Preoperative CT anthropometric measurements and pancreatic pathology increase risk for postoperative pancreatic fistula in patients following pancreaticoduodenectomy.

Postoperative pancreatic fistula (POPF) is a common complication following pancreaticoduodenectomy (PD). However, risk factors for this complication remain controversial. We conducted a retrospective analysis of 107 patients who underwent PD. POPF was diagnosed in strict accordance with the definition of the 2016 update of pancreatic fistula from the International Study Group on Pancreatic Fistula (ISGPF). Univariate and multivariate logistic regression analyses were performed to identify independent risk factors for POPF. A total of 19 (17.8%) subjects of pancreatic fistula occurred after PD, including 15 (14.1%) with grade B POPF and 4 (3.7%) with grade C POPF. There were 33 (30.8%) patients with biochemical leak. Risk factors for POPF (grade B and C) were larger area of visceral fat (odds ratio [OR], 1.40; p = 0.040) and pathology other than pancreatic adenocarcinoma or pancreatitis (OR, 12.45; p = 0.017) in the multivariate regression analysis. This result could assist the surgeon to identify patients at a high risk of developing POPF.

Pancreaticopleural fistula: an uncommon cause of amylase-rich pleural effusion.

Pancreaticopleural fistula (PPF) causing pleural effusion as a complication of chronic pancreatitis is a rare finding. We present this finding in a 52-year-old man with a medical history significant for alcohol abuse, acute on chronic pancreatitis and severe chronic obstructive pulmonary disease, who presented with worsening dyspnoea for 3 days. CT scan of the chest showed a new large right-sided pleural effusion. Thoracentesis was performed and pleural fluid analysis showed an amylase-rich, exudative pleural effusion. The effusion reaccumulated within 3 days necessitating repeat thoracentesis. Endoscopic retrograde chloangiopancreatography showed contrast leak through a single disruption in the dorsal pancreatic duct, suspicious for an underlying PPF. The patient underwent stenting of the pancreatic duct with subsequent resolution of right-sided pleural effusion.

Significance of fistulography findings to the healing time of postoperative pancreatic fistula after pancreaticoduodenectomy.

PURPOSE: Pancreatic fistula (PF) is a common and serious complications after pancreaticoduodenectomy (PD). However, few studies have discussed the time required for PF healing in patients with this complication. This study investigates the PF healing time (PF-HT) and its association with findings of postoperative fistulography performed via the drainage tubes. METHODS: The subjects of this study were 35 patients with PF among a total of 144 patients who underwent PD for periampullary diseases in our hospital. PF-HT, which was defined as the duration from the first postoperative fistulography to removal of the drainage tubes, was assessed in the enrolled patients. Fistulography findings were classified into four types based on fluid collection and communication with the jejunal loop. We investigated the factors affecting the PF-HT, including the fistulography findings. RESULTS: The average PF-HT was 22 ± 20 days. Multivariate analysis revealed that the fistulography type was the only independent factor that affected PF-HT significantly. The PF-HT was significantly shorter in patients without fluid collection than in those with fluid collection. Moreover, those patients with fluid collection and a communication had a significantly shorter PF-HT than those without a communication. CONCLUSIONS: We found that fistulography findings were significantly associated with the PF-HT. This suggests that fistulography findings could help to predict the time needed for PF healing.

Evaluation of preoperative risk factors for postpancreatectomy hemorrhage.

