Pancreaticopleural fistula causing pleural effusion: a case report and review of the literature.

BACKGROUND: Pancreaticopleural fistula is a rare complication of pancreatitis and poses diagnostic and therapeutic challenges. This case report sheds light on the unique challenges posed by pancreaticopleural fistula as a rare complication of pancreatitis. The aim is to contribute valuable insights to the scientific literature by presenting a case involving a middle-aged man with acute necrotizing pancreatitis and associated pleural effusion. CASE PRESENTATION: A 41-year-old Asian male with a history of pancreatitis and chronic alcohol use presented with severe dyspnea, chest pain, and left-sided pleural effusion. Elevated serum amylase lipase levels and imaging confirmed acute necrotizing pancreatitis with a computed tomography severity index of 8/10. Magnetic resonance cholangiopancreatography revealed pancreatic necrosis and pseudocyst formation and findings suggestive of pancreaticopleural fistula. The patient was then treated with octreotide therapy. CONCLUSION: The management of pancreaticopleural fistula demands a comprehensive and individualized approach. Recognition guided by high clinical suspicion coupled with appropriate investigations and a careful balance between medical, endoscopic, and surgical interventions is crucial for achieving favorable outcomes. This case report adds to the scientific literature by providing insights into the complexities of pancreaticopleural fistula and emphasizing the importance of personalized strategies in its management.

Clinical usefulness of routinely performed drain fluid cultures after pancreaticoduodenectomy. A new ally to predict patients' outcomes?

BACKGROUND: Previous studies showed that bacterial contamination of surgical drains was associated with higher morbidity and mortality following pancreaticoduodenectomy (PD). However, there is still no agreement on the routine use of fluid drainage cultures in the management of patients underwent PD. Therefore, we aimed to clarify the role of surgical drain bacterial contamination in predicting patients' postoperative course. METHOD: Single-centre study including patients underwent PD at Humanitas Research Hospital (2010-2021). Preoperative, intraoperative and postoperative data were collected. Routinely performed fluid drain cultures on postoperative day (POD) 5 were analyzed and compared among patients throughout the cohort. RESULTS: A total of 825 patients were analyzed. Bacterial contamination of surgical drains was observed in 420 (50.9 %) patients and it was found to be associated with a higher rate of B/C grade pancreatic fistula (POPF) (P < 0.001), Clavien-Dindo≥3 (P < 0.001), 30-day mortality (P = 0.011), wound infection (P < 0.001), relaparotomies (P = 0.003) and greater length of hospital stay (LOS) (P < 0.001). Also, E. coli surgical drain contamination was demonstrated to double the risk of B/C grade POPF development (OR = 1.628, 95 % IC = 1.009-2.625, P = 0.046). Finally, preoperative biliary drainage (OR = 2.474, 95 % IC = 1.855-3.298, P < 0.001), age ≥75 years old (OR = 1.492, 95 % IC = 1.077-2.067, P = 0.016) and isolated Roux-en-Y pancreaticojejunostomy (OR = 1.639, 95 % IC = 1.229-2.188, P < 0.001) were identified as risk factors for surgical drains bacterial contamination. CONCLUSION: Bacterial contamination of surgical drains predicts the development of B/C grade POPF and other major complications after PD. Therefore, we suggest the routine use of fluid drain cultures following PD.

Post-pancreatectomy acute pancreatitis after pancreatoduodenectomy: Analysis of a clinically-relevant complication in a single-center retrospective study.

