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1.
J Am Coll Surg ; 234(5): 928-937, 2022 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-35426407

RESUMO

BACKGROUND: Pancreatic duct diameter and pancreatic texture are important predictive factors for a postoperative pancreatic fistula (POPF) and are assessed intraoperatively by the surgeon. However, surgical evaluation is arbitrary and difficult to objectify, especially in minimally invasive approaches in pancreatic surgery. STUDY DESIGN: We conducted a retrospective analysis of 275 patients that underwent pancreatoduodenectomy from 2012 to 2019 at our institution. Pancreatic duct diameter and pancreatic fibrosis were assessed by histopathologic examination of the pancreatic resection margin using intraoperative frozen sections and correlated with the occurrence of POPF and clinically relevant POPF (CR-POPF). RESULTS: The POPF and CR-POPF rates were 27% and 19%, respectively. Univariate analysis indicated that the indication for surgery, the surgically determined pancreatic duct diameter, and pancreatic texture, as well as the histopathologically determined pancreatic duct diameter and pancreatic fibrosis were significant predictive factors for POPF and CR-POPF. A multivariate analysis revealed histopathologically determined pancreatic duct diameter and pancreatic fibrosis as independent risk factors for POPF (OR [odds ratio] 2.3 [1.1 to 4.5], p = 0.022 and OR 2.4 [1.1 to 5.1], p = 0.023, respectively) and CR-POPF (OR 2.2 [1.1 to 4.8], p = 0.037 and OR 2.6 [1.1 to 6.1], p = 0.036). CONCLUSIONS: Histopathologically determined pancreatic duct diameter and pancreatic fibrosis are quantitatively measurable independent risk factors for POPF and CR-POPF. An intraoperative objective histopathologic evaluation of these parameters using frozen sections could support the surgical assessment of the pancreatic duct diameter and the pancreatic texture.


Assuntos
Pancreatopatias , Fístula Pancreática , Fibrose , Humanos , Margens de Excisão , Pancreatopatias/cirurgia , Fístula Pancreática/diagnóstico , Fístula Pancreática/epidemiologia , Fístula Pancreática/etiologia , Pancreaticoduodenectomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Estudos Retrospectivos , Fatores de Risco
2.
Gan To Kagaku Ryoho ; 49(4): 478-481, 2022 Apr.
Artigo em Japonês | MEDLINE | ID: mdl-35444141

RESUMO

In performing PD, it is very important to understand the running and anatomy of the hepatic artery and the positional relation with the tumor before surgery, leading to planning a proper surgical procedure. In this case series, we report 2 cases in which radical resection was achieved by pancreaticoduodenectomy(PD)with combined hepatic artery resection(without reconstruction)while paying attention to the positional relationship between the bifurcated hepatic artery and the tumor in the head of the pancreas. Case 1: A 73-year-old man. He visited the hospital with jaundice and was diagnosed with distal bile duct cancer. Preoperative contrast-enhanced CT showed that the replaced right hepatic artery(RRHA)was involved by the tumor. Intraoperatively, it was confirmed by ultrasonography that the arterial blood flow in the right lobe of the liver was flowing from the left hepatic artery through the hepatic hilar plate after clamping the right hepatic artery. Thus, PD with combined RRHA resection(without reconstruction)was performed. After the operation, there was no problem with hepatic artery blood flow, and R0 resection was achieved. Case 2: A 65-year-old man. He visited the hospital with jaundice as the chief complaint and was diagnosed with pancreatic head cancer with encasement in the proper hepatic artery(PHA). In this case, the right hepatic artery branches from the SMA and the left hepatic artery branches from the left gastric artery. Intraoperative findings showed no problem with hepatic artery blood flow even after test-clamping the common hepatic artery, and the common hepatic artery was not reconstructed. There is no postoperative complication, and R0 resection was achieved pathologically. Conclusion: For pancreatic head tumors with hepatic artery infiltration, it is important to understand the anatomy of hepatic artery preoperatively and to confirm the intraoperative blood flow. In such cases, pancreaticoduodenectomy with hepatic artery resection may contribute to achieving R0.


