Schematic Pancreatic Configuration: A Risk Assessment for Postoperative Pancreatic Fistula After Pancreaticoduodenectomy

Introduction

Postoperative pancreatic fistula (POPF) remains a serious complication after pancreaticoduodenectomy (PD). Preoperative risk assessment of POPF is desirable in careful preparation for operation. The aim of this study was to assess simple and accurate risk factors for clinically relevant POPF based on a schematic understanding of the pancreatic configuration using preoperative multidetector computed tomography.

Methods

Three hundred and eighteen consecutive patients who underwent PD in the National Cancer Center Hospital East between November 2006 and March 2013 were investigated. Pre-, intra-, and postoperative clinicopathological findings as well as pancreatic configuration data were analyzed for the risk of clinically relevant POPF. POPF was defined according to the International Study Group of Pancreatic Fistula classification. POPF grade A occurred in 52 patients (16.4 %), grade B in 84 (26.4 %), and grade C in 6 (1.9 %).

Conclusions

Independent risk factors for POPF grade B/C included main pancreatic duct diameter (MPDd) < 2 mm (P = 0.001), parenchymal thickness ≥ 8 mm (P = 0.018), not performing portal vein/superior mesenteric vein resection (P = 0.004), and amylase level of drainage fluid on postoperative day 3 ≥ 375 IU/L (P < 0.001). Pancreatic configuration data including MPDd and parenchymal thickness were good indicators of clinically relevant POPF.     

Pancreatic Anastomotic Leakage after Pancreaticoduodenectomy. Risk factors, Clinical predictors, and Management (Single Center Experience)

Background

Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) remains a challenge even at high-volume centers.

Methods

This study was designed to analyze perioperative risk factors for POPF after PD and evaluate the factors that predict the extent and severity of leak. Demographic data, preoperative, intraoperative, and postoperative variables were collected.

Results

A total of 471 consecutive patients underwent PD in our center. Fifty-seven patients (12.1 %) developed a POPF of any type; 21 patients (4.5 %) had a fistula type A, 22 patients (4.7 %) had a fistula type B, and the remaining 14 patients (3 %) had a POPF type C. Cirrhotic liver (P = 0.05), BMI > 25 kg/m² (P = 0.0001), soft pancreas (P = 0.04), pancreatic duct diameter <3 mm (0.0001), pancreatic duct located <3 mm from the posterior border (P = 0.02) were significantly associated with POPF. With the multivariate analysis, both BMI and pancreatic duct diameter were demonstrated to be independent factors. The hospital mortality in this series was 11 patients (2.3 %), and the development of POPF type C was associated with a significantly increased mortality (7/14 patients). The following factors were predictors of clinically evident POPF: a postoperative day (POD) 1 and 5 drain amylase level >4,000 IU/L, WBC, pancreatic duct diameter <3 mm, and pancreatic texture.

Conclusions

Cirrhotic liver, BMI, soft pancreas, pancreatic duct diameter <3 mm, pancreatic duct near the posterior border are risk factors for development of POPF. In addition a drain amylase level >4,000 IU/L on POD 1 and 5, WBC, pancreatic duct diameter, pancreatic texture may be predictors of POPF B, C.     

Impact of the highest amylase level in drain fluid on surgical outcomes and postoperative interventions in patients undergoing pancreaticoduodenectomy

