Perioperative nutritional management of patients undergoing pancreatoduodenectomy: an international survey among surgeons

BackgroundThere is still a lack of good evidence regarding the optimal perioperative nutritional management for patients undergoing pancreatoduodenectomy (PD). The aim of this international survey was to assess the current practice among pancreatic surgeons.MethodsA web survey of 30 questions was sent to the members of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA) and International Hepato-Pancreato-Biliary Association (IHPBA). All members were invited by email to answer the online survey. A reminder was sent after 4 weeks.ResultsIn total 420 out of 2500 surgeons (17%) answered the survey. Almost half of the surgeons (44%) did not organize a preoperative nutritional consultation for their patients. Seventy-seven percent of the participants did not have specific nutritional thresholds before the operation. A majority (66%) routinely used biological parameters to detect or follow malnutrition. Regarding intraoperative details, 69% of the respondents routinely leaved a nasogastric tube at the end of PD for gastric drainage. Sixty-six percent of the participants reported a postoperative nutritional follow-up consultation during hospitalization, and 58% of them had established local standardized protocols for postoperative nutritional support.ConclusionManagement of perioperative nutrition in patients undergoing PD was very disparate internationally. No specific preoperative nutritional thresholds were used, and postoperative feeding routes and timing were diverse.     

Surgical management and pathological assessment of pancreatoduodenectomy with venous resection: an international survey among surgeons and pathologists

BackgroundThe aim of this survey was to gain insights in the current surgical management and pathological assessment of pancreatoduodenectomy with portal–superior mesenteric vein resection (VR).MethodsA systematic literature search was performed to identify international expert surgeons (N = 150) and pathologists (N = 40) who published relevant studies between 2009 and 2019. These experts and Dutch surgeons (N = 17) and pathologists (N = 20) were approached to complete an online survey.ResultsOverall, 76 (46%) surgeons and 37 (62%) pathologists completed the survey. Most surgeons (71%) estimated that preoperative imaging corresponded correctly with intraoperative findings of venous involvement in 50–75% of patients. An increased complication risk following VR was expected by 55% of surgeons, mainly after Type 4 (segmental resection-venous conduit anastomosis). Most surgeons (61%) preferred Type 3 (segmental resection-primary anastomosis). Most surgeons (75%) always perform the VR themselves. Standard postoperative imaging for patency control was performed by 54% of surgeons and 39% adjusted thromboprophylaxis following VR. Most pathologists (76%) always assessed tumor infiltration in the resected vein and only 54% of pathologists always assess the resection margins of the vein itself. Variation in assessment of tumor infiltration depth was observed.ConclusionThis international survey showed variation in the surgical management and pathological assessment of pancreatoduodenectomy with venous involvement. This highlights the lack of evidence and emphasizes the need for research on imaging modalities to improve patient selection for VR, surgical techniques, postoperative management and standardization of the pathological assessment.     

Pain management in patients with haemophilia: a European survey

Summary. There are no evidence-based guidelines on pain management in people with haemophilia (PWH), who may suffer acute, disabling pain from haemarthroses and chronic arthropathic pain. To review evidence and to investigate current clinical practice in pain assessment and management in PWH the European Haemophilia Therapy Standardisation Board undertook a literature review and a survey in 22 Haemophilia Treatment Centres (HTC), using a questionnaire and seven clinical scenarios. Consensus was sought on pain assessment and management in PWH. Few clinical studies on pain management in PWH were identified. The HTCs care for 1678 children (47% severe haemophilia, 84% on prophylaxis, 17% with arthropathy and 8% with chronic pain) and 5103 adults (44% severe haemophilia, 40% on prophylaxis, 67% with arthropathy and 35% with chronic pain). Analgesics are prescribed by HTCs in 80% of cases (median; range 0-100%) and in 10% (median; range 0-80%) are bought over the counter. Pain and analgesic use are assessed when reported by patients and at check-ups. Only eight centres use a specific pain scale and/or have specific pain guidelines. Two HTCs arrange regular consultations with pain specialists. For acute pain, the preferred first-line drug is paracetamol for children, and paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs) for adults. Children with chronic pain are treated with paracetamol or NSAIDs, whereas adults usually receive Cox-2 inhibitors. Second-line therapy is heterogeneous. There is little published evidence to guide pain assessment and management in PWH, and clinical practice varies considerably across Europe. General and specific recommendations are needed.     

