with high morbidity. Intra-abdominal infection (IAI) is common following hepatectomy and affects treatment outcomes. This study was performed to investigate perioperative factors and determine whether the preoperative serum albumin level is associated with IAI following major hepatectomy. METHODS: From January 2008 to December 2018, 268 patients underwent major hepatectomy. We retrospectively analyzed demographic data and preoperative and perioperative variables. IAI was defined as organ/space surgical site infection. Risk factors for IAI were analyzed by logistic regression analysis. RESULTS: In total, 268 patients were evaluated. IAI was observed in 38 patients (14.6%). The mortality rate in the IAI group was 15.7%. Multivariate logistic analysis confirmed that the serum albumin level (odds ratio 0.91; 95% confidence interval 0.84-0.97; P = 0.03) and operative duration (odds ratio 1.50; 95% confidence interval 1.18-1.91; P < 0.01) were independent factors associated with IAI. A logistic model using the serum albumin level and operative duration to estimate the probability of IAI was analyzed. The area under the receiver operating characteristic curve for predicting IAI was 0.78. CONCLUSION: The serum albumin level and operative duration were independent factors predicting IAI following major hepatectomy.

Malignant transformation of phyllodes tumor: a case report and review of literature.

Malignant phyllodes may transform from benign phyllodes; low-aggressive malignant phyllodes tumor is manageable by locally wide excision.