ObjectivesThe clinical significance of the highest drain fluid amylase (DFA) level beyond pancreaticoduodenectomy (PD) postoperative day three (POD 3) remains unclear. This study investigated the impact of highest DFA level beyond POD 3 on postoperative pancreatic fistula (POPF) severity and outcomes of patients undergoing PD with POPF.MethodsPatient demographics of biochemical POPF and clinically relevant POPF (CR-POPF) were compared. Predictive factors were assessed using binary logistic regression. Receiver operating characteristic curve analysis was performed to determine the optimal cutoff value of highest DFA (beyond POD 3). We compared length of hospital stay, surgical mortality rates, and need for postoperative interventions by highest DFA level.ResultsPatients with CR-POPF had an older age (p = 0.039), required intraoperative blood transfusion (p = 0.006), and had greater highest DFA levels (p = 0.001) than those with biochemical POPF. The optimal highest DFA cutoff was 2014.5 U/L. Multivariate analysis showed that percentage of patients with intraoperative blood transfusion (p = 0.011; odds ratio, 3.716) and a highest DFA > 2014.5 U/L beyond POD 3 (p = 0.001; odds ratio, 5.722) was predictive of CR-POPF.ConclusionHighest DFA > 2014.5 U/L beyond POD 3 is an independent predictor for CR-POPF. At a highest DFA >2014.5 U/L, 30-day surgical mortality rate, length of stay, and need for postoperative interventions did not differ.     

Usefulness of Drain Amylase, Serum C-Reactive Protein Levels and Body Temperature to Predict Postoperative Pancreatic Fistula After Pancreaticoduodenectomy

Background

Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) is a worrisome and life-threatening complication. Recently, early drain removal has been recommended as a means of preventing POPF. The present study sought to determine how to distinguish clinical POPF from non-clinical POPF in the early postoperative period after PD to aid in early drain removal.

Methods

From March 2002 through December 2010, 176 patients underwent PD and were enrolled in this study to examine factors predictive of clinical POPF after PD. POPF was defined and classified according to the International Study Group of Pancreatic Surgery guideline, and grade B/C POPF was defined as clinical POPF.

Results

Grade A POPF occurred in 39 (22.2 %) patients, grade B in 19 (10.8 %) patients, and grade C in 11 (6.3 %) patients. Clinical POPF (grade B/C) occurred in 17.1 % of patients. Multivariate analysis revealed male gender and body mass index (BMI) ≥22.5 kg/m² to be the independent preoperative risk factors predictive of POPF. Receiver operating characteristic curves showed that the combination of drain amylase ≥750 IU/L, C-reactive protein (CRP) ≥20 mg/dL, and body temperature ≥37.5 °C on postoperative day 3 could effectively distinguish clinical POPF from non-clinical POPF. Sensitivity, specificity, and accuracy were 84.6, 98.2, and 95.7 %, respectively.

Conclusions

Male gender and BMI ≥22.5 were the independent preoperative predictive risk factors for POPF. We assume that when amylase is <750 IU/L, serum CRP is <20 mg/dL, and body temperature is <37.5 °C the drain can safely be removed, even if POPF is indicated.     

Higher cumulative fluid following a pancreaticoduodenectomy as a single modifiable factor for post-operative pancreatic fistula: An analysis of risk factor

BackgroundPostoperative pancreatic fistula (POPF) is one of the major complications after pancreaticoduodenectomy. There have been many studies into the risk factors determining POPF. Some studies have reported a higher peri-operative fluid balance associated with POPF, however, the pertinent findings remain controversial. The aims of this study were to determine risk factors of clinically relevant-post operative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy and an association between peri-operative fluid balance and the incidence of CR-POPF.Materials and methodsThis is a retrospective cohort study included all adult patients who underwent an elective open pancreaticoduodenectomy in our center from 2005 to 2018. Patients who did not have POPF related data were excluded from study. We divided patients into CR-POPF and no CR-POPF group. Peri-operative data including amount and type of fluid were compared between two groups. Logistic regression analysis was used to identify the independent risk factors of CR-POPF.ResultsThere were 223 pancreaticoduodenectomies done in our center during that period. The incidence of CR-POPF was 15.2 %. Patients in CR-POPF group had significant higher BMI, higher serum globulin level, smaller pancreatic duct diameter and higher cumulative fluid balance per body weight (FBPBW) at post-operative day 3. Multivariable analysis showed BMI >23 kg/m², diagnosis other than pancreatic duct adenocarcinoma or chronic pancreatitis and higher cumulative FBPBW at post-operative day 3 were the independent risk factors for CR-POPF.ConclusionsPost-operative fluid balance was the post-operative modifiable risk factor to reduce CR-POPF. Higher positive post-operative fluid balance should be avoided especially in higher CR-POPF risk patients.     