PURPOSE: To investigate the risk factors for post-pancreatectomy hemorrhage (PPH). METHODS: The incidence, outcome, and risk factors for PPH were evaluated in 1169 patients who underwent pancreatectomy. RESULTS: The incidence and mortality rates of PPH were 3% and 11% in all pancreatectomies, 4% and 11% in pancreatoduodenectomy, 1% and 20% in distal pancreatectomy, and 3% and 0% in total pancreatectomy, respectively. Male sex [odds ratio (OR) 2.32], body mass index (BMI) ≥ 25 kg/m2 (OR 3.70), absence of diabetes mellitus (DM; HbA1c ≤ 6.2%; OR 3.62), and pancreatoduodenectomy (OR 3.06) were risk factors for PPH after all pancreatectomies. The PPH incidence was 0%, 1%, 2%, 6%, and 20% in patients with risk scores of 0 (n = 65), 1 (n = 325), 2 (n = 455), 3 (n = 299), and 4 (n = 25), respectively. The differences between risk-score groups 0-2 (2%) and 3-4 (7%) were significant (P < 0.05, OR 4.7). In patients who had undergone pancreatoduodenectomy, postoperative pancreatic fistula (POPF; OR 31.7) and absence of DM (OR 3.45) were risk factors for PPH. There was no significant association between POPF and PPH after distal pancreatectomy (P = 0.28). The incidence of POPF post-pancreatoduodenectomy was 20%. BMI ≥ 25 kg/m2 (OR 3.17), serum albumin < 3.5 g/dl (OR 1.77), absence of DM (OR 1.75), distal extrahepatic bile duct carcinoma (OR 4.05), and carcinoma of the papilla of Vater (OR 5.19) were risk factors for POPF post-pancreatoduodenectomy. CONCLUSION: Our study clarified the preoperative risk factors for PPH and recommends using a risk scoring system that includes "absence of DM" for predicting PPH.

Clinical efficacy of middle pancreatectomy contrasts distal pancreatectomy: a single-institution experience and review of literature.

BACKGROUND: We aim to analyse the difference of clinical efficacy between middle pancreatectomy (MP) and distal pancreatectomy (DP). METHODS: A retrospective study was used to analyse 39 cases of MP and 52 cases of DP from the Department of Hepatopancreatobiliary Surgery of the Affiliated Hospital of Qingdao University from February 2007 to December 2016. Furthermore, we identify randomized controlled trials or strictly designed clinical controlled trials on MP and DP. We performed a meta-analysis of the final included studies using RevMan 5.3 software to illustrate the differences in efficacy between MP and DP. RESULTS: In the MP group, the operation time and diet start time were significantly longer than DP group. However, there was no significant difference in serious complications including clinically significant pancreatic fistula (grades B and C), delayed gastric emptying, reoperative and mortality. Furthermore, compared with DP, patients in MP group could benefit from long-term post-operative exocrine and endocrine function. Finally, we performed a meta-analysis including 14 studies with a total of 1104 patients and proved that the pancreatic fistula rate, endocrine and exocrine function were significantly different in the two groups. CONCLUSION: The MP is a safe and feasible surgical method. It can well preserve the endocrine and exocrine function of pancreas and improve the life quality of patients.

Robotic pancreatoduodenectomy with vascular resection: Outcomes and learning curve.

INTRODUCTION: The safety, efficacy, and learning curve for robotic pancreatoduodenecomy has been reported; however, the outcomes and learning curve of robotic pancreatoduodenecomy with vascular resections remain unknown. Our aim was to evaluate the outcomes of robotic pancreatoduodenecomy with vascular resections compared with robotic pancreatoduodenecomy without vascular resection and to identify the learning curve and benchmarks for improved performance during robotic pancreatoduodenecomy with vascular resections. METHODS: A retrospective review of consecutive patients who underwent robotic pancreatoduodenecomy with vascular resections and robotic pancreatoduodenecomy between 2011 and 2017. Patients were analyzed consecutively, and a cumulative sum analysis was performed to detect improvements in performance over time. RESULTS: Of 380 consecutive robotic pancreatoduodenecomy patients, 50 (13%) underwent robotic pancreatoduodenecomy with vascular resections. Compared with robotic pancreatoduodenecomy, robotic pancreatoduodenecomy with vascular resections were more likely to have had pancreatic adenocarcinoma (84% vs 42%) and had received neoadjuvant therapy (35% vs 65%, P < .01). Robotic pancreatoduodenecomy with vascular resections operative time revealed a steady, significant decrease (Rho = -0.38, p = .006) with marked initial improvement after the first 8 cases and maturation of the learning curve after 35 cases. A significant decrease in duration of the hospital stay was observed throughout the experience (Rho = -0.528, P < .0001), whereas margin status, pancreatic fistula, major morbidity, and mortality remained constant and comparable to robotic pancreatoduodenecomy alone. CONCLUSION: Robotic pancreatoduodenectomy with vascular resections is safe and feasible. For surgeons who have surpassed the learning curve of robotic pancreatoduodenectomy, it appears that improvements in performance of robotic pancreatoduodenecomy with vascular resections can be observed after 35 cases.