Early postoperative fluid retention is a strong predictor for complications after pancreatoduodenectomy

BackgroundPerioperative fluid overload has been reported to increase complications after a variety of operative procedures. This study was conducted to investigate the incidence of fluid retention after pancreatic resection and its association with postoperative complications.MethodsData from 1174 patients undergoing pancreatoduodenectomy between 2010 and 2016 were collected from the Swedish National Pancreatic and Periampullary Cancer Registry. Early postoperative fluid retention was defined as a weight gain ≥2 kg on postoperative day 1. Outcome measures were overall complications, as well as procedure-specific complications.ResultsThe weight change on postoperative day 1 ranged from −1 kg to +9 kg. A total of 782 patients (66.6%) were considered to have early fluid retention. Patients with fluid retention had significantly higher rates of total complications (p = 0.002), surgical complications (p = 0.001), pancreatic anastomotic leakage (p = 0.018) and wound infection (p = 0.023). Multivariable logistic regression confirmed early fluid retention as an independent risk factor for total complications (OR 1.46; p = 0.003), surgical complications (OR 1.49; p = 0.002), pancreatic anastomotic leakage (OR 1.48; p = 0.027) and wound infection (OR 1.84; p = 0.023).ConclusionsFluid retention is common after elective pancreatic resection, and its associated with an increased rate of postoperative complications.     

Late hemorrhage after pancreatoduodenectomy and heavy ion beam therapy

The patient was a 57-year-old man diagnosed with cancer of the pancreatic head. After treatment by heavy ion beam therapy, pylorus-preserving pancreatoduodenectomy was performed. The tumor was pT3, pN0, pM0, stage IIA. Sixteen months after the surgery, the patient was admitted to the hospital because he was vomiting blood. Hemorrhaging caused by failure of the cut end of the gastroduodenal artery into the elevated jejunum was confirmed by angiogram, and the hemorrhaging could be stopped by a transcatheter arterial embolization operation. Twenty-four months after surgery, the patient was readmitted because he was once again vomiting blood. Hemorrhaging from the elevated jejunum was suspected by hemorrhagic scintigram, but the source could not be identified on further examination, and the choice of treatment was difficult. The patient died on the 9th day after admittance to the hospital. Even on examination at autopsy, the source of the hemorrhaging could not be identified. No recurrence of cancer could be found. This has proven to be a perplexing case, in that hemorrhaging from the end of the routinely cut gastroduodenal artery occurred 16 and 24 months after heavy ion beam therapy and pylorus-preserving pancreatoduodenectomy for pancreatic cancer.     

Venous thromboembolic prophylaxis after a hepatic resection: patterns of care among liver surgeons

Introduction

No consensus exists for post-hepatectomy venous thromboembolic (VTE) prophylaxis. Factors impacting VTE prophylaxis patterns among hepato-pancreato-biliary (HPB) surgeons were defined.

Method

Surgeons were invited to complete a web-based survey on VTE prophylaxis. The impact of physician and clinical factors was analysed.

Results

 Two hundred responses were received. Most respondents were male (91%) and practiced at academic centres (88%) in the United States (80%). Surgical training varied: HPB (24%), transplantation (24%), surgical oncology (34%), HPB/transplantation (13%), or no specialty (5%). Respondents estimated VTE risk was higher after major (6%) versus minor (3%) resections. Although 98% use VTE prophylaxis, there was considerable variability: sequential compression devices (SCD) (91%), unfractionated heparin Q12h (31%) and Q8h (32%), and low-molecular weight heparin (39%). While 88% noted VTE prophylaxis was not impacted by operative indication, 16% stated major resections reduced their VTE prophylaxis. Factors associated with the decreased use of pharmacologic prophylaxis included: elevated international normalized ratio (INR) (74%), thrombocytopaenia (63%), liver insufficiency (58%), large EBL (46%) and complications (8%). Forty-seven per cent of respondents wait until ≥post-operative day 1 (POD1) and 35% hold pharmacologic VTE prophylaxis until no signs of coagulopathy. A minority (14%) discharge patients on pharmacologic prophylaxis. While 81% have institutional VTE guidelines, 79% believe hepatectomy-specific guidelines would be helpful.

Conclusion

There is considerable variation regarding VTE prophylaxis among liver surgeons. While most HPB surgeons employ VTE prophylaxis, the methods, timing and purported contraindications differ significantly.     

