The impact of pancreaticojejunostomy versus pancreaticogastrostomy reconstruction on pancreatic fistula after pancreaticoduodenectomy: meta-analysis of randomized controlled trials

Background

Pancreatic fistula (PF) remains a common source of morbidity following pancreaticoduodenectomy (PD). Despite numerous studies, the optimal method of pancreatic remnant reconstruction is controversial. This study examines the hypothesis that pancreaticogastrostomy (PG) is associated with a lower risk for PF after PD compared with pancreaticojejunostomy (PJ).

Methods

Five electronic databases and the grey literature were searched for randomized controlled trials (RCTs) comparing PJ and PG after PD. Two reviewers independently selected studies, extracted data and assessed methodology. The primary outcome was the occurrence of PF of International Study Group on Pancreatic Fistula (ISGPF) Grade B or C.

Results

Four RCTs including 676 patients were included. Pancreaticogastrostomy reduced the risk for PF [relative risk (RR) 0.41, 95% confidence interval (CI) 0.21–0.62] without any difference between high- and low-risk patients. Absolute risk reduction for PF was 4% (95% CI 2.4–5.6) in low-risk patients compared with 10% (95% CI 6.5–14.8) in high-risk patients undergoing PG rather than PJ. The strength of evidence for PF outcome was moderate according to the GRADE classification.

Conclusions

Reconstruction by PG decreases the rate of PF in comparison with PJ. Surgeons should consider reconstructing the pancreatic remnant following PD with PG, particularly in patients at high risk for PF.     

The bridge stent technique for salvage of pancreaticojejunal anastomotic dehiscence

Objectives

Although infrequent, Grade C postoperative pancreatic fistulae (POPF) following pancreaticoduodenectomy (PD) are morbid and potentially lethal. Traditional management of a disrupted pancreaticojejunostomy (PJ) anastomosis consists of either wide external drainage or completion pancreatectomy. The aim of this study is to describe an alternative management approach to PJ dehiscence after PD.

Methods

A bridge stent technique is employed in the setting of a disrupted PJ anastomosis. Upon re-exploration, a 5-Fr or 8-Fr silastic feeding tube stent is placed across a gap between the jejunal enterotomy and the pancreatic duct, and secured with an absorbable suture at both ends. Depending upon the degree of local inflammation, this may be externalized by coursing the stent downstream through the pancreaticobiliary drainage limb in a Witzel fashion.

Results

Over 8 years and 357 PDs with duct-to-mucosa PJ reconstruction, seven ISGPF (International Study Group on Pancreatic Fistula) Grade C fistulae occurred (2%). Two patients ultimately died secondary to POPF (neither anastomosis was dehisced). The described technique was used in the other five patients, all of whom had evidence of a dehisced PJ anastomosis. All originally had at least two or three recognized risk factors for POPF development (high-risk pathology, soft gland, duct diameter ≤3 mm, estimated blood loss ≥1000 ml). All patients survived this complication and were discharged from hospital. There have been no longterm external fistulae, nor any recognized PJ strictures or remnant atrophy (median follow-up: 10.7 months).

Conclusions

In the context of a dehisced pancreaticojejunal anastomosis, the bridge stent technique is a safe and effective method of management that contributes to diminished mortality and helps to salvage pancreatic function.     

Pancreatic fistula after a pancreaticoduodenectomy for ductal adenocarcinoma and its association with morbidity: a multicentre study of the French Surgical Association

Backgrounds

A pancreatic fistula (PF) is the most relevant complication after a pancreaticoduodenectomy (PD). This retrospective multicentric study attempts to elucidate the risk factors and complications of a PF in a large cohort of patients undergoing a PD for ductal adenocarcinoma.