An invaginated pancreaticogastrostomy following subtotal stomach-preserving pancreaticoduodenectomy: A prospective observational study

Background/objectivePostoperative pancreatic fistula (POPF) leads to life-threatening complications after pancreaticoduodenectomy (PD). Pancreaticogastrostomy (PG) often adopted as a reconstruction technique after PD to prevent POPF. Delayed gastric emptying (DGE) following PD is the most common complication that compromises the quality of life. Subtotal stomach-preserving PD (SSPPD) preserves the pooling ability of the stomach and minimize the occurrence of DGE. This study aimed to describe our PG technique following SSPPD and evaluate the perioperative outcomes.MethodsThe study included patients who underwent PG following SSPPD from August 2013 to July 2020 at our institution. An invaginated PG was performed by one-layer eight interrupted sutures with a lost stent. Patients’ demographics and perioperative outcomes were documented.ResultsThis technique was applied in 72 patients with a median age of 75 years. The median operative time was 342 min. The clinically relevant POPF, DGE and post-pancreatectomy hemorrhage was 4 (5.6%), 5 (6.9%), and 10 (13.9%), respectively. Although the drain fluid amylase concentration on postoperative day 3 was significantly higher in clinically relevant POPF (CR-POPF) positive group (median, 2006 U/L vs. 74 U/L in CR-POPF negative group, p = 0.002), none of the risk factors including disease pathology, pancreatic duct diameter, texture of pancreas and excessive blood loss were significantly associated with CR-POPF. Other morbidity ≥ Clavien-Dindo classification II occurred in 29 patients (40.3%). The 90-days operative mortality was two (2.8%).ConclusionsThis novel method of one-layer invaginated PG following SSPPD is safe and dependable procedure with acceptable morbidity and mortality.     

Value of monitoring postoperative intra‐abdominal drainage fluid for the diagnosis of postoperative pancreatic fistula: Results of a prospective study in 134 patients

Objective: To evaluate the value of monitoring postoperative intra‐abdominal drainage in the diagnosis and treatment of postoperative pancreatic fistula (POPF). Methods: Intra‐abdominal drainage adjacent to the pacreaticoenteric anastomosis was prospectively collected from 134 patients accepted for pancreatic surgery in our department between November 2005 and August 2007 to determine the concentration of amylase and bacteriology. Also, the clinical outcome of each patient was recorded. The international study group definition was used to diagnose POPF. Results: The overall incidence of POPF was 39.6% in 53 patients diagnosed as POPF, among which 50 patients (37.3%, 50/134) were graded as I/II of POPF. The rising trend of the amylase level in the drainage fluid (P = 0.001), the texture of the pancreatic remnant (P = 0.042), and the amylase level on the 3rd and 7th postoperative days demonstrated good diagnostic values in univariate analysis (P < 0.001). The amylase value in drains on the 3rd postoperative day (POD3) and the 7th postoperative day (POD7) were the predicting factors (P < 0.001) of POPF by multivariate analysis. Conclusions: The amylase values in drains on the 3rd postoperative day and on the 7th postoperative day (POD7) were both valuable factors in the diagnoses of POPF. It is very important to monitor the dynamic change of amylase concentration in the drainage, not the result of a single test. These clinical factors could help us to detect the incidence of POPF earlier.     

Postoperative Serum Amylase Predicts Pancreatic Fistula Formation Following Pancreaticoduodenectomy

Introduction

Early identification of patients at risk for developing pancreatic fistula (PF) after pancreaticoduodenectomy (PD) may facilitate prevention or treatment strategies aimed at reducing its associated morbidity.

Materials and Methods

A retrospective review of 176 consecutive PD performed between 2006 and 2011 was conducted in order to analyze the association between the serum amylase on postoperative day 1 (POD1) and the development of PF.