Definition of colorectal anastomotic leakage: A consensus survey among Dutch and Chinese colorectal surgeons

AIM To determine the level of consensus on the definition of colorectal anastomotic leakage(CAL) among Dutch and Chinese colorectal surgeons.METHODS Dutch and Chinese colorectal surgeons were asked to partake in an online questionnaire. Consensus in the online questionnaire was defined as 80% agreement between respondents on various statements regarding a general definition of CAL,and regarding clinical and radiological diagnosis of the complication.RESULTS Fifty-nine Dutch and 202 Chinese dedicated colorectal surgeons participated in the online survey. Consensus was found on only one of the proposed elements of a general definition of CAL in both countries: ‘extravasation of contrast medium after rectal enema on a CT scan'. Another two were found relevant according to Dutch surgeons: ‘necrosis of the anastomosis found during reoperation',and ‘a radiological collection treated with percutaneous drainage'. No consensus was found for all other proposed elements that may be included in a general definition.CONCLUSION There is no universally accepted definition of CAL in the Netherlands and China. Diagnosis of CAL based on clinical manifestations remains a point of discussion in both countries. Dutch surgeons are more likely to report ‘subclinical' leaks as CAL,which partly explains the higher reported Dutch CAL rates.     

Early oral feeding after pancreatoduodenectomy: a systematic review and meta-analysis

BackgroundThe effect of early oral feeding (EOF) after pancreatoduodenectomy (PD) upon perioperative complications and outcomes is unknown, therefore the aim of this systematic review and meta-analysis was to investigate the effect of EOF on clinical outcomes after PD, such as postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE) and length of stay (LOS).MethodsA systematic review and meta-analysis was performed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance and assimilated evidence from studies reporting outcomes for patients who received EOF after PD compared to enteral tube feeding (EN) or parenteral nutrition (PN).ResultsFour studies reported outcomes after EOF compared to EN/PN after PD and included 553 patients. Meta-analyses showed no difference in rates of CR-POPF (OR 0.74; 95%CI 0.44–1.24; p = 0.25) or DGE (Grade B/C) (OR 0.83; 95%CI 0.31–2.21; p = 0.70). LOS was significantly shorter in the EOF group compared to the EN/PN group (Mean Difference ?3.40 days; 95% ?6.11-0.70 days; p = 0.01).ConclusionCurrent available evidence suggests that EOF after PD is not associated with increased risk of DGE, does not exacerbate POPF and appears to reduce length of stay.     

Surgical management of the rheumatoid hand: consensus and controversy among rheumatologists and hand surgeons

OBJECTIVE: Rheumatoid arthritis (RA) is a common cause of debilitating hand deformities, but management of these deformities is controversial, characterized by large variations in the surgical rates of common RA hand procedures. We conducted a national survey evaluating potential differences in physicians' management of RA hand deformities. METHODS: We mailed a survey instrument to a random national sample of 500 rheumatologists and 500 hand surgeons in the US. We evaluated physicians' attitudes toward the other specialties' management of common RA hand deformities and toward the indications for performing rheumatoid hand surgery. RESULTS: We found 70% of rheumatologists consider hand surgeons deficient in understanding the medical options available for RA, while 73.6% of surgeons believe rheumatologists have insufficient knowledge of the surgical options for RA hand diseases. However, 66.9% of surgeons and 79.5% of rheumatologists had no exposure to the other specialty during training. The 2 physician groups disagree significantly on the indications for commonly performed RA hand procedures such as metacarpophalangeal joint arthroplasty (p < 0.001), small joint synovectomy (p < 0.001), and distal ulna resection (p = 0.001). When physicians do not agree with others' management of RA hand deformities, only 62.4% of surgeons and 61.9% of rheumatologists relay their concern to the other specialty. CONCLUSION: Rheumatologists and hand surgeons have minimal interdisciplinary training, communicate with each other infrequently, and significantly disagree on the indications for RA hand surgery. Research must focus on the surgical outcomes of RA hand procedures and on improving communication between rheumatologists and hand surgeons.     