Assuntos
Icterícia , Neoplasias Pancreáticas , Idoso , Artéria Hepática/cirurgia , Humanos , Icterícia/etiologia , Masculino , Pancreatectomia/efeitos adversos , Neoplasias Pancreáticas/complicações , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/efeitos adversos
4.
BJS Open ; 6(2)2022 Mar 08.
Artigo em Inglês | MEDLINE | ID: mdl-35470380

RESUMO

BACKGROUND: Recent studies have suggested postoperative acute pancreatitis (POAP) as a serious complication after pancreaticoduodenectomy (PD) and have speculated on its possible role in the pathogenesis of postoperative pancreatic fistula (POPF). This study aimed to assess the impact of POAP on post-PD outcomes and fistula risk score (FRS) performance in predicting POAP. METHODS: All PDs at Helsinki University Hospital between 2013 and 2020 were analysed. POAP was defined as a plasma amylase activity greater than the normal upper limit on postoperative day (POD) 1 and stratified as clinically relevant (CR)-POAP once C-reactive protein (CRP) reached or exceeded 180 mg/l, and non-CR-POAP once CRP was less than 180 mg/l on POD 2. The Comprehensive Complication Index (CCI) was used to assess total postoperative morbidity. Different FRSs were assessed using receiver operating characteristic curves. RESULTS: Of the 508 patients included, POAP occurred in 202 (39.8 per cent) patients, of whom 91 (17.9 per cent) had CR-POAP. The incidence of CR-POPF was 12.6 per cent (64 patients). Patients with non-CR-POAP had a similar morbidity to patients with no POAP (median CCI score 24.2 versus 22.6; P = 0.142), while CCI score was significantly higher (37.2) in patients with CR-POAP (P < 0.001). CR-POAP was associated with increased rates of CR-POPF, delayed gastric emptying, haemorrhage, and bile leak, while non-CR-POAP was associated only with CR-POPF. Ninety-day mortality was 1.6 per cent, 0.9 per cent, and 3.3 per cent in patients with no-POAP, non-CR-POAP, and CR-POAP, respectively. Updated alternative FRS showed the best performance in predicting CR-POAP (area under the curve 0.834). CONCLUSION: CR-POAP was associated with a higher CCI score, suggesting CR-POAP as a distinct entity from non-CR-POAP. FRSs can be used to assess the risk of CR-POAP.


Assuntos
Pancreaticoduodenectomia , Pancreatite , Doença Aguda , Proteína C-Reativa , Humanos , Fístula Pancreática/epidemiologia , Fístula Pancreática/etiologia , Pancreaticoduodenectomia/efeitos adversos , Pancreatite/epidemiologia , Pancreatite/etiologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Estudos Retrospectivos
7.
ANZ J Surg ; 92(5): 1097-1104, 2022 May.
Artigo em Inglês | MEDLINE | ID: mdl-35388582

RESUMO

BACKGROUND: The clinically relevant postoperative pancreatic fistula (CR-POPF) is still a challenging complication of pancreaticoduodenectomy (PD). This study aims to explore the predictors of CR-POPF after PD, including net parenchymal thickness (NPT) of pancreatic neck. METHODS: The consecutive patients who underwent PD at a tertiary hospital were retrospectively reviewed. Univariate and multivariate analyses were conducted on the perioperative data, which was mainly extracted from the objective data, containing the results from the laboratory tests and the imaging examination. NPT refers to the total thickness of pancreatic gland excluding main pancreatic duct (MPD) at the CT film. RESULTS: Univariate analyses showed that total serum bilirubin (TBiL) and albumin (ALB) levels, MPD size and NPT were significantly different between the patients with and without CR-POPF. The white blood cell count, the rate of intra-abdominal infection (IAI) and the postoperative length of hospital stay (LOS) were associated with the incidence of CR-POPF. The proportion of patients with pancreatic adenocarcinoma or chronic pancreatitis was significantly lower in the CR-POPF group than in the non-CR-POPF group. Multivariate analyses manifested that ALB ≤35 g/L and NPT >10 mm were two of the independent risk factors for CR-POPF. CONCLUSION: Preoperative ALB ≤35 g/L and NPT > 10 mm were both the independent predictors of CR-POPF. CR-POPF was associated with the higher IAI rate and the extended LOS.


Assuntos
Adenocarcinoma , Neoplasias Pancreáticas , Adenocarcinoma/cirurgia , Humanos , Fístula Pancreática/diagnóstico , Fístula Pancreática/epidemiologia , Fístula Pancreática/etiologia , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco
8.
BMC Surg ; 22(1): 127, 2022 Apr 02.
Artigo em Inglês | MEDLINE | ID: mdl-35366868

