ABSTRACT
BACKGROUND: Postoperative pancreatic fistula (POPF) is responsible of most major complications and fatalities after PD. By avoiding POPF, TP may improve operative outcomes in high-risk patients. The aim was to compare total pancreatectomy (TP) and pancreatoduodenectomy (PD) in high-risk patients and evaluate results of implementing a risk-tailored strategy in clinical practice. METHODS: Between 2014 and 2023, 139 patients (76 men, median age 67 years) underwent resection of disease located in the head of the pancreas. Starting January 1, 2022, we offered TP to patients at high POPF risks (fistula risk score (FRS) ≥7) and to patients with intermediate POPF risks (FRS: 3-6) and high risks of failure to rescue (age> 75 years, ASA score ≥3). We compared outcomes of TP and PD and evaluated the results of the new strategy implementation on operative outcomes. Propensity score-based analysis was performed to limit bias of between-group comparison. RESULTS: Eventually, 26 (19%) patients underwent TP and 113 (81%) patients underwent PD. Severe complications occurred in 42 (30%) patients and 13 (9%) patients died. TP resulted in shorter lengths of hospital stay (median: 14 days [11; 18] vs. 17 days [13; 24], p = 0.016) and less risks of post-pancreatectomy hemorrhage (PPH) (0% vs. 20%, p < 0.001) compared to PD. Crude and propensity match analysis showed that the implementation of a risk-tailored strategy led to significant reduction of reoperation, POPF, PPH and mortality rates. CONCLUSION: The use of TP as part of a risk-tailored strategy in high-risk patients can be lifesaving.
Subject(s)
Pancreatectomy , Pancreatic Fistula , Pancreatic Neoplasms , Pancreaticoduodenectomy , Postoperative Complications , Humans , Pancreaticoduodenectomy/methods , Pancreaticoduodenectomy/adverse effects , Male , Female , Aged , Pancreatectomy/methods , Pancreatectomy/adverse effects , Middle Aged , Pancreatic Fistula/prevention & control , Pancreatic Fistula/epidemiology , Pancreatic Fistula/etiology , Postoperative Complications/epidemiology , Postoperative Complications/prevention & control , Pancreatic Neoplasms/surgery , Pancreatic Neoplasms/mortality , Retrospective Studies , Propensity Score , Risk Assessment , Treatment Outcome , Aged, 80 and over , Length of Stay/statistics & numerical data , Risk FactorsABSTRACT
PURPOSE: Anal canal duplication is a rare malformation characterized by a second perineal opening positioned behind the anus, which is generally observed at 6 o'clock in the lithotomy position. The purpose was to describe six new cases of anal canal duplication (in addition to our previously reported series of six patients) with the aim of providing further clinical information about this anomaly. METHODS: We described 6 new cases of anal canal duplication in terms of symptoms, anatomical disposition, imaging results, and histopathology. Clinical details of these cases and those already reported (n = 12) were summarized and compared to existing literature. RESULTS: A total of 12 cases were reported over 34 years. 17% of the patients were male, constituting the only subgroup to present a communication with the digestive tract. A single patient, diagnosed at 12 years, was symptomatic. Half of the patients had at least one associated malformation. All patients underwent surgery, either with a posterior sagittal or perineal approach. CONCLUSION: Diagnosis of anal canal duplication should be suspected when a perineal opening positioned behind the anus is present, and necessitates further exploration by a comprehensive clinical examination and imaging. Surgery is always required, typically performed via a posterior sagittal approach. The postoperative course is usually uncomplicated.