BACKGROUND: /Objectives: This study aimed to evaluate the frequency, clinical impact, and risk factors of post-pancreatectomy acute pancreatitis (PPAP) after pancreatoduodenectomy (PD) according to the definition proposed by the International Study Group for Pancreatic Surgery (ISGPS). METHODS: patients undergoing PD between 2010 and 2021 were retrospectively analyzed. PPAP was defined according to the ISGPS criteria, including elevated serum amylase for 48 h and concurring pancreatitis alterations on a CT scan. RESULTS: 272 patients were finally included in the study. PPAP occurred in 40 (14.7 %) patients, and it was significantly related to higher rates of clinically-relevant postoperative pancreatic fistula (CR-POPF) (p < 0.001), post-pancreatectomy hemorrhage (PPH) (p < 0.001) and major complications (Clavien-Dindo ≥ 3a) (p < 0.001). Moreover, PPAP in the absence of CR-POPF (n = 18) was significantly related to longer hospital stay (p < 0.001), PPH (p < 0.001), major complications (Clavien-Dindo≥ 3a, p = 0.001) and higher intensive care unit costs (p = 0.029) compared to patients not developing PPAP. In the univariable and multivariable analysis, the duct size (p = 0.004) and high-risk pathologies (p = 0.004) but not intraoperative bleeding (p = 0.066) represented independent risk factors for PPAP. In the same analysis, patients receiving a bridging therapy with low molecular-weight heparin showed significantly lower rates of PPAP (p = 0.045). CONCLUSIONS: PPAP represents a relevant complication after PD. Its risk factors are similar to those for CR-POPF, while anticoagulants could represent a possible prevention strategy.

Tomoelastography and Pancreatic Extracellular Volume Fraction Derived From MRI for Predicting Clinically Relevant Postoperative Pancreatic Fistula.

BACKGROUND: Pancreatic stiffness and extracellular volume fraction (ECV) are potential imaging biomarkers for pancreatic fibrosis. Clinically relevant postoperative fistula (CR-POPF) is one of the most severe complications after pancreaticoduodenectomy. Which imaging biomarker performs better for predicting the risk of CR-POPF remains unknown. PURPOSE: To evaluate the diagnostic performance of ECV and tomoelastography-derived pancreatic stiffness for predicting the risk of CR-POPF in patients undergoing pancreaticoduodenectomy. STUDY TYPE: Prospective. POPULATION: Eighty patients who underwent multiparametric pancreatic MRI before pancreaticoduodenectomy, among whom 16 developed CR-POPF and 64 did not. FIELD STRENGTH/SEQUENCE: 3 T/tomoelastography and precontrast and postcontrast T1 mapping of the pancreas. ASSESSMENT: Pancreatic stiffness was measured on the tomographic c-map, and pancreatic ECV was calculated from precontrast and postcontrast T1 maps. Pancreatic stiffness and ECV were compared with histological fibrosis grading (F0-F3). The optimal cutoff values for predicting CR-POPF were determined, and the correlation between CR-POPF and imaging parameters was evaluated. STATISTICAL TESTS: The Spearman's rank correlation and multivariate linear regression analysis was conducted. The receiver operating characteristic curve analysis and logistic regression analysis was performed. A double-sided P < 0.05 indicated a statistically significant difference. RESULTS: Pancreatic stiffness and ECV both showed a significantly positive correlation with histological pancreatic fibrosis (r = 0.73 and 0.56, respectively). Patients with advanced pancreatic fibrosis had significantly higher pancreatic stiffness and ECV compared to those with no/mild fibrosis. Pancreatic stiffness and ECV were also correlated with each other (r = 0.58). Lower pancreatic stiffness (<1.38 m/sec), lower ECV (<0.28), nondilated main pancreatic duct (<3 mm) and pathological diagnosis other than pancreatic ductal adenocarcinoma were associated with higher risk of CR-POPF at univariate analysis, and pancreatic stiffness was independently associated with CR-POPF at multivariate analysis (odds ratio: 18.59, 95% confidence interval: 4.45, 77.69). DATA CONCLUSION: Pancreatic stiffness and ECV were associated with histological fibrosis grading, and pancreatic stiffness was an independent predictor for CR-POPF. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY STAGE: 5.

PREDICTION OF EXTERNAL PANCREATIC FISTULA DEVELOPMENT IN PATIENTS WITH ACUTE INFECTED NECROTISING PANCREATITIS.