Dislocation of intra-abdominal drains after pancreatic surgery: results of a prospective observational study.

PURPOSE: The use of intra-abdominal drains after major surgical procedures represents a well-established but controversial practice. No data are available regarding both the occurrence and the potential impact of their postoperative accidental dislocation. The aim of this study is to assess the actual rate of dislocation of intra-abdominal drains postoperatively and to evaluate its clinical impact. METHODS: This is a prospective observational study using major pancreatic surgery as a model. Ninety-one consecutive patients undergoing pancreatoduodenectomy (PD) or distal pancreatectomy (DP) underwent low-dose, non-enhanced computed tomography (LDCT) on postoperative days (POD) 1 and 3 in a blinded fashion to assess the position of drains. We compared the outcomes of patients with dislocated and correctly placed drains. RESULTS: Overall, drains were dislocated in 30 patients (33%), without differences between PD and DP. Most of dislocations were already present on POD 1 (77%). Postoperative complications occurred in 57% of patients, and the rate of postoperative pancreatic fistula (POPF) was 27%. The dislocated cohort had lesser morbidity (40% vs. 66%; relative risk (RR), 0.35; 95% CI, 0.14-0.86; P = 0.020), and the rate of POPF (3% vs. 39%, respectively; RR, 0.05; 95% CI, 0.01-0.42; P < 0.001). After PD, patients with dislocated drains had a shorter hospital stay (12 vs. 20 days; P = 0.015). No significant differences in terms of need for percutaneous drainage procedures, abdominal collections, or grade C POPFs were found between the groups. CONCLUSIONS: Dislocation of intra-abdominal drains is an early and frequent event after major pancreatic resection. Its occurrence might protect against the negative effects of maintaining drainage, eventually leading to better postoperative outcomes. This data reinforces the knowledge that surgical drains might be detrimental in selected cases.

Predictive Factors of Pancreatic Fistula After Pancreaticoduodenectomy and External Validation of Predictive Scores.

BACKGROUND/AIM: The Fistula Risk Score (FRS), as other risk scores, is a validated model predicting the development of a clinically relevant post-operative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD). We evaluated risk factors related with CR-POPF and correlated four predictive scores with the likelihood of developing CR-POPF in our cohort. PATIENTS AND METHODS: The records of 107 patients who underwent PD from 2007 to 2015 were obtained from a prospectively maintained database and reviewed. CR-POPFs were categorized by the International Study Group of Pancreatic Fistula (ISGPF) standards. Firstly, a univariate and multivariate analysis of risk factors related to CR-PPOPF was performed, and then the data were correlated with FRS, Wellner's, Robert's and Yamamoto's scores. RESULTS: In total, 30 patients developed a CR-POPF. On multivariate analysis, abdominal thickness (OR=1.02, p=0.010), Wirsung's duct diameter (OR=0.57, p=0.029), pancreatic consistency (OR=3.18, p=0.011) and histological diagnosis of the lesion (OR=1.65, p=0.012) represented independent predictive factors of CR-POPF. FRS (R2=0.596, p=0.001), Wellner's score (R2=0.285, p=0.005) and Roberts' score (R2=0.385, p=0.002) correlated with the likelihood of developing CR-POPF. CONCLUSION: Abdominal thickness, Wirsung's duct diameter, pancreatic consistency and histological diagnosis were independent predictive factors of CR-POPF. Predictive scores reflected the likelihood of CR-POPF, FRS being the score with the highest predictive value.

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.

Embedding fistulojejunostomy: An easy and secure technique for refractory external pancreatic fistula.

BACKGROUND: Refractory external pancreatic fistula (REPF) is a rare but troublesome event. Fistulojejunostomy with direct suture of the fistula wall to jejunal wall has been demonstrated as a solution. However, it is sometimes technically difficult and some cases of failure were reported. METHODS: An embedding fistulojejunostomy (EFJ) was designed. The fistula tract was detached from the abdominal wall and impactedly inserted into a Roux-en-Y jejunal lumen without direct suture of the fistula wall to the jejunal wall. Five patients with REPF for > 3 months underwent this procedure in the past 10 years. The preoperatively-placed drainage tubes temporarily exteriorized the pancreatic fluid for 30 days. RESULTS: All fistulojejunostomy procedures were accomplished within 15 minutes. Four patients had uneventful recovery with a postoperative hospital stay ≤ 10 days. One patient had wound infection and needed hospitalization for 23 days. Except for one patient who required pancreatic enzyme supplements for 8 months, no other patient had pancreatic exocrine insufficiency. After follow up for 12-124 months, no patient required pancreatic enzyme supplements, and no patient had recurrent fistula or diabetes mellitus. CONCLUSION: EFJ makes fistulojejunostomy easier and more secure with a satisfactory early and long-term outcome. It may be a desirable technique for REPF.