RESUMO

BACKGROUND: To explore the application value of free omental wrapping and modified pancreaticojejunostomy in pancreaticoduodenectomy (PD). METHODS: The clinical data of 175 patients who underwent pancreaticoduodenectomy from January 2015 to December 2020 were retrospectively analysed. In total, 86 cases were divided into Group A (omental wrapping and modified pancreaticojejunostomy) and 89 cases were divided into Group B (control group). The incidences of postoperative pancreatic fistula and other complications were compared between the two groups, and univariate and multivariate logistic regression analyses were used to determine the potential risk factors for postoperative pancreatic fistula. Risk factors associated with postoperative overall survival were identified using Cox regression. RESULTS: The incidences of grade B/C pancreatic fistula, bile leakage, delayed bleeding, and reoperation in Group A were lower than those in Group B, and the differences were statistically significant (P < 0.05). Group A had an earlier drainage tube extubation time, earlier return to normal diet time and shorter postoperative hospital stay than the control group (P < 0.05). The levels of C-reactive protein (CRP), interleukin-6 (IL-6), and procalcitonin (PCT) inflammatory factors 1, 3 and 7 days after surgery also showed significant. Univariate and multivariate logistic regression analyses showed that a body mass index (BMI) ≥ 24, pancreatic duct diameter less than 3 mm, no isolation of the greater omental flap and modified pancreaticojejunostomy were independent risk factors for pancreatic fistula (P < 0.05). Cox regression analysis showed that age ≥ 65 years old, body mass index ≥ 24, pancreatic duct diameter less than 3 mm, no isolation of the greater omental flap isolation and modified pancreaticojejunostomy, and malignant postoperative pathology were independent risk factors associated with postoperative overall survival (P < 0.05). CONCLUSIONS: Wrapping and isolating the modified pancreaticojejunostomy with free greater omentum can significantly reduce the incidence of postoperative pancreatic fistula and related complications, inhibit the development of inflammation, and favourably affect prognosis.


Assuntos
Pancreaticoduodenectomia , Pancreaticojejunostomia , Idoso , Humanos , Pancreatectomia/efeitos adversos , Fístula Pancreática/epidemiologia , Fístula Pancreática/etiologia , Pancreaticoduodenectomia/efeitos adversos , Pancreaticojejunostomia/efeitos adversos , Estudos Retrospectivos
9.
BMJ Open ; 12(4): e054138, 2022 Apr 13.
Artigo em Inglês | MEDLINE | ID: mdl-35418425

RESUMO

INTRODUCTION: Partial pancreatoduodenectomy (PD) is the treatment of choice for many malignant and benign diseases of the pancreatic head. Postoperative complication rates of up to 40% are regularly reported. One of the most common and potentially life-threatening complication is the postoperative pancreatic fistula (POPF). Parenchymal risk factors like main pancreatic duct diameter or texture of the pancreatic gland have already been identified in retrospective studies. The aim of this study is to evaluate the diagnostic value of parenchymal risk factors on POPF in a prospective manner. METHODS AND ANALYSIS: All patients scheduled for elective PD at the Department of General, Visceral and Transplantation Surgery of the University of Heidelberg will be screened for eligibility. As diagnostic factors, diameter and texture of the pancreatic gland as well as radiological and histopathological features will be recorded. Furthermore, the new four class risk classification system by the International Study Group of Pancreatic Surgery (ISGPS) will be recorded. The postoperative course will be monitored prospectively. The primary endpoint will be the association of the main pancreatic duct size and the texture of the pancreatic gland on POPF according to the updated ISGPS definition. The diagnostic value of the above-mentioned factors for POPF will be evaluated in a univariable and multivariable analysis. ETHICS AND DISSEMINATION: PARIS is a monocentric, prospective, diagnostic study to evaluate the association of parenchymal risk factors and the development of POPF approved by the Ethics Committee of the medical faculty of Heidelberg University (S-344/2019). Results will be available in 2022 and will be published at national and international meetings. With this knowledge, the intraoperative and perioperative decision-making process could be eased and improve the individual outcome of patient. TRIAL REGISTRATION NUMBER: DRKS00017184.


Assuntos
Fístula Pancreática , Pancreaticoduodenectomia , Humanos , Fístula Pancreática/epidemiologia , Fístula Pancreática/etiologia , Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/métodos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Risco
10.
Pancreatology ; 22(3): 421-426, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-35304104

RESUMO

BACKGROUND: Somatostatin analogues (SA) are currently used to prevent postoperative pancreatic fistula (POPF) development. However, its use is controversial. This study investigated the effect of different SA protocols on the incidence of POPF after pancreatoduodenectomy in a nationwide population. METHODS: All patients undergoing elective open pancreatoduodenectomy were included from the Dutch Pancreatic Cancer Audit (2014-2017). Patients were divided into six groups: no SA, octreotide, lanreotide, pasireotide, octreotide only in high-risk (HR) patients and lanreotide only in HR patients. Primary endpoint was POPF grade B/C. The updated alternative Fistula Risk Score was used to compare POPF rates across various risk scenarios. RESULTS: 1992 patients were included. Overall POPF rate was 13.1%. Lanreotide (10.0%), octreotide-HR (9.4%) and no protocol (12.7%) POPF rates were lower compared to the other protocols (varying from 15.1 to 19.1%, p = 0.001) in crude analysis. Sub-analysis in patients with HR of POPF showed a significantly lower rate of POPF when treated with lanreotide (10.0%) compared to no protocol, octreotide and pasireotide protocol (21.6-26.9%, p = 0.006). Octreotide-HR and lanreotide-HR protocol POPF rates were comparable to lanreotide protocol, however not significantly different from the other protocols. Multivariable regression analysis demonstrated lanreotide protocol to be positively associated with a low odds-ratio (OR) for POPF (OR 0.387, 95% CI 0.180-0.834, p = 0.015). In-hospital mortality rates were not affected. CONCLUSION: Use of lanreotide in all patients undergoing pancreatoduodenectomy has a potential protective effect on POPF development. Protocols for HR patients only might be favorable too. However, future studies are warranted to confirm these findings.


