A Modern Series of Secondary Aortoenteric Fistula - A 19-Year Experience.

OBJECTIVES: Secondary aortoenteric fistula is a rare and life-threatening condition. Clear evidence on the ideal therapeutic approach is largely missing. This study aims to analyze symptoms, etiology, risk factors, and outcomes based on procedural details. PATIENTS AND METHODS: All patients with secondary aortoenteric fistula admitted between 2003 and 2021 were included. Patient characteristics, surgical procedure details, and postoperative outcomes were analyzed. Outcomes were stratified and compared according to the urgency of operation and the procedure performed. Descriptive statistics were used. The primary endpoint was in-hospital mortality. RESULTS: A total of twentytwo patients (68% male, median age 70 years) were identified. Main symptoms were gastrointestinal bleeding, pain, and fever. From the twentytwo patients ten patients required emergency surgery and ten urgent surgery. Emergency patients were older on average (74 vs 63 years, P = .015) and had a higher risk of postoperative respiratory complications (80% vs 10%, P = .005). Primary open surgery with direct replacement of the aorta or an extra-anatomic bypass with an additional direct suture or resection of the involved bowel was performed in sixteen patients. In four patients underwent endovascular bridging treatment with the definitive approach as a second step. Other two patients died without operation (1x refusal; 1x palliative cancer history). In-hospital mortality was 27%, respectively. Compared to patients undergoing urgent surgery, those treated emergently showed significantly higher in-hospital (50% vs 0%, P = .0033) mortalities. CONCLUSION: Despite rapid diagnosis and treatment, secondary aortoenteric fistula remains a life-threatening condition with 27% in-hospital mortality, significantly increased upon emergency presentation.

Continuous versus interrupted abdominal wall closure after emergency midline laparotomy: CONTINT: a randomized controlled trial [NCT00544583].

BACKGROUND: High-level evidence regarding the technique of abdominal wall closure for patients undergoing emergency midline laparotomy is sparse. Therefore, we conducted a randomized controlled trial (RCT) to evaluate the efficacy and safety of two commonly applied abdominal wall closure strategies after primary emergency midline laparotomy. METHODS/DESIGN: CONTINT was a multi-center pragmatic open-label exploratory randomized controlled parallel trial. Two different abdominal wall closure strategies in patients undergoing primary midline laparotomy for an emergency surgical intervention with a suspected septic focus in the abdominal cavity were compared: the continuous, all-layer suture and the interrupted suture technique. The primary composite endpoint was burst abdomen within 30 days after surgery or incisional hernia within 12 months. As reliable data on this composite primary endpoint were not available for patients undergoing emergency surgery, it was planned to initially recruit 80 patients and conduct an interim analysis after these had completed the 12 months follow-up. RESULTS: From August 31, 2009, to June 28, 2012, 124 patients were randomized of whom 119 underwent surgery and were analyzed according to the intention-to-treat (ITT) principal. The primary composite endpoint did not differ between the continuous suture (C: 27.1%) and the interrupted suture group (I: 30.0%). None of the individual components of the primary endpoint (reoperation due to burst abdomen after 30 days (C: 13.5%, I: 15.1%) and reoperation due to incisional hernia (C: 3.0%, I:11.1%)) differed between groups. Time needed for fascial closure was longer in the interrupted suture group (C: 12.8 ± 4.5 min, I: 17.4 ± 6.1 min). BMI was associated with burst abdomen during the first 30 days with an OR of 1.17 (95% CI 1.04-1.32). CONCLUSION: This RCT showed no difference between continuous suture with slowly absorbable suture versus interrupted rapidly absorbable sutures after primary emergency midline laparotomy in rates of postoperative burst abdomen and incisional hernia after one year. However, the trial was stopped after the interim analysis due to futility as there was no chance to show superiority of one suture technique.

INR and not bilirubin levels predict postoperative morbidity in patients with malignant obstructive jaundice.

BACKGROUND: There are no established predictors for deciding between upfront surgery and PBD in pancreatic head malignancy. Once PBD is present, the ideal drainage-time remains elusive. The aim was, to identify predictors in jaundiced patients and ideal PBD-duration. METHODS: Analysis of 304 patients with pancreatic head malignancy (56% with PBD, n = 170) undergoing pancreaticoduodenectomy was performed. Postoperative morbidity and survival were analyzed. RESULTS: Postoperative complications increased after PBD (98.2% vs. 88.8%; p < 0.001). Patients with PBD received more postoperative antibiotics (42.4% vs. 21.6%; p < 0.001) and wound infections were increased (21.4% vs. 9.4%; p = 0.006). INR predicted postoperative morbidity (p = 0.026), whereas serum-bilirubin (p = 0.708), leucocytes (p = 0.158) and MELD-score (p = 0.444) had no impact. Complications were not different between long (>4 weeks) and short (<4 weeks) PBD-duration (p = 0.608). No life-threatening complications (CDIV + V) occurred after long drainage (0.0% vs. 8.9%; p = 0.028) and long-term survival was not compromised. CONCLUSIONS: INR is a suitable predictor for postoperative outcome, while serum-bilirubin levels had no predictive value. The INR can help deciding between PBD and upfront surgery. If PBD is inevitable, drainage duration of >4 weeks reduced major complications. CATEGORY: Clinical study.