OBJECTIVE: The aim: To search for risk factors for the development of external pancreatic fistula (EPF) in patients with acute infected necrotizing pancreatitis. PATIENTS AND METHODS: Materials and methods: A prospective single-center observational study was conducted with the participation of 160 adult patients with infected acute necrotizing pancreatitis (ANP) who required intervention at different stages of the disease. Depending on the amylase activity of the drainage secretions, the groups with and without diagnosed EPF were compared according to 15 demographic, clinical, laboratory and instrumental parameters of the disease. To identify predictors of the risk of developing EPF in ANP, a regression logistic analysis was performed and logistic regression models were built for each factor attribute. RESULTS: Results: We did not find statistically significant differences in the indicators characterising patients on the first day of illness, as well as in the comparison of indicators characterising local complications of AP, the timing of AP infection, the incidence of sepsis and the level of PON in sepsis. When comparing the groups by the frequency of the type of microbial agent of infected APB, no statistically significant differences were found. Comparative pairwise analysis between the groups by morphological characteristics revealed statistical differences in the frequency of focal superficial and transmural PN (p < 0.001). Next, we performed a regression logistic analysis and built logistic regression models for each factor attribute, namely age, gender, BMI, BISAP score and Charlson comorbidity index, morphological characteristics of necrotizing pancreatitis. After univariate regression analysis, a statistically significant association between the depth of PN and the risk of developing PFN was found (OR 2.7 (1.4-5.2), p=0.001). CONCLUSION: Conclusions: We found that the risk of developing an external pancreatic fistula was associated with the depth of pancreatic necrosis.

Body composition analysis using convolutional neural network in predicting postoperative pancreatic fistula and survival after pancreatoduodenectomy for pancreatic cancer.

PURPOSE: To evaluate whether body composition measurements acquired using convolutional neural networks (CNNs) from preoperative CT images could predict postoperative pancreatic fistula (POPF) and overall survival (OS) after pancreaticoduodenectomy in patients with pancreatic ductal adenocarcinoma (PDAC). METHODS: 257 patients (160 men; median age [interquartile range], 67 [60-74]) who underwent pancreaticoduodenectomy for PDAC between January 2013 and December 2017 were included in this retrospective study. Body composition measurements were based on a CNN trained to segment CT images into skeletal muscle area, visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT). Skeletal muscle area, VAT, and SAT were normalized to height square and labeled as skeletal muscle, VAT, and SAT indices, respectively. The independent risk factors for clinically relevant POPF (grade B or C) were determined using a multivariate logistic regression model, and prognostic factors for OS were assessed using Cox proportional hazards regression analyses. RESULTS: After pancreatioduodenectomy, 27 patients developed POPF grade B or C (10.5 %, 27/257). The VAT index (odds ratio [OR] = 7.43, p < 0.001) was the only independent prognostic factor for POPF grade B or C. During the median follow-up period of 23 months, 205 (79.8 % [205/257]) patients died. For prediction of OS, skeletal muscle index (hazard ratio [HR] = 0.58, p = 0.018) was a significant factor, along with vascular invasion (HR = 1.85, p < 0.001) and neoadjuvant therapy (HR = 0.58, p = 0.011). CONCLUSIONS: A high VAT index and a low skeletal muscle index can be utilized in predicting the occurrence of POPF grade B or C and poor OS, respectively.

Closed incision negative pressure wound therapy following pancreaticoduodenectomy for prevention of surgical site infections in high-risk patients.

BACKGROUND: Surgical site infection (SSI) is one of the most common sources of morbidity after pancreaticoduodenectomy. Surgical site infections are associated with readmissions, prolonged length of stay, delayed initiation of adjuvant chemotherapy and negative effects on quality of life. Incisional vacuum-assisted closure (iVAC) devices applied on closed incisions may reduce SSI rates. The objective of this retrospective review is to evaluate the impact of iVAC on SSI rate after pancreaticoduodenectomy. METHODS: A cohort of patients undergoing pancreaticoduodenectomy at a single institution who had at least 1 risk factor for SSI and who received an iVAC were compared with a historical cohort of high-risk patients who received conventional dressings after pancreaticoduodenectomy. The primary outcome was incidence of SSI within 30 days, abstracted from chart review. Secondary outcomes were 30-day readmission, 90-day mortality, rate of postoperative pancreatic fistula and rate of delayed gastric emptying. RESULTS: In total, 175 patients were included, of whom 61 received an iVAC. The incidence of SSI was 13% (8 of 61 patients) and 16% (18 of 114 patients) in the iVAC and conventional dressing groups, respectively (odds ratio 0.81, 95% confidence interval 0.33-1.98). Preoperative biliary drainage was the most frequent SSI risk factor. Binary logistic regression using SSI as the outcome demonstrated no significant association with iVAC use when adjusted for SSI risk factors. There were no differences in rates of postoperative pancreatic fistula, delayed gastric emptying or 90-day mortality. CONCLUSION: This report describes the outcomes of the integration of iVAC devices into routine clinical practice at a high-volume institution. Application of this device after pancreaticoduodenectomy for patients at elevated risk of SSI was not associated with a reduction in the rate of SSIs.