Results

Serum amylase was recorded on POD1 in 146 of 176 PD cases (83.0 %). Twenty-seven patients (18.5 %) developed a postoperative PF: 6 type A, 19 type B, and 2 type C. Patients with a PF had a mean serum amylase on POD1 of 659?±?581 compared to 246?±?368 in those without a fistula (p?<?0.001). On logistic regression, a serum amylase >140 U/L on POD1 was strongly associated with developing a PF (OR, 5.48; 95 % CI, 1.94–15.44). Sensitivity and specificity of a postoperative serum amylase >140 U/L was 81.5 and 55.5 %, respectively. Positive and negative predictive values were 29.3 and 93.0 %, respectively.

Conclusion

An elevated serum amylase on POD1 may be used, in addition to other prognostic factors, to help stratify risk for developing PF following PD.     

血清淀粉酶与胰十二指肠切除术后胰瘘形成的相关性

目的探讨血清淀粉酶与胰十二指肠切除术(PD)后胰瘘形成(PF)的相关性。方法回顾性研究2009-06-2013-04间就诊的176例接受PD的患者,分析患者的基线资料及术后第1天(POD1)血清淀粉酶和发生PF的关系。结果 176例患者中,146例监测血清淀粉酶(83.0%),其中27例(18.5%)患者在术后发生PF:6例A型、19例B型和2例C型。发生PF患者POD1平均血清淀粉酶显著高于未发生PF的患者[(659±581)U/L比(246±368)U/L,P<0.001]。多因素回归分析显示,POD1血清淀粉酶>140U/L与发生PF显著相关(OR,5.48;95%CI,1.94¹5.44,P<0.01)。术后血清淀粉酶>140 U/L的敏感性和特异性分别为81.5%和55.5%;阳性和阴性预测值分别为29.3%和93.0%。结论除其他预后因素外,POD1血清淀粉酶升高有助于评估PD术后发生PF的风险。     

How Do We Predict the Clinically Relevant Pancreatic Fistula After Pancreaticoduodenectomy?—An Analysis in 244 Consecutive Patients

Background  

The most important problem in pancreatic fistula is whether one can distinguish clinical pancreatic fistula, grade B + C fistula by the International Study Group on Pancreatic Fistula (ISGPF), from transient pancreatic fistula (grade A), in the early period after pancreaticoduodenectomy (PD). It remains unclear what predictive risk factors can precisely predict which clinical relevant or transient pancreatic fistula when diagnosed pancreatic fistula on POD3 by ISGPF criteria.     

Risk factors, predictors and prevention of pancreatic fistula formation after pancreatoduodenectomy

Background/Purpose Although the operative mortality and morbidity associated with pancreatoduodenectomy (PD) has been decreasing, pancreatic fistula remains a potentially fatal complication. The aim of this study was to identify risk factors and predictors of pancreatic fistula formation, and ways to prevent this in a consecutive series of PD patients in a single institution. Methods The association between pancreatic fistula formation and various clinical parameters was investigated in 50 patients who underwent PD at Kochi Medical School from January 1991 through February 2006. Results The incidence of pancreatic fistula in these patients was 28%. Multivariate analysis identified three independent factors correlated with the occurrence of pancreatic fistula: (1) absence of fibrotic texture of the pancreas examined intraoperatively (relative risk [RR], 1.6; 95% confidence interval [CI], 1.2–2.0; P = 0.01); (2) serum amylase concentration greater than 195 U/l (1.69 times the normal upper limit) on the first postoperative day (RR, 2.4; 95% CI, 1.0–5.7; P = 0.01); and (3) not having early postoperative enteral nutrition (RR, 3.2; 95% CI, 1.2–9.0; P = 0.004). Conclusions Soft texture of the pancreas and increased serum amylase the day after PD are both risk factors with predictive value for pancreatic fistula. The incidence of fistula formation is reduced by early postoperative enteral nutrition.     