Assuntos
Fístula Pancreática , Pancreaticoduodenectomia , Humanos , Octreotida/uso terapêutico , Pâncreas/cirurgia , Fístula Pancreática/epidemiologia , Fístula Pancreática/etiologia , Fístula Pancreática/prevenção & controle , Pancreaticoduodenectomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Fatores de Risco , Somatostatina/uso terapêutico
11.
Can J Surg ; 65(2): E135-E142, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35236667

RESUMO

BACKGROUND: We aimed to define the appropriateness of interventions for the prevention of postoperative pancreatic fistulas (POPF) after pancreatectomy, given the lack of consistent data on this topic. METHODS: Using the RAND/UCLA appropriateness method, we assembled an expert panel to rate clinical scenarios for interventions to prevent POPF after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP). RESULTS: The following interventions were rated appropriate: individualized risk prediction for all patients; perioperative pasireotide administration for patients undergoing PD who have a soft pancreatic gland and a pancreatic duct size of less 3 mm and for patients undergoing DP; pancreaticogastrostomy for patients undergoing PD who have a soft pancreatic gland and pancreaticojejunostomy for PD for patients with a pancreatic duct size of 6 mm or greater regardless of pancreatic gland texture; duct-to-mucosa anastomosis for all patients undergoing PD and dunking anastomosis for patients undergoing PD who have a pancreatic duct size of less than 3 mm with a firm pancreatic gland; simple stapled and reinforced stapled transection for all DP; surgical drains for PD and DP in patients with a soft pancreatic gland; and open and minimally invasive surgery for DP and open surgery for PD. The following were rated inappropriate: gastrointestinal anastomosis for stump closure in all DP and omission of surgical drain in PD for patients with a pancreatic duct diameter less than 3 mm and a soft pancreatic gland. CONCLUSION: The expert panel identified appropriate and inappropriate scenarios for POPF prevention following pancreatectomy, to provide guidance to clinicians. However, the appropriateness of the interventions in the majority of the clinical scenarios was rated as uncertain, demonstrating equipoise.


Assuntos
Pancreatectomia , Fístula Pancreática , Canadá , Humanos , Pâncreas , Pancreatectomia/efeitos adversos , Fístula Pancreática/etiologia , Fístula Pancreática/prevenção & controle , Pancreaticoduodenectomia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle
12.
Cochrane Database Syst Rev ; 3: CD013462, 2022 03 15.
Artigo em Inglês | MEDLINE | ID: mdl-35289922