Methods

Using a survey tool, clinical data of 1325 patients undergoing a PD for ductal adenocarcinoma at 37 institutions, between January 2004 and December 2009, were collected. Peri-operative risk factors associated with PF and its association with morbidity and mortality were assessed. Morbidity and PF were graded according to the ISGPF (International Study group for pancreatic fistula) definition and the Dindo–Clavien classification.

Results

Overall PF, mortality, morbidity and relaparotomy rates were 14.3%, 3.8%, 54.4% and 11.7%, respectively. PF occurred more frequently after a pancreaticojejunostomy (PJ) compared with a pancreaticogastrostomy (PG) (16.8% vs. 10.4%; P = 0.0012). Independent risk factors for PF by multivariate analysis were absence of pre-operative diabetes (P = 0.0014), PJ reconstruction (P = 0.0035), soft pancreatic parenchyma (P < 0.0001) and low-volume centre (P = 0.0286). Clinically relevant PF (grade B and C) and severe complications (Dindo–Clavien grade IIIB, IV, V) were significantly more frequent after PJ than PG (71.6% vs. 28.3%; P = 0.030 and 24.8% vs. 19.1%; P = 0.015, respectively). Overall mortality and relaparotomy rates were similar after PG and PJ.

Conclusions

A soft pancreatic parenchyma, the absence of pre-operative diabetes, PJ and low-volume centre are independent risk factors for PF after PD for ductal adenocarcinoma. A significantly higher incidence and clinical severity of PF are associated with PJ.     

Is isolated Roux loop pancreaticojejunostomy superior to conventional reconstruction in pancreaticoduodenectomy?

Objectives:

Pancreatic fistula (PF) predicts mortality and morbidity in patients undergoing pancreaticoduodenectomy (PD). This study aimed to assess whether isolated Roux loop pancreaticojejunostomy (IPJ) is superior to conventional pancreaticojejunostomy (CPJ).

Methods:

Between September 2003 and July 2007, we performed 108 PDs. All patients underwent classical Kausch–Whipple PD with pancreaticojejunostomy (PJ). Patients were divided into two groups based on the type of PJ. Patients in group 1 underwent IPJ and those in group 2 underwent CPJ. A retrospective analysis of prospectively maintained data was performed to compare outcomes in the two groups.

Results:

There were 53 patients in group 1 and 55 in group 2. The two groups were comparable in both pre- and intraoperative parameters. The overall incidence of PF was 10.1% (five cases in group 1 vs. six in group 2). The course of clinically significant PF was similar in both groups in terms of fistula behaviour, management and the duration of spontaneous closure. Two patients in each group died. Overall complications, mortality and length of hospital stay were also similar; however, duration of surgery was significantly higher in group 1 vs. group 2 (442 min and 370 min, respectively; P= 0.005).

Conclusions:

Isolated Roux loop pancreaticojejunostomy is not superior to conventional PJ; instead, it increases the duration of surgery.     

Comparison of Modified Blumgart pancreaticojejunostomy and pancreaticogastrostomy after pancreaticoduodenectomy

Background

The aim of this study was to compare perioperative outcomes after Blumgart pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) for pancreatic-enteric reconstruction following pancreaticoduodenectomy.

Methods

Data of patients undergoing Blumgart PJ and PG were retrieved from prospectively-collected database. Matched patients in each surgical groups were included based on the Callery risk scoring system for clinically relevant postoperative pancreatic fistula (CR-POPF) (grades B and C). Surgical parameters and risks were compared between these two groups.

Results

A total of 206 patients undergoing PD were included. Blumgart PJ was associated with shorter postoperative hospital stay (median (range) 25 (10–99) vs. 27 (10–97) days, P = 0.022). There was no surgical mortality in the Blumgart PJ group, but a 4.9% perioperative mortality in the PG, P = 0.030. The CR-POPF by Blumgrt PG is significantly lower than that by PG for overall patients (7% vs. 20%, P = 0.007), especially for those in intermediate fistula risk zone (6% vs. 21%, P = 0.048) and high fistula risk zone (14% vs. 47%, P = 0.038).