Chronic Glucocorticoid Use is a Potential Risk Factor for Delayed Pancreatic Fistula after Laparoscopic Distal Pancreatectomy: A Retrospective Analysis.

Pancreatic fistula is a potentially morbid complication after distal pancreatectomy. Chronic glucocorticoid use is one of the risk factors for pancreatic fistula in pancreaticoduodenectomy, though it has not been reported in distal pancreatectomy. We explored whether chronic glucocorticoid use can be a risk factor for pancreatic fistula in distal pancreatectomy. We reviewed 408 consecutive patients who underwent elective distal pancreatectomy from 2011 to 2021. We evaluated two kinds of pancreatic fistula (postoperative pancreatic fistula and delayed pancreatic fistula). We defined delayed pancreatic fistula as a patient who was re-admitted for pancreatic fistula after the first discharge from the hospital. Preoperative characteristics and postoperative outcomes were analyzed. Two hundred sixty-seven patients underwent open distal pancreatectomy, while 141 patients had laparoscopic distal pancreatectomy. A comparison of patient with and without chronic glucocorticoid use showed that only patients with chronic glucocorticoid use developed delayed pancreatic fistula (0% vs. 16.7%; p < 0.001). In addition, delayed pancreatic fistula occurred in only laparoscopic distal pancreatectomy patients with chronic glucocorticoid use (0% vs. 25.0%; p < 0.001). Although sample size is small, it is reasonable to presume that chronic glucocorticoid use is a potential risk factor for delayed pancreatic fistula in laparoscopic distal pancreatectomy.

Octreotide and postoperative pancreatic fistula after pancreaticoduodenectomy: What we know so far? A narrative review.

Postoperative pancreatic fistula (POPF) is the most feared complication following pancreatic resection. Octreotide, a synthetic somatostatin analog, has been widely used by pancreatic surgeons worldwide after pancreatic resections, often as per surgeon's discretion, to prevent POPF especially in cases at high risk of developing POPF. We herein analyze the data available till date of the subject. A PubMed search with keywords "somatostatin OR octreotide OR somatostatin analogues AND postoperative pancreatic fistula" was made. Further filters were applied in the search "Clinical Trial, Meta-Analysis, Randomized Controlled Trial, Systematic Review, from 1990 - 2021," and the 68 results thus obtained were analyzed and included in this narrative review. There is considerable heterogeneity among the studies assessing the role of octreotide in the prevention of POPF making data comparison difficult, and hence results remain inconclusive. Most of the earlier studies used different definitions of POPF and other complications; included patients with varied pancreatic pathologies such as cancer, chronic pancreatitis, and benign lesions; surgical techniques such as pancreaticoduodenectomy, distal pancreatectomy, and other procedures; use of somatostatin and its analogs such as octreotide, lanreotide, pasireotide, and vapreotide; varied surgeon and institutional volume; and so on. Besides, pancreatic surgery is per se a complex surgical procedure and has its own inherent biases related to patient and the pancreas itself affecting the overall outcome. Data indicate favorable role of newer somatostatin analogs, and further studies are urgently needed. The question about the efficacy of prophylactic octreotide to reduce POPF after pancreaticoduodenectomy remains open to debate.

Postoperative pancreatic fistula after pancreaticoduodenectomy: if you lack knowledge of what to search for, you will be unable to locate what you desire.