Comparison of patient outcomes with and without stenting tube in pancreaticoduodenectomy.

Objective To evaluate the clinical effect of different pancreaticojejunostomy techniques in the treatment of pancreaticoduodenectomy and investigate the applicability of pancreaticojejunostomy without pancreatic duct stenting. Methods From January 2012 to December 2015, 87 patients who underwent pancreaticoduodenectomy were randomly assigned to either Group A (duct-to-mucosa anastomosis with pancreatic duct stenting, n = 43) or Group B (pancreas-jejunum end-to-side anastomosis without stenting (n = 44). The operative duration of pancreaticojejunostomy, postoperative hospital stay, and incidence of postoperative complications were compared between the two methods. Results The operative duration of pancreaticojejunostomy without use of the pancreatic duct stent was significantly shorter in Group B than in Group A (t = 7.137). The postoperative hospital stay was significantly shorter in Group B than in Group A (t = 2.408). The differences in the incidence of postoperative complications such as pancreatic fistula, abdominal bleeding, abdominal infection and delayed gastric emptying were not significantly different between the two groups (χ2 = 0.181, 0.322, 0.603, and 0.001, respectively). Conclusion Pancreaticoduodenectomy without pancreatic duct stenting is safe and reliable and can reduce the operative time and hospital stay. No significant differences were observed in the incidence of postoperative complications.

Are Internal or External Pancreatic Duct Stents the Preferred Choice for Patients Undergoing Pancreaticoduodenectomy? A Meta-Analysis.

The technique of pancreatic duct stenting during pancreatic anastomosis can markedly reduce the incidence of postoperative pancreatic fistula (PF) after pancreaticoduodenectomy (PD). The method of drainage includes using either an external or an internal stent; the meta-analysis result shows us that there were no differences in the rates of postoperative complications between PD using internal stents and PD using external stents; internal stents may be more favorable during postoperative management of drainage tube. What is more, internal stents could reduce the digestive fluid loss and benefit the digestive function.

[Endoscopic pancreatic stenting in pancreatic fistulas management]. / Endoskopicheskoe transpapillyarnoe pankreaticheskoe stentirovanie v lechenii svishchei podzheludochnoi zhelezy (s kommentariem A.G. Krigera).

AIM: To present 18-year experience of endoscopic transpapillary stenting in patients with pancreatic fistula. MATERIAL AND METHODS: The study included 48 patients with pancreatic fistula resistant to conservative management. Pancreatic stenting was successful in 32 (66.7%) patients. In 30 (93.8%) of them stenting appeared as the final stage of pancreatic fistula treatment. RESULTS: Inclidence of complications after endoscopic treatment was 4.2%. We evaluated long-term results in 23 cases within 8-184 months. There were good results in 21 (91.3%) cases and satisfactory - in 2 (8.7%) cases. We had not unsatisfactory results in our experience.

Preoperative computed tomography scan to predict pancreatic fistula after distal pancreatectomy using gland and tumor characteristics.

BACKGROUND: Preoperative risk stratification for postoperative pancreatic fistula in patients undergoing distal pancreatectomy is needed. METHODS: Risk factors for postoperative pancreatic fistula in 220 consecutive patients undergoing distal pancreatectomy at 2 major institutions were recorded retrospectively. Gland density was measured on noncontrast computed tomography scans (n = 101), and histologic scoring of fat infiltration and fibrosis was performed by a pathologist (n = 120). RESULTS: Forty-two patients (21%) developed a clinically significant pancreatic fistula within 90 days of surgery. Fat infiltration was significantly associated with gland density (P = .0013), but density did not predict pancreatic fistula (P = .5). Recursive partitioning resulted in a decision tree that predicted fistula in this cohort with a misclassification rate less than 15% using gland fibrosis (histology), density (HU), margin thickness (cm), and pathologic diagnosis. CONCLUSIONS: This multicenter study shows that no single perioperative factor reliably predicts postoperative pancreatic fistula after distal pancreatectomy. A decision tree was constructed for risk stratification.