RESUMO

BACKGROUND: Postoperative pancreatic fistula is a common and serious complication following pancreaticoduodenectomy. Duct-to-mucosa pancreaticojejunostomy has been used in many centers to reconstruct pancreatic digestive continuity following pancreatoduodenectomy, however, its efficacy and safety are uncertain. OBJECTIVES: To assess the benefits and harms of duct-to-mucosa pancreaticojejunostomy versus other types of pancreaticojejunostomy for the reconstruction of pancreatic digestive continuity in participants undergoing pancreaticoduodenectomy, and to compare the effects of different duct-to-mucosa pancreaticojejunostomy techniques. SEARCH METHODS: We searched the Cochrane Library (2021, Issue 1), MEDLINE (1966 to 9 January 2021), Embase (1988 to 9 January 2021), and Science Citation Index Expanded (1982 to 9 January 2021). SELECTION CRITERIA: We included all randomized controlled trials (RCTs) that compared duct-to-mucosa pancreaticojejunostomy with other types of pancreaticojejunostomy (e.g. invagination pancreaticojejunostomy, binding pancreaticojejunostomy) in participants undergoing pancreaticoduodenectomy. We also included RCTs that compared different types of duct-to-mucosa pancreaticojejunostomy in participants undergoing pancreaticoduodenectomy. DATA COLLECTION AND ANALYSIS: Two review authors independently identified the studies for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CIs). For all analyses, we used the random-effects model. We used the Cochrane RoB 1 tool to assess the risk of bias. We used GRADE to assess the certainty of the evidence for all outcomes. MAIN RESULTS: We included 11 RCTs involving a total of 1696 participants in the review. One RCT was a dual-center study; the other 10 RCTs were single-center studies conducted in: China (4 studies); Japan (2 studies); USA (1 study); Egypt (1 study); Germany (1 study); India (1 study); and Italy (1 study). The mean age of participants ranged from 54 to 68 years. All RCTs were at high risk of bias. Duct-to-mucosa versus any other type of pancreaticojejunostomy We included 10 RCTs involving 1472 participants comparing duct-to-mucosa pancreaticojejunostomy with invagination pancreaticojejunostomy: 732 participants were randomized to the duct-to-mucosa group, and 740 participants were randomized to the invagination group after pancreaticoduodenectomy. Comparing the two techniques, the evidence is very uncertain for the rate of postoperative pancreatic fistula (grade B or C; RR 1.45, 95% CI 0.64 to 3.26; 7 studies, 1122 participants; very low-certainty evidence), postoperative mortality (RR 0.77, 95% CI 0.39 to 1.49; 10 studies, 1472 participants; very low-certainty evidence), rate of surgical reintervention (RR 1.12, 95% CI 0.65 to 1.95; 10 studies, 1472 participants; very low-certainty evidence), rate of postoperative bleeding (RR 0.85, 95% CI 0.51 to 1.42; 9 studies, 1275 participants; very low-certainty evidence), overall rate of surgical complications (RR 1.12, 95% CI 0.92 to 1.36; 5 studies, 750 participants; very low-certainty evidence), and length of hospital stay (MD -0.41 days, 95% CI -1.87 to 1.04; 4 studies, 658 participants; very low-certainty evidence). The studies did not report adverse events or quality of life outcomes. One type of duct-to-mucosa pancreaticojejunostomy versus a different type of duct-to-mucosa pancreaticojejunostomy We included one RCT involving 224 participants comparing duct-to-mucosa pancreaticojejunostomy using the modified Blumgart technique with duct-to-mucosa pancreaticojejunostomy using the traditional interrupted technique: 112 participants were randomized to the modified Blumgart group, and 112 participants were randomized to the traditional interrupted group after pancreaticoduodenectomy. Comparing the two techniques, the evidence is very uncertain for the rate of postoperative pancreatic fistula (grade B or C; RR 1.51, 95% CI 0.61 to 3.75; 1 study, 210 participants; very low-certainty evidence), postoperative mortality (there were no deaths in either group; 1 study, 210 participants; very low-certainty evidence), rate of surgical reintervention (RR 1.93, 95% CI 0.18 to 20.91; 1 study, 210 participants; very low-certainty evidence), rate of postoperative bleeding (RR 2.89, 95% CI 0.12 to 70.11; 1 study, 210 participants; very low-certainty evidence), overall rate of surgical complications (RR 1.10, 95% CI 0.80 to 1.51; 1 study, 210 participants; very low-certainty evidence), and length of hospital stay (15 days versus 15 days; 1 study, 210 participants; very low-certainty evidence). The study did not report adverse events or quality of life outcomes. AUTHORS' CONCLUSIONS: The evidence is very uncertain about the effects of duct-to-mucosa pancreaticojejunostomy compared to invagination pancreaticojejunostomy on any of the outcomes, including rate of postoperative pancreatic fistula (grade B or C), postoperative mortality, rate of surgical reintervention, rate of postoperative bleeding, overall rate of surgical complications, and length of hospital stay. The evidence is also very uncertain whether duct-to-mucosa pancreaticojejunostomy using the modified Blumgart technique is superior, equivalent or inferior to duct-to-mucosa pancreaticojejunostomy using the traditional interrupted technique. None of the studies reported adverse events or quality of life outcomes.


Assuntos
Fístula Pancreática , Pancreaticoduodenectomia , Idoso , Humanos , Pessoa de Meia-Idade , Membrana Mucosa , Pancreatectomia/efeitos adversos , Fístula Pancreática/etiologia , Fístula Pancreática/prevenção & controle , Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/métodos , Pancreaticojejunostomia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Ensaios Clínicos Controlados Aleatórios como Assunto
13.
Sci Rep ; 12(1): 4064, 2022 03 08.
Artigo em Inglês | MEDLINE | ID: mdl-35260701