OBJECTIVE: Postoperative pancreatic fistula (POPF) is the most common and critical complication of pancreatoduodenectomy (PD). In this study, we aimed to define preoperative, perioperative, and postoperative conditions that may cause POPF and examine the predictive value of drain fluid amylase (DFA) values in showing the clinical severity of POPF. PATIENTS AND METHODS: Between December 2018 and December 2019, 49 patients who underwent PD for malignant reasons by a single team were retrospectively analyzed. Patients with benign indications, vascular reconstruction, preoperative biliary drainage catheterization, resectable liver metastases, POPF that occurred after reoperation, and patients undergoing neoadjuvant oncological treatment were excluded from the study. The patients were divided into two groups developing (FP) and non-developing (FN) POPF. RESULTS: There was no difference between the groups in terms of gender (p=0.781), age (p=0.219), American Society of Anesthesiologists (ASA) score (p=0.338), and comorbidity status (p=0.219). The mean body mass index (BMI) kg/m2 values of the patients in the FN and FP groups were 25.2±4.0 kg/m2 and 27.4±2.6 kg/m2, respectively (p=0.042). An increased BMI increases the risk of POPF. Preoperative prognostic nutritional index (PNI) score (p=0.588), preoperative total bilirubin level (p=0.707), pancreatic duct diameter (p=0.334), pancreatic texture (p=0.334), operation time (p=0.659) do not pose a risk for POPF. Increased perioperative bleeding amounted to a risk for POPF (123.8±46.7 ml, 244.7±66.3 ml in FN and FP groups, respectively, p=0.024). Drain fluid amylase (DFA) values (p<0.001, p=0.043, p=0.019, respectively) were found to be high in patients with POPF on postoperative days 1, 4, and 7. CONCLUSIONS: Increased BMI and excess perioperative blood loss increase the risk of POPF. DFA level is an easily applicable method that provides early diagnosis for POPF.

Management and outcomes of pseudoaneurysms presenting with late hemorrhage following pancreatic surgery: A six-year experience from a tertiary care center.

BACKGROUND/PURPOSE: Late hemorrhage following pancreatic surgery is associated with significant morbidity and mortality. Pseudoaneurysm (PSA) is an important source of late hemorrhage, which is effectively and safely managed by embolization. We aim to retrospectively review the outcomes of embolization for pseudoaneurysms causing late post-pancreatectomy hemorrhage over a period of six-years at our tertiary care center. METHODS: Between 2014 and 2020, 616 pancreatic surgeries were performed and 25 patients had late hemorrhage (occurring > 24 hours post-operatively). The clinical parameters related to late hemorrhage, associated complications, embolization details, treatment success and their short-and long-term outcomes were analyzed. RESULTS: Sixteen of 25 patients had PSA on digital subtraction angiography. Embolization was performed in these patients with technical and clinical success rates of 94.1% and 100%, respectively. Compared to patients without PSA, patients with PSA had significant hemoglobin drop (2.5 g/dL vs. 1.5 g/dL, p = 0.01), higher incidence of sentinel bleed (50% vs. 11.1%, p = 0.05) and lower requirement for surgery for bleeding (0% vs. 44.4%, p = 0.02). Clincally relevant postoperative pancreatic fistula and bile leak were seen in 72% and 52% of patients, respectively. Eight of these embolized patients died due to sepsis. The long-term outcome was good, once the patients were discharged. CONCLUSION: Late hemorrhage after pancreatic surgery was associated with high mortality due to complications such as pancreatic fistula and bile leak. Sentinel bleeding was an important clinical indicator of PSA. Angiographic embolization is safe and effective without any adverse short or long-term outcomes.

Trends and Variations in Drain Use Following Pancreatoduodenectomy: Is Early Drain Removal Becoming More Common?

BACKGROUND: Although previous studies have noted the potential benefit of early drain removal (EDR) after pancreatoduodenectomy (PD), there is a paucity of data on the timing of drain removal utilizing a national database that reflect the "real world" setting. Given the ongoing controversy related to PD drain use and management, we sought to define trends in drain use among a large national cohort, as well as identify factors associated with EDR following PD. METHODS: The ACS NSQIP targeted pancreatectomy database was used to identify patients who underwent PD between 2014 and 2020. The trend in proportion of patients with EDR (removal ≤ POD3) as well as predictors of EDR were assessed. Risk-adjusted postoperative outcomes were evaluated by multivariable regression analysis. RESULTS: Among 14,356 patients, 16.2% of patients (N = 2324) experienced EDR, and the proportion of patients with EDR increased by 68% over the study period (2014: 10.9% vs. 2020: 18.3%, p < 0.001). Higher drain fluid amylase on POD1-3 [LogWorth (LW) = 44.3], operative time (LW = 33.2), and use of minimally invasive surgery (LW = 14.0) were associated with EDR. Additionally, EDR was associated with decreased risk of overall and serious morbidity, PD-related morbidity (e.g., pancreatic fistula), reoperation, prolonged length of stay and readmission (all p < 0.05). CONCLUSIONS: Routine drain placement remains a common practice among most surgeons. EDR following PD increased over time was associated with lower post-operative complications and shorter LOS. Despite evidence that EDR was safe and may even be associated with lower complications, only 1 in 6 patients were managed with EDR.