Conclusions

Blumgart PJ is superior to PG in terms of pancreatic leakage and surgical mortality. Blumgart PJ can be recommended for pancreatic reconstruction after PD for all pancreatic remnant subtypes.     

Pancreaticogastrostomy is associated with significantly less pancreatic fistula than pancreaticojejunostomy reconstruction after pancreaticoduodenectomy: a meta-analysis of seven randomized controlled trials

Objectives

This study aimed to compare pancreaticojejunostomy (PJ) with pancreaticogastrostomy (PG) after pancreaticoduodenectomy (PD).

Methods

A literature search of PubMed and the Cochrane Central Register of Controlled Trials for studies comparing PJ with PG after PD was conducted. The primary outcome for meta-analysis was pancreatic fistula. Secondary outcomes were morbidity, mortality, biliary fistula, intra-abdominal fluid collection, hospital length of stay (LoS), postoperative haemorrhage and reoperation. Outcome measures were odds ratios (ORs) and mean differences with 95% confidence intervals (CIs).

Results

Seven recent RCTs encompassing 1121 patients (559 PJ and 562 PG cases) were involved in this meta-analysis. Incidences of pancreatic fistula (10.6% versus 18.5%; OR 0.52, 95% CI 0.37–0.74; P = 0.0002), biliary fistula (2.3% versus 5.7%; OR 0.42, 95% CI 0.03–3.15; P = 0.03) and intra-abdominal fluid collection (8.0% versus 14.7%; OR 0.50, 95% CI 0.34–0.74; P = 0.0005) were significantly lower in the PG than the PJ group, as was hospital LoS (weighted mean difference: −1.85, 95% CI −3.23 to −0.47; P = 0.008). Subgroup analysis indicated that severe pancreatic fistula (grades B or C) occurred less frequently in the PG than the PJ group (8.3% versus 20.5%; OR 0.37, 95% CI 0.23–0.59; P < 0.00001). However, there was no significant difference in morbidity (48.9% versus 51.0%; OR 0.90, 95% CI 0.70–1.16; P = 0.41), mortality (3.2% versus 3.5%; OR 0.82, 95% CI 0.43–1.58; P = 0.56), delayed gastric emptying (16.6% versus 14.7%; relative risk: 1.02, 95% CI 0.62–1.68; P = 0.94), postoperative haemorrhage (9.6% versus 11.1%; OR 0.82, 95% CI 0.54–1.24; P = 0.35) or reoperation (9.9% versus 9.8%; OR 0.93, 95% CI 0.60–1.43; P = 0.73).

Conclusions

Pancreaticogastrostomy provides benefits over PJ after PD, including in the incidences of pancreatic fistula, biliary fistula and intra-abdominal fluid collection and in hospital LoS. Therefore, PG is recommended as a safer and more reasonable alternative to PJ reconstruction after PD.     

Revision of anastomotic stenosis after pancreatic head resection for chronic pancreatitis: is it futile?

Background:

Because survival after pancreaticoduodenectomy for cancer is limited, it is difficult to assess longterm pancreaticojejunal anastomotic patency. However, in patients with benign disease, pancreaticojejunal anastomotic stenosis may become problematic. What happens when pancreaticojejunal anastomosis revision is undertaken?

Methods:

Patients undergoing pancreatic anastomotic revision after pancreatic head resection for benign disease between 1997 and 2007 at the Medical University of South Carolina were identified. A retrospective chart review and analysis were undertaken with the approval of the Institutional Review Board for the Evaluation of Human Subjects. Longterm follow-up was obtained by patient survey at a clinic visit or by telephone.