RESUMO

Clinically relevant postoperative pancreatic fistula (CR-POPF) is a common severe surgical complication after pancreatic surgery. Current risk stratification systems mostly rely on intraoperatively assessed factors like manually determined gland texture or blood loss. We developed a preoperatively available image-based risk score predicting CR-POPF as a complication of pancreatic head resection. Frequency of CR-POPF and occurrence of salvage completion pancreatectomy during the hospital stay were associated with an intraoperative surgical (sFRS) and image-based preoperative CT-based (rFRS) fistula risk score, both considering pancreatic gland texture, pancreatic duct diameter and pathology, in 195 patients undergoing pancreatic head resection. Based on its association with fistula-related outcome, radiologically estimated pancreatic remnant volume was included in a preoperative (preFRS) score for POPF risk stratification. Intraoperatively assessed pancreatic duct diameter (p < 0.001), gland texture (p < 0.001) and high-risk pathology (p < 0.001) as well as radiographically determined pancreatic duct diameter (p < 0.001), gland texture (p < 0.001), high-risk pathology (p = 0.001), and estimated pancreatic remnant volume (p < 0.001) correlated with the risk of CR-POPF development. PreFRS predicted the risk of CR-POPF development (AUC = 0.83) and correlated with the risk of rescue completion pancreatectomy. In summary, preFRS facilitates preoperative POPF risk stratification in patients undergoing pancreatic head resection, enabling individualized therapeutic approaches and optimized perioperative management.


Assuntos
Fístula Pancreática , Pancreaticoduodenectomia , Humanos , Pâncreas/diagnóstico por imagem , Pâncreas/cirurgia , Pancreatectomia/efeitos adversos , Fístula Pancreática/diagnóstico por imagem , Fístula Pancreática/epidemiologia , Fístula Pancreática/etiologia , Pancreaticoduodenectomia/efeitos adversos , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco
15.
Surg Infect (Larchmt) ; 23(4): 351-356, 2022 May.
Artigo em Inglês | MEDLINE | ID: mdl-35231198

RESUMO

Background: Infectious complications after pancreaticoduodenectomy (PD) are a major cause of morbidity. The association of bactibilia with the occurrence of surgical site infection (SSI) is debatable. Patients and Methods: Consecutive patients who underwent PD between July 2019 and December 2020 were included. All patients underwent standard pre-operative preparation and imaging. Pre-operative biliary drainage (PBD) was done as clinically indicated. A bile sample was collected just before the transection of common bile duct (CBD). Post-operative outcomes including SSI were analyzed. Results: Fifty-four patients were assessed for enrollment; 50 were found to be resectable during surgery and were included. The incidence of bactibilia was 46%. Nineteen (38%) patients developed SSIs and the occurrence was higher in patients who had positive bile culture (14 [60.8%] vs. 5 [18.5%]; p = 0.002). A similar organism between bile culture and SSI was seen in nine (64.2%) of 14 patients. Patients who had positive bile culture had more frequent change of antibiotic (16 [69%] vs. 8 [29.6%]; p = 0.005) and required prolonged duration of postoperative antibiotic agents (12 days [IQR, 8-14] vs. 8 days [IQR, 6-10]; p = 0.003). There was no association between bile culture growth and development of post-operative pancreatic fistula, delayed gastric emptying, and post-operative pancreatic hemorrhage. Patients with bactibilia had prolonged post-operative stay (17 days [IQR, 11-20] vs. 11 days [IQR, 8-14]; p = 0.010) and severe post-operative complications (8 [34.7%] vs. 2 [7.4%]; p = 0.008). Conclusions: Bactibilia is associated with the development of SSI and may provide a guide in selection of antibiotics.


Assuntos
Bile , Pancreaticoduodenectomia , Antibacterianos/uso terapêutico , Drenagem/efeitos adversos , Humanos , Fístula Pancreática/epidemiologia , Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/métodos , Complicações Pós-Operatórias/tratamento farmacológico , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/tratamento farmacológico
16.
World J Surg ; 46(6): 1465-1473, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-35306589

RESUMO

BACKGROUND: Late-onset biliary complications (LBC) after pancreatoduodenectomy (PD) can be serious. This study aimed to clarify the frequency and risk factors of severe LBC after PD. METHODS: We defined LBC as biliary complications occurring 3 months after PD and severe LBC as cases that required intensive care. A total of 318 patients who underwent PD between 2010 and 2018 with at least 1 year of postoperative follow-up were evaluated. RESULTS: Hospitalization for severe LBC was required in 59 patients (19%), of whom 20 had liver abscesses (6.3%); 18, acute cholangitis (5.7%); 12, biliary stones (3.8%); and 21, biliary strictures (6.6%). Interventional radiological or endoscopic treatment was required in 32 patients (10%), of whom 9 had a benign primary disease with biliary stones and/or strictures. Thirteen of the remaining 23 patients with a malignant primary disease had liver abscesses and cholangitis. Significant independent risk factors for severe LBC in patients with malignant primary disease were recurrence around the hepaticojejunostomy (odds ratio 6.5, P = 0.013) and chemotherapy (odds ratio 13.5, P < 0.001). CONCLUSIONS: Severe LBC after PD may occur regardless of whether the primary disease is benign or malignant. The course of severe LBC differs according to the primary disease, and therefore, appropriate follow-up and optimal treatment should be recommended according to the condition of the patient and the disease state.