[Diffuse large B-cell lymphoma complicated with pancreatic fistula and peritonitis following initial chemotherapy].

A 59-year-old-woman complained of weight loss and abdominal pain. A CT scan revealed a 20 cm large retroperitoneal mass, and she was diagnosed with diffuse large B-cell lymphoma via biopsy of the mass. After 75% CHP therapy, she developed an acute abdomen and CT revealed generalized peritonitis. Amylase in the ascites fluid was elevated, and infiltration into the pancreas was suspected on CT before treatment, suggesting a pancreatic fistula caused by tumor shrinkage. Enterobacteria were found in ascites fluid culture, suggesting a gastrointestinal perforation complication. The patient was refractory to treatment, and death was confirmed due to progression of the primary disease. The pathological autopsy revealed diffuse pancreatic infiltration, suggesting that the pancreatic fistula was caused by pancreatic injury. Pancreatic fistula is a known complication of surgical procedures but is rarely caused by tumor shrinkage due to chemotherapy. Since there is no preventive method for pancreatic injury caused by tumor shrinkage, early diagnosis and early treatment of pancreatic fistula are critical, and ascites fluid analysis, including amylase, was thought to be useful for the diagnosis.

Surgical methods influence on the risk of anastomotic fistula after pancreaticoduodenectomy: a systematic review and network meta-analysis.

BACKGROUND: Pancreaticoduodenectomy is the first choice surgical intervention for the radical treatment of pancreatic tumors. However, an anastomotic fistula is a common complication after pancreaticoduodenectomy with a high mortality rate. With the development of minimally invasive surgery, open pancreaticoduodenectomy (OPD), laparoscopic pancreaticoduodenectomy (LPD), and robotic pancreaticoduodenectomy (RPD) are gaining interest. But the impact of these surgical methods on the risk of anastomosis has not been confirmed. Therefore, we aimed to integrate relevant clinical studies and explore the effects of these three surgical methods on the occurrence of anastomotic fistula after pancreaticoduodenectomy. METHODS: A systematic literature search was conducted for studies reporting the RPD, LPD, and OPD. Network meta-analysis of postoperative anastomotic fistula (Pancreatic fistula, biliary leakage, gastrointestinal fistula) was performed. RESULTS: Sixty-five studies including 10,026 patients were included in the network meta-analysis. The rank of risk probability of pancreatic fistula for RPD (0.00) was better than LPD (0.37) and OPD (0.62). Thus, the analysis suggests the rank of risk of the postoperative pancreatic fistula for RPD, LPD, and OPD. The rank of risk probability for biliary leakage was similar for RPD (0.15) and LPD (0.15), and both were better than OPD (0.68). CONCLUSIONS: This network meta-analysis provided ranking for three different types of pancreaticoduodenectomy. The RPD and LPD can effectively improve the quality of surgery and are safe as well as feasible for OPD.

Management of clinically relevant postoperative pancreatic fistula-related fluid collections after distal pancreatectomy.