Oligometastatic pulmonary metastasis in pancreatic cancer patients: Safety and outcome of resection.

OBJECTIVE: To assess the perioperative and long-term outcome following pulmonary resection in patients with metachronous metastasis of pancreatic ductal adenocarcinoma (PDAC). BACKGROUND: Most patients with PDAC relapse or develop tumor spread to secondary organs. Currently, it remains unclear how to proceed with pulmonary metastasis in the metachronous setting. In particular, the role of surgery remains controversial. METHODS: Data of patients with pulmonary metachronous metastasis after PDAC collected from 2003 to 2015 in databases of two high-volume pancreatic cancer centers were retrospectively analyzed. Clinical and pathological aspects of primary PDAC as well as the perioperative and long-term outcome following pulmonary metastasectomy (PM) was evaluated, respectively. Patients with synchronous liver metastasis or metastasis to other secondary organs were excluded. Univariate survival analysis was performed. RESULTS: We identified 15 patients undergoing pulmonary resection for suspected metastasis after primary pancreatic resection. Operative and histopathologic evaluation revealed resectable pancreatic pulmonary metastasis in 11 patients (73.3%). The median disease-free survival (DFS) and overall survival (OS) after PM diagnosis was 18 months and 26 months, respectively. The median time to metachronous metastasis (TMM) was 17 months [3-64 months]. Perioperative morbidity was low with only one readmission (8.3%). There was no perioperative mortality. Patients who developed pulmonary metastasis later than 17 months after primary surgery showed better OS compared to those who did earlier (32.2 vs. 14.75 months, p = 0.025). In addition, patients with high-grade tumors had worse survival (12.4 vs. 31 months, p = 0.02). Elevated serum CEA levels or CA 19-9 levels were also not associated with shortened OS. CONCLUSIONS: This study suggests that pulmonary metastasectomy after PDAC is safe and effective. Patients with extended DFS after primary pancreatic surgery as well as favorable tumor grading seem to particularly benefit from pulmonary surgery.

Pancreatic stump closure techniques and pancreatic fistula formation after distal pancreatectomy: Meta-analysis and single-center experience.

BACKGROUND: Pancreatic fistula/PF is the most frequent and feared complication after distal pancreatectomy/DP. However, the safest technique of pancreatic stump closure remains an ongoing debate. Here, we aimed to compare the safety of different pancreatic stump closure techniques for preventing PF during DP. METHODS: We performed a PRISMA-based meta-analysis of all relevant studies that compared at least two techniques of stump closure during DP with regard to PF rates/PFR. We further performed a retrospective analysis of our institutional PFR in correlation with stump closure techniques. RESULTS: 8301 studies were initially identified. From these, ten randomized controlled trials/RCTs, eleven prospective and 59 retrospective studies were eligible. Stapler closure (26%vs.31%, OR:0.73, p = 0.02), combination of stapler and suture (30%vs.33%, OR:0.70, p = 0.05), or stump anastomosis (14%vs.28%, OR:0.51, p = 0.02) were associated with lower PFR than suture closure alone. Spleen preservation/splenectomy, or laparoscopic/open DP, TachoSil®, fibrin-like glue-application, or bioabsorbable-stapler-reinforcements (Seamguard®) did not influence PFR after DP. In contrast, autologous patches (falciform ligament/seromuscular patches) resulted in lower PFR than no patch application (21.9%vs.25,8%, OR:0.60, p = 0.006). In our institution, the major three techniques of stump closure resulted in comparable PFR (suture:27%, stapler:29%, or combination:24%). However, selective suturing/clipping of the main pancreatic duct during pancreatic stump closure prevented severe PF (p = 0.02). CONCLUSION: After DP, stapler closure, pancreatic anastomosis, or falciform/seromuscular patches lead to lower PFR than suture closure alone. However, the differences are rather small, and further RCTs are needed to test these effects. Selective closure of the main pancreatic duct during stump closure may prevent severe PF.

The impact of surgically placed, intraperitoneal drainage on morbidity and mortality after pancreas resection- A systematic review & meta-analysis.

