Clinical relevant pancreatic fistula after pancreatoduodenectomy: when negative amylase levels tell the truth.

Drain Amylase level are routinely determined to diagnose pancreatic fistula after Pancreatocoduodenectomy. Consensus is lacking regarding the cut-off value of amylase to diagnosis clinically relevant postoperative pancreatic fistulae (POPF). The present study proposes a model based on Amylase Value in the Drain (AVD) measured in the first three postoperative days to predict a POPF. Amylase cut-offs were selected from a previous published systematic review and the accuracy were validated in a multicentre database from 12 centres in 2 countries. The present study defined POPF the 2016 ISGPS criteria (3 times the upper limit of normal serum amylase). A learning machine method was used to correlate AVD with the diagnosis of POPF. Overall, 454 (27%) of 1638 patients developed POPF. Machine learning excluded a clinically relevant postoperative pancreatic fistulae with an AUC of 0.962 (95% CI 0.940-0.984) in the first five postoperative days. An AVD at a cut-off of 270 U/L in 2 days in the first three postoperative days excluded a POPF with an AUC of 0.869 (CI 0.81-0.90, p < 0.0001). A single AVD in the first three postoperative days may not exclude POPF after pancreatoduodenectomy. The levels should be monitored until day 3 and have two negative values before removing the drain. In the group with a positive level, the drain should be kept in and AVD monitored until postoperative day five.

Idiopathic Intracranial Hypertension: Shunt Failure and the Role of Obesity.

BACKGROUND: Idiopathic intracranial hypertension (IIH) is a chronic condition characterized by raised intracranial pressure in the absence of a known etiology. IIH typically presents in overweight women of childbearing age. Surgical intervention for IIH involves diversion of cerebrospinal fluid, often by the placement of a shunt. Experience suggests higher shunt failure rates in patients with IIH than shunts placed for other etiologies. Here we sought to both establish and compare failure rates for IIH and non-IIH shunts and to examine association with body mass index (BMI). METHODS: This study was a single-center retrospective consecutive cohort over a 13-year period. There were 1264 non-IIH patients and 116 patients with IIH included in the study. This was a retrospective analysis of time to shunt failure using Kaplan-Meier methods for IIH and non-IIH shunts. Secondary analysis of BMI, shunt type, and sex on IIH shunt failure was also conducted. RESULTS: The median time to failure of the initial IIH shunt was 22.9 months (interquartile range [IQR], 4-55) compared with 57 months (IQR, 12-87) in non-IIH shunts (P < 0.001; 95% confidence interval, 58.6-233.6). In the IIH group, the median shunt survival for BMI above the healthy range (18.5-25 kg/m2) was 18 months relative to 44 months for those with a healthy BMI. CONCLUSIONS: Our study suggests that in IIH, relative to hydrocephalus of other causes, shunts have higher failure rates and often require more frequent revisions. Higher shunt failure rates in patients with IIH may be associated with an unhealthy BMI.