BACKGROUND: Distal pancreatectomy is burdened by a high rate of clinically relevant postoperative pancreatic fistula (CR-POPF). The presence of a fistula-related abdominal collection often requires additional treatment such as antibiotics, percutaneous drainage, and endoscopic drainage thus prolonging patient recovery. Aim of this study was to describe the management of abdominal collections related to CR-POPF and identify variables associated with the need for invasive procedures. METHODS: A retrospective review of clinical data for patients who underwent distal pancreatectomy between 2015 and 2020 was conducted. All postoperative CT-scan imaging performed for clinical signs related to POPF was reviewed. The main outcome of the study was the need for procedural management (percutaneous or endoscopic) of CR-POPF-related fluid collections at 90 days after surgery. A multivariate regression analysis was adopted to analyze factors influencing procedural management of the collection. RESULTS: Five hundred sixteen patients were included in the study. Laparoscopic resection was performed in 290 patients (56%). At 90 days after surgery, CR-POPF occurred in 207 (40.1%) patients. A symptomatic collection related to fistula was observed in 130 patients (25.2%). Factors associated with fluid collections were increased body mass index (BMI) (25.5 versus 24, p = 0.001) and intraoperative blood loss (median of 250 versus 200 ml, p < 0.001). Procedural management was required in 70 patients (13.6%); 52 patients required interventional radiology and 18 endoscopic drainage. At multivariate analysis, risk factors for invasive procedures were the following CT-scan parameters: fluid collection diameter greater than 5 cm (OR 6.366, 95%CI 2.29-17.66, p = 0.001), presence of blood in the fluid collection (OR 10.618, 95%CI 1.94-58.09, p = 0.006), and enhancement of its walls (OR 4.073, 95%CI 1.22-13.57, p = 0.022). CONCLUSION: CR-POPF-related fluid collections affect about a quarter of patients undergoing distal pancreatectomy. CT-scan provides important information which can guide the management of the collection in a "step-up" fashion.

Laparoscopic pancreatic enucleation: cystic lesions and proximity to the Wirsung duct increase postoperative pancreatic fistula.

BACKGROUND: Risk factors for postoperative pancreatic fistula (POPF) following pancreatic enucleation by the open approach (OpenEN) are well known. However, ENs are more frequently performed laparoscopically (LapEN). The aim of this study was to analyze the risk factors of POPF following LapEN. METHODS AND PATIENTS: All patients in our prospective database who underwent LapEN were evaluated. We report the demographics, surgical, early and long-term outcomes. Numerous variables were analyzed to identify the risk factors of POPF. RESULTS: From 2008 to 2020, 650 laparoscopic pancreatic resections were performed including 64 EN (10%). The median age was 51 years old (17-79), median BMI was 24 (19-48), and 44 patients were women (69%). The main presentation was an incidental diagnosis (n = 40; 62%), pain (n= 10;16%), and hypoglycemia (n = 8;12%). The main indications were neuroendocrine tumors (40; 63%), mucinous cystadenomas (15; 23%), intraductal papillary mucinous neoplasie (3; 5%), and other benign cysts (6; 9%). Lesions were located on the distal pancreas (43; 67%), head (n = 17; 27%), and neck (4; 6%). The median size was 20 mm (9-110); 30 mm (20-110) for mucinous cystadenoma and 18 mm (8-33) for NET. The median operative time was 90 mn (30-330), median blood loss was 20 ml (0-800) ml, and there were no transfusions and one conversion. There were no mortalities and overall morbidity (n = 22; 34%) included grades B and C POPF (10;16%) and post-pancreatectomy hemorrhage (4; 6%). The median hospital stay was 7 days (3-42). There were no invaded lymph nodes and all cystic lesions were nonmalignant. After a mean follow-up of 24 months, there was no recurrence. The risk factors for grades B/C POPF were mucinous cystadenoma and proximity to the Wirsung duct < 3 mm. CONCLUSION: In this series, the outcome of LapEN was excellent with no mortality and a low rate of morbidity. However, the risk of POPF is increased with cystic lesions and those close to the Wirsung duct.

Preoperative C-Reactive Protein-to-Albumin Ratio Predicts Postoperative Pancreatic Fistula following Pancreatoduodenectomy: A Single-Center, Retrospective Study.

Postoperative pancreatic fistula (POPF) following pancreatoduodenectomy (PD) is a potentially lethal complication, and it is clinically important to determine its risk preoperatively. Although C-reactive protein-to-albumin ratio (CAR) is reported to be a prognostic marker for postoperative complications in several cancers, no evidence is currently available regarding the association between preoperative CAR and POPF following PD for periampullary tumors. This study examined whether preoperative CAR could predict POPF following PD. Clinical data were retrospectively retrieved from Ehime University Hospital. The optimal cut-off value for CAR was determined using receiver operating characteristic (ROC) curve analysis. This study enrolled 203 consecutive patients undergoing PD for periampullary tumors. The CAR value was significantly higher in the POPF group than in the non-POPF group (p < 0.001). According to the ROC curve analysis, the optimal cut-off value for CAR was 0.09. Patients with CAR ≥ 0.09 had higher incidence rates of POPF than their counterparts. CAR ≥ 0.09 was a risk factor for POPF in the multivariate logistic regression analysis (odds ratio 34.5, 95% confidence interval 11.75-101.38, p < 0.001). This is the first report demonstrating an association between CAR and POPF following PD. Preoperative CAR is an independent predictive marker for POPF following PD.