Postoperative Pancreatic Fistula in Surgery for Perihilar Cholangiocarcinoma

There are numerous studies on postoperative pancreatic fistula (POPF) in pancreatic surgery but few studies on POPF in extrahepatic bile duct resection with or without hepatectomy for perihilar cholangiocarcinoma (PHCC). The aim of this study is to investigate the incidence of and risk factors for POPF in this challenging surgery. All consecutive patients who underwent surgical resection for presumed PHCC between January 2008 and December 2017 were retrospectively reviewed, with special attention paid to POPF. Among 416 patients, 90 patients showed a drain amylase level of > 3 times the normal limit on day 3 or after. The severity of POPF was biochemical leakage in 46 patients and grade B in 44 patients. No patient had grade C POPF; thus, the incidence of clinically relevant POPF was 10.6% (44/416). The resection line of the common bile duct was closely associated with POPF; 23 (27.7%) of the 83 patients who underwent intrapancreatic resection of the common bile duct developed POPF. The occurrence of intra-abdominal abscess and liver failure was significantly higher in patients with POPF, but the 90-day mortality was similar. The multivariate analysis identified a body mass index of ≥ 22 and intrapancreatic bile duct resection as independent risk factors for POPF. POPF occurs in approximately 10% of patients undergoing resection for PHCC. Careful postoperative management with attention to POPF is required, especially in patients who undergo intrapancreatic resection of the common bile duct and in those with a high body mass index.     

Modified Technique of Pancreaticogastrostomy for Soft Pancreas with Two Continuous Hemstitch Sutures: A Single-Center Prospective Study

Postoperative pancreatic fistula (POPF) remains a persistent problem after pancreaticoduodenectomy (PD), especially in the presence of a soft, nonfibrotic pancreas. To reduce the risk of POPF, pancreaticogastrostomy (PG) is an optional reconstruction technique for surgeons after PD. This study presents a new technique of PG for a soft, nonfibrotic pancreas with double-binding continuous hemstitch sutures and evaluates its safety and reliability. From January 2011 to June 2012, 92 cases of patients with periampullary malignancy with a soft pancreas underwent this technique. A modified technique of PG was performed with two continuous hemstitch sutures placed in the mucosal and seromuscular layers of the posterior gastric wall, respectively. Then the morbidity and mortality was calculated. This technique was applied in 92 patients after PD all with soft pancreas. The median time for the anastomosis was 12 min (range, 8–24). Operative mortality was zero, and morbidity was 16.3 % (n?=?15), including hemorrhage (n?=?2), biliary fistula (n?=?2), pulmonary infection (n?=?1), delayed gastric emptying (DGE; n?=?5, 5.4 %), abdominal abscess (n?=?3, one caused by PF), and POPF (n?=?2, 2.2 %). Two patients developed a pancreatic fistula (one type A and one type B) classified according to the International Study Group on Pancreatic Fistula. The described technique is a simple and safe reconstruction procedure after PD, especially for patients with a soft and fragile pancreas.     

Rectal NSAIDs for the prevention of post-ERCP pancreatitis: A meta-analysis of randomized controlled trials

Background and purposeAcute pancreatitis is the most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP). We conducted a meta-analysis to evaluate the efficacy and safety of rectal nonsteroidal anti-inflammatory drugs (NSAIDs) for the prevention of post-ERCP pancreatitis (PEP).MethodsPubMed and Embase databases were searched through April 2013. Results are reported as relative risk (RR) or weighted mean difference (WMD) with 95% confidence interval (95% CI). The primary outcome measure was the incidence of PEP. Secondary outcome measures included the severity of PEP and serum amylase level 2 h, 24 h after ERCP.ResultsSeven trials containing 1846 patients were eligible. Rectal NSAIDs significantly reduced the incidence of PEP (RR 0.45, 95% CI 0.34–0.61, P < 0.001). The results were maintained in subsequent subgroup analysis. Rectal NSAIDs also was associated with a reduction in the incidence of mild PEP (RR 0.54, 95% CI 0.35–0.83, P = 0.005), moderate to severe PEP (RR 0.39, 95% CI 0.22–0.70, P = 0.002), or serum amylase level 2 h after ERCP (WMD ?91.09 IU/L, 95% CI ?149.78 to ?32.40, P = 0.002).ConclusionsRectal NSAIDs reduced the incidence and severity of PEP, as well as serum amylase level 2 h after ERCP.     