Assuntos
Colangite , Cálculos Biliares , Abscesso Hepático , Colangite/etiologia , Colangite/cirurgia , Constrição Patológica/etiologia , Cálculos Biliares/cirurgia , Humanos , Abscesso Hepático/etiologia , Pancreaticoduodenectomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Estudos Retrospectivos
17.
Turk J Gastroenterol ; 33(2): 119-126, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-35238780

RESUMO

BACKGROUND: Surgeons continue to be concerned about complications after pancreaticoduodenectomy, especially postoperative pancreatic fistula. Among the factors that cause postoperative pancreatic fistula, the pancreaticojejunostomy technique has stood out in recent studies. In this study, we aimed to compare the surgical outcomes, especially POPF, of the modified Blumgart and the traditional anastomosis techniques in patients who underwent pancreaticoduodenectomy. METHODS: A total of 144 patients who underwent pancreaticoduodenectomy were divided into 2 groups according to the performed pancreaticojejunostomy technique (modified Blumgart anastomosis, n = 91 and traditional anastomosis, n = 53). Preoperative clinicodemographic data, perioperative findings, and postoperative results were compared between the groups. Additionally, factors associated with clinically relevant postoperative pancreatic fistula were analyzed. RESULTS: The modified Blumgart anastomosis group had lower clinically relevant postoperative pancreatic fistula rate than traditional anastomosis group (n = 8 (8.8%) versus n = 14 (26.4%), P = .005). On the contrary, the biochemical leakage rate was higher in the modified Blumgart anastomosis group (n = 30 (33%) versus n = 9 (17%), P = .037). While postoperative pancreatic fistula-related reoperation rate was lower (n = 2 (2.2%) versus n = 7 (13.2%), P = .013), the length of hospital stay was also shorter (11 days (5-47 days) versus 21 days (6-46 days), P < .001) in the modified Blumgart anastomosis group. Univariate and multivariate analyses revealed that modified Blumgart anastomosis was an independent and negative predictive factor for clinically relevant postoperative pancreatic fistula (odds ratio = 0.274, 95% confidence interval = 0.103-0.728, P = .009). CONCLUSION: Compared to the traditional anastomosis, modified Blumgart anastomosis decreases the rate of transition from biochemical leakage to clinically relevant postoperative pancreatic fistula and postoperative pancreatic fistula-related reoperation and also shortens the length of hospital stay. In addition, modified Blumgart anastomosis is an independent and negative predictive factor for the development of clinically relevant postoperative pancreatic fistula.


Assuntos
Fístula Pancreática , Pancreaticoduodenectomia , Anastomose Cirúrgica/efeitos adversos , Anastomose Cirúrgica/métodos , Humanos , Fístula Pancreática/epidemiologia , Fístula Pancreática/etiologia , Fístula Pancreática/prevenção & controle , Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/métodos , Pancreaticojejunostomia/efeitos adversos , Pancreaticojejunostomia/métodos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Resultado do Tratamento
18.
J Am Coll Surg ; 234(4): 677-684, 2022 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-35290288

RESUMO

BACKGROUND: Robotic surgery is a burgeoning minimally invasive approach to pancreaticoduodenectomy. This study was undertaken to compare survival after robotic vs "open" pancreaticoduodenectomy for ductal adenocarcinoma using propensity score-matched patients. STUDY DESIGN: With institutional review board approval, we prospectively followed 521 patients who underwent robotic (n = 311) or open (n = 210) pancreaticoduodenectomy. Patients who underwent robotic (n = 75) or open (n = 75) pancreaticoduodenectomy were propensity score-matched by age, sex, and American Joint Committee on Cancer stage. Neoadjuvant therapy was rarely administered, and adjuvant therapy was stressed (FOLFIRINOX for patients <70 years of age and gemcitabine + nab-paclitaxel for patients >70 years of age). Data are presented as median (mean ± SD). RESULTS: Operative duration was longer and estimated blood loss and length of stay were less with robotic pancreaticoduodenectomy (421 [409 ± 94.0] vs 267 [254 ± 81.2] minutes; 307 [(150 ± 605.3] vs 444 [255 ± 353.1] mL; 7 [5 ± 5.1] vs 11 [8 ± 9.5] days; p < 0.00001 for all). There were no differences in complications (Clavien-Dindo class ≥III, p = 0.30), in-hospital mortality (p = 0.61), or 30-day readmission rates (p = 0.19). Median survival after robotic vs open pancreaticoduodenectomy was 37 vs 24 months (p = 0.08). For propensity score-matched patients, operative duration for robotic pancreaticoduodenectomy was longer (442 [438 ± 117.7] vs 261 [249 ± 67.1] minutes) and estimated blood loss was less (269 [200 ± 296.1] vs 468 [300 ± 394.9] mL), as was length of stay (7 [5 ± 5.1] vs 10 [7 ± 8.6] days; p < 0.00001 for all). There were no differences in complication rates (Clavien-Dindo class ≥ III, p = 0.31) or in-hospital mortality (p = 0.40); 30-day readmissions were fewer after robotic pancreaticoduodenectomy (7% vs 20%, p = 0.03). Median survival for the robotic vs the open approach was 41 vs 17 months (p = 0.02). CONCLUSION: Patients that underwent robotic pancreaticoduodenectomy had longer operations, less estimated blood loss, shorter length of stay, and fewer 30-day readmissions; they lived much longer than patients who underwent open pancreaticoduodenectomy. We believe that robotic pancreaticoduodenectomy provides salutary and survival benefits for reasons yet unknown.