Emergency department visits after pancreatoduodenectomy: examining a novel quality metric

BackgroundPostoperative emergency department (ED) visits represent fragmented care, are costly, and often evolve into readmission. Readmission rates after pancreatoduodenectomy (PD) are defined, while ED visits following PD are not. We examined the pattern of 30-day post-discharge ED visits for PD patients.MethodsA quaternary institutional database analysis of adult patients who underwent PD between 2010–2017 was reviewed for ED utilization within 30 days from discharge.ResultsOf the 1,004 patients who underwent PD, 12% (N = 117) patients sought care in the ED within 30 days from postoperative discharge. The median time to ED presentation was 5 days post-discharge (IQR 3–9). Half of ED visits occurred during nights and weekends (N = 59, 50%). Of ED-utilizing patients, 64% (N = 76) were admitted to the hospital and 29% (N = 34) were discharged from the ED. ED visits were associated with a Clavien-Dindo Classification of 0 in 10.2% (N = 13) of patients, I-II in 62.4% (N = 73), and III-V in 26.5% (N = 31).DiscussionPost-discharge ED utilization is a novel quality metric and represents a potential target population for reducing hospital readmissions. Over two-thirds (72%) of ED visits were associated with low acuity complications, and promoting institutional strategies addressing postoperative ED visits may improve patient care and efficient utilization of healthcare resources.     

Pathophysiology after pylorus-preserving pancreatoduodenectomy: a comparative study of pancreatogastrostomy and pancreatojejunostomy.

BACKGROUND/AIMS: Pylorus-preserving pancreatoduodenectomy using the pancreatogastrostomy technique may result in pancreatic exocrine insufficiency and obstruction of the pancreatic duct. A prospective randomized comparison of pancreatogastrostomy and pancreatojejunostomy was therefore performed to assess pathophysiologic changes after pylorus-preserving pancreatoduodenectomy. METHODOLOGY: The study population consisted of 23 patients (pancreatogastrostomy: 10, pancreatojejunostomy: 13) who were observed for 2 years. RESULTS: Neither physical condition (dietary intake, body weight, performance status, and frequency of bowel movements) nor nutritional parameters (serum levels of total protein, albumin, total cholesterol, and cholinesterase) differed significantly between the two groups; these parameters recovered to pre-operative levels within 1 year in both groups. Changes in pancreatic function diagnosis (PFD) test results were similar between the two groups. The glucose tolerance test results revealed deterioration of glucose tolerance in 2 patients (20%) in the pancreatogastrostomy group and 3 patients (23%) in the pancreatojejunostomy group. In 2 of 3 patients in each group with non-dilated pancreatic ducts before surgery, the pancreatic ducts dilated after surgery. Diabetes developed after surgery in one such patient in each group. No significant differences were observed between the two groups with respect to changes in glucose tolerance test results and the diameter of the pancreatic duct. CONCLUSIONS: This prospective randomized study demonstrates no difference in pathophysiologic changes between patients undergoing pancreatogastrostomy or pancreatojejunostomy after pylorus-preserving pancreatoduodenectomy, at least in the first 2 years.     

Pancreatic juice output and amylase level in the drainage fluid after pancreatoduodenectomy in relation to leakage

BACKGROUND/AIMS: The objective of this study was to clarify the relationship between the consistency of the pancreas and pancreatic anastomotic leakage after pancreatectomy. METHODOLOGY: Sixty-two patients who underwent proximal pancreatectomy with pancreaticoenterostomy were reviewed with regard to the consistency of the pancreas, size of the main pancreatic duct, postoperative pancreatic juice output, and pancreatic leakage after partial pancreatoduodenectomy. The pancreatic parenchyma was classified as having soft, intermediate and hard consistency (group 1, 2 and 3, respectively). Monitoring the output of pancreatic juice and amylase level in the drainage fluid after operation for the purpose of detecting of dehiscence of pancreaticoenterostomy. RESULTS: The mean pancreatic juice output during a period of 10 days (postoperative days 5 to 14) was 2446 +/- 27 cc in group 1 (n = 26), 846 +/- 13.5 cc in group 2 (n = 19) and 460 +/- 8.1 cc in group 3 (n = 17). Anastomotic leakage occurred in four (15%) patients in group 1, three (15%) in group 2, and none in group 3. In patients with leakage, abrupt decrease or fluctuating output of pancreatic juice occurred and amylase level in the drainage fluid was more than 10,000 IU/L POD 7. CONCLUSIONS: Patients with a pancreatic parenchyma with an intermediate or normal consistency produced more pancreatic juice and had a higher leak rate. Monitoring the output of pancreatic juice and amylase level in the drainage fluid after operation may provide a clue to the detection of dehiscence of pancreaticoenterostomy.