Factibilidad y morbimortalidad en doscientos casos consecutivos de pancreaticogastrostomía después de duodenopancreatectomía

BackgroundPostoperative mortality associated with pancreaticoduodenectomy (PD) in high-volume hospitals is below 5%, yet morbidity rates range between 45% and 60%. Recent studies show a lower incidence of complications and postoperative pancreatic fistula (POPF) in pancreaticogastrostomy (PG). The primary objective was to assess the incidence and predictive factors for complications: POPF, post-pancreatectomy hemorrhage (PPH) and delayed gastric emptying (DGE) following the criteria of the ISGPS and Clavien-Dindo classifications.MethodsA prospective observational study that included all patients who underwent PD between 2008 and 2016. PG was the surgical procedure of choice for PD reconstruction.ResultsTwo hundred forty-nine patients underwent surgery with intention of performing a PD. The feasibility of PG was 90.5%. One hundred and six (53%) patients had complications, 36 (18%) were severe (Clavien-Dindo grade ≥III). Death within 90 postoperative days was 4%. DGE was the most frequent complication (22.5%), followed by PPH (21%). The clinical POPF rate was 15% (6% Clavien-Dindo grade ≥III). The primary risk factors associated with complications were age >70 years (1.9 [1-3.55]), being male (1.89 [1; 3.6]) and soft pancreatic texture (3.38 [1.5; 7.37]).ConclusionsIn this paper, we report a feasibility study for PG (90.5%). The primary risk factors associated with complications were age >70 years, being male and soft pancreatic texture. Soft pancreatic texture is also associated with the development and severity of POPF.     

C-Reactive Protein and Procalcitonin as Predictors of Postoperative Inflammatory Complications After Pancreatic Surgery

Background

The association between postoperative inflammatory markers and risk of complications after pancreaticoduodenectomy (PD) is controversial. We sought to assess the diagnostic value of perioperative C-reactive protein (CRP) and procalcitonin (PCT) levels in the early identification of patients at risk for complications after PD.

Methods

In 2014, 84 patients undergoing elective PD were enrolled in a prospective database. Clinicopathological characteristics, CRP and PCT, as well as short-term outcomes, such as complications and pancreatic fistula, were analyzed. Complications and pancreatic fistula were defined based on the Clavien-Dindo classification and the International Study Group on Pancreatic Fistula (ISGPF) classification, respectively. High CRP and PCT were classified using cut-off values based on ROC curve analysis.

Results

The majority (73.8 %) of patients had pancreatic adenocarcinoma. CRP and PCT levels over the first 5 postoperative days (POD) were higher among patients who experienced a complication versus those who did not (p?<?0.001). Postoperative CRP and PCT levels were also higher among patients who developed a grade B or C pancreatic fistula (p?<?0.05). A CRP concentration >84 mg/l on POD 1 (AUC 0.77) and >127 mg/l on POD 3 (AUC 0.79) was associated with the highest risk of overall complications (OR 6.86 and 9.0, respectively; both p?<?0.001). Similarly patients with PCT >0.7 mg/dl on POD 1 (AUC 0.67) were at higher risk of developing a postoperative complication (OR 3.33; p?=?0.024). On POD 1, a CRP >92 mg/l (AUC 0.72) and a PCT >0.4 mg/dl (AUC 0.70) were associated with the highest risk of pancreatic fistula (OR 5.63 and 5.62, respectively; both p?<?0.05).

Conclusions

CRP and PCT concentration were associated with an increased risk of developing complications and clinical relevant pancreatic fistula after PD. Use of these biomarkers may help identify those patients at highest risk for perioperative morbidity and help guide postoperative management of patients undergoing PD.