Assuntos
Laparoscopia , Neoplasias Pancreáticas , Procedimentos Cirúrgicos Robóticos , Protocolos de Quimioterapia Combinada Antineoplásica , Humanos , Tempo de Internação , Pancreaticoduodenectomia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Pontuação de Propensão , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos
19.
Chirurgia (Bucur) ; 117(1): 94-100, 2022 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-35272759

RESUMO

Anastomotic fistulae are the most common and dreaded postoperative complications of pancreaticoduodenectomy. Delayed gastric emptying (DGE) and slow recovery of bowel function are contributing causes for postoperative pancreatic fistula (PoPF) that should be taken into consideration. The present study evaluates data from 17 consecutive cases that underwent pancreaticoduodenectomy for pancreatic adenocarcinoma with pancreaticojejunal anastomosis and circular stapled mechanical gastrojejunal anastomosis instead of the standard terminolateral technique. Three patients developed Grade A DGE (one also developed grade B PoPF) and one patient required reinsertion of the nasogastric tube due to Grade B PoPF. Overall, the incidence of DGE was 23.5%. Three patients developed Grade B pancreatic fistulae that were successfully managed conservatively. Twelve patients resumed early bowel movement within 4 days, two reinterventions were required for postoperative bleeding. Mean hospital stay was 11.5 days. Patients with DGE had a mean hospital stay of 14.5 days. No gastrojejunostomy leak was encountered. Mortality was nil. Therefore we consider the posterior circular stapled gastrojejunostomy a simple, reproducible, safe technical alternative for avoiding DGE and consequently help lower the risk of PoPF, increased costs associated with prolonged hospital stay and an improved postoperative quality of life.


Assuntos
Adenocarcinoma , Derivação Gástrica , Gastroparesia , Neoplasias Pancreáticas , Adenocarcinoma/complicações , Adenocarcinoma/cirurgia , Derivação Gástrica/efeitos adversos , Derivação Gástrica/métodos , Gastroparesia/etiologia , Humanos , Neoplasias Pancreáticas/complicações , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/efeitos adversos , Pancreaticoduodenectomia/métodos , Qualidade de Vida , Resultado do Tratamento
20.
BMC Oral Health ; 22(1): 52, 2022 03 03.
Artigo em Inglês | MEDLINE | ID: mdl-35241043

RESUMO

BACKGROUND: Zinc is mainly absorbed in the duodenum and proximal jejunum, which are removed during pancreaticoduodenectomy (PD). Little is known about the adverse oral events and skin disorders caused by zinc deficiency after PD. Herein, we reviewed studies on the development of zinc deficiency after PD and reported about a patient with zinc deficiency after PD who required home intravenous zinc replacement. CASE PRESENTATION: A 73-year-old woman with glossitis, taste disorder, and acrodermatitis enteropathica-like eruption on her fingers presented to the Division of Dentistry and Oral Surgery 69 days after PD. Her serum zinc level markedly decreased to 30 µg/dL. Oral zinc administration was inadequate to treat hypozincemia after PD; therefore, multi-trace elements were injected intravenously during readmission. Her serum zinc levels recovered, and her lesions gradually improved. Furthermore, a central venous port was implanted to maintain normal serum zinc levels, and she continued self-injecting zinc at home. CONCLUSIONS: Zinc deficiency after PD rarely occurs. The clinical oncologist community, including dentists responsible for the oral care of cancer patients, should be aware of the oral adverse events, such as dysgeusia, glossitis, and oral pain, associated with zinc deficiency after cancer surgery and that induced by chemotherapy or head and neck radiation therapy.


Assuntos
Acrodermatite , Pancreaticoduodenectomia , Acrodermatite/tratamento farmacológico , Acrodermatite/etiologia , Acrodermatite/patologia , Idoso , Suplementos Nutricionais , Feminino , Humanos , Pancreaticoduodenectomia/efeitos adversos , Zinco
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