Significance of preoperative radiographic pancreatic density in predicting pancreatic fistula after surgery for pancreatic neuroendocrine tumors.

BACKGROUND: Postoperative pancreatic fistula remains the most severe and worrisome complication after surgery. Predictive preoperative assessment remains challenging. The authors examine the role of pancreatic computed tomography density in predicting postoperative pancreatic fistula after surgery for pancreatic neuroendocrine tumors. METHODS: A single institutional retrospective review of pancreatic surgery for neuroendocrine tumors between 1998 and 2010 was conducted. Preoperative contrast-enhanced computed tomography scans were reviewed, with mean region of interest measurements of pancreatic parenchymal density obtained from 10-mm thick axial computed tomography images. RESULTS: A total of 119 patients were identified: 59 with enucleations and 60 with resections. Decreased preoperative pancreatic density was significantly associated with an increased grade of postoperative pancreatic fistula (P < .01). Subgroup analyses revealed that decreased gland density was associated with increased grade of postoperative pancreatic fistula in the resection (P < .01) but not in the enucleation group (P = .34). CONCLUSIONS: A significant association between postoperative pancreatic fistula grade and preoperative pancreatic computed tomography density is observed in patients undergoing resection for pancreatic neuroendocrine tumors.

Primary versus secondary delayed gastric emptying (DGE) grades B and C of the International Study Group of Pancreatic Surgery after pancreatoduodenectomy: a retrospective analysis on a group of 132 patients.

Delayed gastric emptying (DGE) is a common complication after pancreaticoduodenectomy (PDD) significantly contributing to post-operative morbidity. Clinical risk factors for DGE occurrence after PDD remain controversial. From January 2004 to December 2011, a total of 132 patients underwent PDD for either malignancies (73.5%) or benign diseases (26.5%) in one single universitary center. Post-operative mortality and morbidity were, respectively, 3 and 44.7%. DGE has been defined in accordance with the International Study Group of Pancreatic Surgery (ISGPS) classification. DGE was distinguished in primary or secondary. Factors associated with grades B and C of DGE, based on severity and clinical impact, were assessed by means of univariate and multivariate analysis. Thirty-eight patients (28.8%) had clinical DGE grade B or C. Post-operative complications (pancreatic fistula and/or hemorrhage or anastomotic leak) were reported in 25 out of the 38 patients (65.8%, secondary DGE), while in 13 patients it was not associated to any other complication (34.2%, primary DGE). Post-operative complications (pancreatic fistula and hemorrhage) appeared to be the most important predictive factor for Grade B or C DGE.

Does Braun enteroenterostomy reduce delayed gastric emptying after pancreaticoduodenectomy?

Whether an additional Braun enteroenterostomy is necessary in reducing delayed gastric emptying (DGE) after pancreaticoduodenectomy (PD) has not yet been well investigated. Herein, in this retrospective study, 395 consecutive cases of patients undergoing classic PD from 2009 to 2013 were reviewed. Patients with and without Braun enteroenterostomy were compared in preoperative baseline characteristics, surgical procedure, postoperative diagnosis, and morbidity including DGE. The DGE was defined and classified by the International Study Group of Pancreatic Surgery recommendation. The incidence of DGE was similar in patients with or without Braun enteroenterostomy following PD (37/347, 10.7% vs 8/48, 16.7%, P = 0.220). The patients in the 2 groups were not different in patient characteristics, lesions, surgical procedure, or postoperative complications, although patients without Braun enteroenterostomy more frequently presented postoperative vomiting than those with Braun enteroenterostomy (33.3% vs 15.3%, P = 0.002). Bile leakage, pancreatic fistula, and intraperitoneal abscess were risk factors for postoperative DGE (all P < 0.05). Prokinetic agents and acupuncture were effective in symptom relief of DGE in 24 out of 45 patients and 12 out of 14 patients, respectively.The additional Braun enteroenterostomy following classic PD was not associated with a decreased rate of DGE. Postoperative abdominal complications were strongly correlated with the onset of DGE. Prokinetic agents and acupuncture could be utilized in some patients with DGE.