     

Characterization of postoperative acute pancreatitis (POAP) after distal pancreatectomy

BackgroundPostoperative acute pancreatitis has recently been reported as a specific complication after pancreatoduodenectomy. The aim of this study was to characterize postoperative acute pancreatitis after distal pancreatectomy.MethodsWe analyzed the outcomes retrospectively of 368 patients who underwent distal pancreatectomies during the period January 2016 to December 2019. Postoperative acute pancreatitis was defined as an increase of serum amylase activity greater than our laboratory normal upper limit on postoperative days 0 to 2. We assessed the incidence of postoperative acute pancreatitis after distal pancreatectomy and examined possible predictors of postoperative acute pancreatitis and relationships of postoperative acute pancreatitis with postoperative pancreatic fistula.ResultsThe rates of postoperative acute pancreatitis and postoperative pancreatic fistula after distal pancreatectomy were 67.9% and 28.8%, respectively. Patients who developed postoperative acute pancreatitis experienced an increased rate of severe morbidity (18.4 vs 9.3%; P = .030). Neoadjuvant therapy (odds ratio 0.28, 0.09–0.85; P = .025), age ≥ 65 y (odds ratio 0.34, 0.13–0.85; P = .020), duct size (odds ratio 0.02, 0.002–0.47; P = .013), pancreatic thickness (odds ratio 3.4, 1.29–8.9; P = .013), resection at the body-tail level (odds ratio 4.3, 1.15–23.19; P = .041), and neuroendocrine histology (odds ratio 1.14, 1.06–3.90; P = .013) were independent predictors of postoperative acute pancreatitis. Furthermore, postoperative acute pancreatitis was an independent predictor of postoperative pancreatic fistula (odds ratio 5.8, 2.27–15.20; P < .001). Postoperative pancreatic fistula occurred in 37% of patients who developed postoperative acute pancreatitis. Patients developing postoperative acute pancreatitis alone demonstrated a statistically significantly increased rate of biochemical leakage and bacterial contamination in the peripancreatic drainage fluid.ConclusionPostoperative acute pancreatitis is a frequent event after distal pancreatectomy and, despite its close association with postoperative pancreatic fistula, evidently represents a separate phenomenon. A universally accepted definition of postoperative acute pancreatitis that applies to all types of pancreatic resections is needed, because it may identify patients at greater risk for additional morbidity immediately after pancreatic resections.     

Positive drain fluid culture on postoperative day 1 predicts clinically relevant pancreatic fistula in early drain removal with higher drain fluid amylase after pancreaticoduodenectomy

BackgroundThis study aimed to clarify the risk factors of clinically relevant pancreatic fistula after early drain removal with higher drain fluid amylase after pancreaticoduodenectomy. Clinical evaluation of early drain removal with a higher drain fluid amylase after pancreaticoduodenectomy has been controversial. The safety and effectiveness have not been sufficiently examined.MethodsBetween 2015 and 2020, prophylactic surgical drains were prospectively removed on postoperative day 4 regardless of drain fluid amylase level in 364 study-eligible patients who underwent pancreaticoduodenectomy. Patients were classified according to drain fluid amylase on postoperative day 1: 281 patients with drain fluid amylase <4,000 U/L, and 83 patients with drain fluid amylase ≥4,000 U/L.ResultsClinically relevant pancreatic fistula occurred in 40 of 364 enrolled patients (11.0%). In the entire cohort, male, positive postoperative day 1 drain fluid culture, and postoperative day 1 drain fluid amylase ≥4,000 U/L were independent risk factors for clinically relevant pancreatic fistula after early drain removal. When stratifying by 4,000 U/L of postoperative day 1 drain fluid amylase, the rate of clinically relevant pancreatic fistula in postoperative day 1 drain fluid amylase <4,000 U/L was significantly lower than that in postoperative day 1 drain fluid amylase ≥4,000 U/L (4% vs 35%, P < .001) after early drain removal. Moreover, in postoperative day 1 drain fluid amylase <4,000 U/L, positive postoperative day 1 drain fluid culture did not develop clinically relevant pancreatic fistula after early drain removal. However, in postoperative day 1 drain fluid amylase ≥4,000 U/L, multivariate analysis clarified that positive postoperative day 1 drain fluid culture was the only independent risk factor of clinically relevant pancreatic fistula after early drain removal (odds ratio 26.27, 95% confidence interval 5.59–123.56, P = .001).ConclusionPositive drain fluid culture on postoperative day 1 might predict clinically relevant pancreatic fistula in early drain removal with a higher drain fluid amylase.     