BACKGROUND: Although routinely used, the benefit of surgically placed intraperitoneal drains after pancreas resection is still under debate. To assess the true impact of intraperitoneal drains in pancreas resection, a systematic review with meta-analysis was performed. METHODS: For this, the Preferred-Reporting-Items-for-Systematic-review-and-Meta-Analysis/PRISMA-guidelines were conducted and Pubmed/Medline, Embase, Scopus and The Cochrane Library were screened for relevant studies. RESULTS: 8 retrospective and 3 prospective studies were included in the systematic review. No difference was found between patients with or without intraperitoneal drains in mortality (Risk-ratio/RR 0.74, 95%-Confidence-interval/CI: 0.47-1.18, p = 0.20), in Grade B/C-postoperative pancreatic fistulas/POPF (RR 1.31, 95%-CI: 0.74-2.32, p = 0.35), in intraabdominal abscesses (RR 0.92, 95%-CI: 0.65-1.30, p = 0.64), in surgical site infection (RR 1.20, 95%-CI: 0.85-1.70, p = 0.30), in delayed gastric emptying (RR 1.11, 95%-CI: 0.65-1.90, p = 0.71), in postoperative haemorrhages (RR 0.92 95%-CI: 0.63-1.33, p = 0.65), in reoperations (RR 1.15, 95%-CI: 0.87-1.52, p = 0.33), or in radiological reinterventions (RR 0.95, 95%-CI: 0.69-1.31, p = 0.76). The risk for overall morbidity (RR 1.16, 95%-CI: 1.04-1.29, p = 0.008), of any POPF (RR 2.15, 95%-CI: 1.52-3.04, p < 0.0001) and of readmissions (RR 1.23, 95%-CI: 1.04-1.45, p = 0.01) was increased for patients with intraperitoneal drain compared to patients without following pancreatic resection. CONCLUSION: Regarding the controversial results of the recent prospective, randomized trials this meta-analysis revealed no difference in mortality but an increased risk for postoperative morbidity, POPF and readmissions of patients with intraperitoneal drains after pancreatic resection. Therefore, the indication for intraperitoneal drains should be critically weighed in patients undergoing pancreatic resections.

The influence of neural invasion on survival and tumor recurrence in pancreatic ductal adenocarcinoma - A systematic review and meta-analysis.

OBJECTIVES: To assess the impact of neural invasion/NI on overall survival/OS and tumor recurrence in pancreatic ductal adenocarcinoma/PDAC. SUMMARY BACKGROUND DATA: NI is a histopathological hallmark of PDAC. Although some studies suggested an important role for NI on OS, disease-free/DFS and progression-free survival/PFS in PDAC, there is still no consensus on the actual role of NI on survival and local recurrence in PDAC. METHODS: Pubmed, Cochrane library, Ovid and Google Scholar were screened for the terms "pancreatic ductal adenocarcinoma", "pancreatic cancer", "survival", "tumor recurrence" and "perineural invasion". The Preferred-Reporting-Items-for-Systematic-review-and-Meta-Analysis/PRISMA-guidelines were used for systematic review and meta-analysis. Articles meeting predefined criteria were critically analysed on relevance, and meta-analyses were performed by pooling univariate and multivariate hazard ratios/HR. RESULTS: A total number of 25 studies on the influence of NI on tumor recurrence, and 121 studies analysing the influence of NI on survival were identified by systematic review. The HR of the univariate (HR 1.88; 95%-CI 1.71-2.07; p < 0.00001) and multivariate meta-analysis (HR 1.68; 95%-CI 1.47-1.92; p < 0.00001) showed a major impact of NI on OS. Likewise, NI was associated with decreased DFS (HR 2.53; 95%-CI: 1.67-3.83; p = 0.0001) and PFS (HR 2.41; 95%-CI: 1.73-3.37: p < 0.00001) multivariate meta-analysis. CONCLUSIONS: Although the power of this study is limited by missing pathological procedures to assess the true incidence of NI, NI appears to be an independent prognostic factor for OS, DFS and PFS in PDAC. Therefore, NI should be increasingly considered in patient stratification and in the development of novel therapeutic algorithms.

Preoperative biliary stenting versus operation first in jaundiced patients due to malignant lesions in the pancreatic head: A meta-analysis of current literature.

BACKGROUND: Obstructive jaundice is a common presenting symptom among patients with pancreatic cancer. While benefits of preoperative biliary drainage have been suggested by previous studies, recent evidence has shown no significant improvements of preoperative biliary drainage on the postoperative outcome but rather an increase of complications. There is no clear consensus on whether to treat malignant obstructive jaundice with preoperative biliary drainage prior to operative intervention or to proceed directly to resection. Thus, our aim was to elucidate the impact of preoperative biliary drainage of obstructive jaundice due to malignant pancreatic head tumors on postoperative morbidity and mortality. METHODS: We conducted a meta-analysis in accordance with the PRISMA guidelines and carried out a systematic search of medical databases. The results were analyzed according to predefined criteria. We pooled the incidence of overall complications, wound infection, pancreatic fistula, intra-abdominal abscess, and death within the perioperative time period. RESULTS: We initially identified 1,816 studies, and 25 of these (22 retrospective studies, 3 randomized controlled trials) were finally included in the analysis with a total number of 6,214 patients. Analysis revealed an increased incidence of overall complications (odds ratio: 1.40; 95% confidence interval: 1.14-1.72; P = .002) and wound infections (odds ratio: 1.94; 95% confidence interval: 1.48-2.53; P < .00001) in patients receiving preoperative biliary drainage compared to operative intervention first. Mortality, incidence of pancreatic fistula, or intra-abdominal abscess formation were not affected by preoperative biliary drainage. CONCLUSION: Preoperative biliary drainage does not have a beneficial effect on postoperative outcome. The increase of postoperative overall complications and wound infections urges for precise indications for preoperative biliary drainage and against routine preoperative biliary decompression.