Appraising pancreatic fistula in pancreas transplantation: A comprehensive complication index based analysis of postoperative outcomes and predictors of graft survival.

BACKGROUND: A definition of pancreatic fistula specifically addressing pancreas transplantation (PT) is lacking. This study sought to characterize pancreatic fistula in this setting and to define its clinical relevance on the postoperative course and long-term graft survival (GS). METHODS: Consecutive simultaneous pancreas and kidney transplantations were analysed. The global postoperative course was assessed through the comprehensive complication index (CCI). PF was defined according to the original International Study Group for Pancreatic Surgery (ISGPS) definition. Predictors of poor postoperative course and GS were explored. RESULTS: Seventy-eight patients were analysed. Surgical morbidity was 48.7%, with severe complications occurring in 39.7%. Ninety-day mortality was 2.6%. PF occurred in 56.6% of patients, although its average clinical burden was low and did not correlate with either early or long-term outcomes. Peri-graft fluid collections, postoperative day (POD) 1 drain fluid amylase (DFA) ≥ 2200 U/L, and POD 5 DFA/serum amylase ratio ≥7.0 independently correlated with poor postoperative course. Perigraft fluid collections were associated with reduced GS. CONCLUSION: Conventionally defined pancreatic fistula is frequent following PT, although its clinical impact is negligible. To define clinically relevant PF, novel cut-offs for DFA might be pondered in a future series, while perigraft fluid collections should be strongly considered.

Comparison of short term surgical outcomes of male and female gastrointestinal surgeons in Japan: retrospective cohort study.

OBJECTIVE: To compare short term surgical outcomes between male and female gastrointestinal surgeons in Japan. DESIGN: Retrospective cohort study. SETTING: Data from the Japanese National Clinical Database (includes data on >95% of surgeries performed in Japan) (2013-17) and the Japanese Society of Gastroenterological Surgery. PARTICIPANTS: Male and female surgeons who performed distal gastrectomy, total gastrectomy, and low anterior resection. MAIN OUTCOME MEASURES: Surgical mortality, surgical mortality combined with postoperative complications, pancreatic fistula (distal gastrectomy/total gastrectomy only), and anastomotic leakage (low anterior resection only). The association of surgeons' gender with surgery related mortality and surgical complications was examined using multivariable logistic regression models adjusted for patient, surgeon, and hospital characteristics. RESULTS: A total of 149 193 distal gastrectomy surgeries (male surgeons: 140 971 (94.5%); female surgeons: 8222 (5.5%)); 63 417 gastrectomy surgeries (male surgeons: 59 915 (94.5%); female surgeons: 3502 (5.5%)); and 81 593 low anterior resection procedures (male surgeons: 77 864 (95.4%);female surgeons: 3729 (4.6%)) were done. On average, female surgeons had fewer post-registration years, operated on patients at higher risk, and did fewer laparoscopic surgeries than male surgeons. No significant difference was found between male and female surgeons in the adjusted risk for surgical mortality (adjusted odds ratio 0.98 (95% confidence interval 0.74 to 1.29) for distal gastrectomy; 0.83 (0.57 to 1.19) for total gastrectomy; 0.56 (0.30 to 1.05) for low anterior resection), surgical mortality combined with Clavien-Dindo grade ≥3 complications (adjusted odds ratio 1.03 (0.93 to 1.14) for distal gastrectomy; 0.92 (0.81 to 1.05) for total gastrectomy; 1.02 (0.91 to 1.15) for low anterior resection), pancreatic fistula (adjusted odds ratio 1.16 (0.97 to 1.38) for distal gastrectomy; 1.02 (0.84 to 1.23) for total gastrectomy), and anastomotic leakage (adjusted odds ratio 1.04 (0.92 to 1.18) for low anterior resection). CONCLUSION: This study found no significant adjusted risk difference in the outcomes of surgeries performed by male versus female gastrointestinal surgeons. Despite disadvantages, female surgeons take on patients at high risk. Greater access to surgical training for female physicians is warranted in Japan.