Clinical significance of postoperative acute pancreatitis after pancreatoduodenectomy and distal pancreatectomy

BackgroundThe definition of postoperative acute pancreatitis as a specific complication of pancreatic surgery was proposed in 2016. Its presence and relevance have not been established, especially after a distal pancreatectomy.MethodsMedical records of 319 patients who underwent pancreatoduodenectomy or distal pancreatectomy were analyzed. Postoperative acute pancreatitis was defined as an increase in serum amylase activity greater than the upper normal limit on postoperative day 1, according to Connor’s definition of postoperative acute pancreatitis.ResultsPostoperative acute pancreatitis occurred in 63.4% of 153 of the patients undergoing pancreatoduodenectomy and 65.7% of the 166 undergoing distal pancreatectomies. Patients who developed postoperative acute pancreatitis after pancreatoduodenectomy experienced an increase in the rate of morbidity (22.7% vs 7.1%; P = .0137), including postoperative pancreatic fistula (18.6% vs 1.8%; P = .024), resulting in greater postoperative stays (21 days vs 17 days; P = .0008). Postoperative acute pancreatitis in association with an increased serum C-reactive protein ≥18.0 mg/dL (which we defined as a clinically relevant postoperative acute pancreatitis) more strongly indicated the occurrence of severe complications (P = .0032) and was an independent predictor of postoperative pancreatic fistula after pancreatoduodenectomy (odds ratio, 3.03; P = .0448). Patients who developed postoperative acute pancreatitis after distal pancreatectomy experienced similar postoperative courses regarding morbidity and the duration of postoperative stay.ConclusionThe clinical relevance of postoperative acute pancreatitis differs after a pancreatoduodenectomy versus a distal pancreatectomy. The development of effective strategies for preventing postoperative acute pancreatitis might improve surgical outcomes after pancreatoduodenectomy.     

Topically Applied 2-Octyl Cyanoacrylate (Dermabond) for Prevention of Postoperative Pancreatic Fistula After Pancreaticoduodenectomy

Objective

We examined whether 2-octyl cyanoacrylate (Dermabond) topically applied to the pancreaticojejunostomy (PJ) anastomotic site after pancreaticoduodenectomy (PD) reduces the rate of postoperative pancreatic fistula (POPF).

Methods

Patients who underwent PD with duct-to-mucosa PJ were evaluated (n?=?124). Outcome was compared between patients who received Dermabond (n?=?75) after PD and historic patients who did not (n?=?49). Risk factors for POPF were identified.

Results

Overall and clinically relevant rates of POPF were significantly lower in patients who received Dermabond than in patients who did not (2.6?% and 1.3?% vs. 22?% and 12?%, respectively; p?=?0.001). In univariate analysis, pancreatic duct diameter ??3?mm, low serum albumin level, and no Dermabond were independent risk factors for POPF; in multivariate analysis, no Dermabond was an independent risk factor for POPF. In patients with pancreatic duct diameter ??3?mm, the rate of POPF was significantly lower in patients who received Dermabond than in patients who did not (3.5?% versus 36?%, respectively; p?=?0.0001). Patients who received Dermabond had significantly shorter hospital stays and lower re-operation and re-admission rates.

Conclusions

Topical application of Dermabond to the PJ anastomotic site after PD significantly reduced the rate of POPF, particularly in patients at risk.