Results:

During the study period, 237 patients underwent pancreatic head resection. Of these, 27 patients (17 women; median age 42 years) underwent revision of pancreaticojejunal anastomosis. Six patients (22%) had a pancreatic leak or abscess at the time of the index pancreatic head resection. The indication for revision of anastomosis was intractable pain. All patients underwent preoperative magnetic resonance cholangiopancreatography (MRCP), which indicated anastomotic stricture in 18 patients (63%). Nine other patients underwent exploration based on clinical suspicion caused by recurrent pancreatitis and stenosis was confirmed at the time of surgery. Six patients (22%) had perioperative complications after revision. The median length of stay was 12 days. There were no perioperative deaths; however, late mortality occurred in four patients (15%). Six of 23 survivors (26%) at the time of follow-up (median 56 months) reported longterm pain relief.

Conclusions:

Stricture of the pancreaticojejunal anastomosis after pancreatic head resection presents with recurrent pancreatitis and pancreatic pain. MRCP has good specificity in the diagnosis of anastomotic obstruction, but lacks sensitivity. Pancreaticojejunal revision is safe, but rarely effective, as a means of pain relief in patients with the pain syndrome associated with chronic pancreatitis.     

Combined pancreaticoduodenectomy and extended right hemicolectomy: outcomes and indications

Background:

Pancreaticoduodenectomy (PD) combined with an en bloc extended right hemicolectomy is required to achieve complete oncological resection of various malignancies. Information regarding the indications and outcomes of this procedure is limited.

Study design:

Patients requiring PD combined with extended right hemicolectomy for primary tumours from 2002 to 2008 were identified.

Results:

PD combined with an en bloc extended right hemicolectomy was required in 14 patients, constituting 8% of pancreaticoduodenal resections. Pancreatic adenocarcinoma (8), retroperitoneal sarcoma (2) and colon cancer (2) were the main primary tumours resected. The indication for an extended right hemicolectomy was extensive tumour involvement of the transverse mesentery in seven patients. Clear tumour margins were achieved in 11 individuals. The median operating time was 10 h with intra-operative transfusions required in three patients. One or more complications were noted in eight, with delayed gastric emptying and pancreatic fistula the most common. The median length of hospital stay was 8 days. The overall 2-year survival in this series was 37%, with a median survival of 20 months in pancreatic cancer patients.

Conclusions:

This series suggests that PD combined with an en bloc extended right hemicolectomy is feasible and can achieve complete tumour clearance with acceptable morbidity.     

A simple scoring system based on clinical factors related to pancreatic texture predicts postoperative pancreatic fistula preoperatively

Background:

Postoperative pancreatic fistula (POPF) is regarded as the most serious complication of pancreatic surgery. The preoperative risk stratification of patients by simple means is of interest in perioperative clinical management.

Methods:

Based on prospective data, we performed a risk factor analysis for POPF after pancreatoduodenectomy in 62 patients operated between 2006 and 2008 with special focus on clinical parameters that might serve to predict POPF. A predictive score was developed and validated in an independent second dataset of 279 patients operated between 2001 and 2010.

Results:

Several pre- and intraoperative factors, as well as underlying pathology, showed significant univariate correlation with rate of POPF. Multivariate analysis (binary logistic regression) disclosed soft pancreatic texture (odds ratio [OR] 10.80, 95% confidence interval [CI] 1.80–62.20) and history of weight loss (OR 0.15, 95% CI 0.04–0.66) to be the only independent preoperative clinical factors influencing POPF rate. The subjective assessment of pancreatic hardness by the surgeon correlated highly with objective assessment of pancreatic fibrosis by the pathologist (r = −0.68, P < 0.001, two-tailed Spearman''s rank correlation). A simple risk score based on preoperatively available clinical parameters was able to stratify patients correctly into three risk groups and was independently validated.

Conclusions:

Preoperative stratification of patients regarding risk for POPF by simple clinical parameters is feasible. Pancreatic texture, as evaluated intraoperatively by the surgeon, is the strongest single predictive factor of POPF. The findings of the study may have important implications for perioperative risk assessment and patient care, as well as for the choice of anastomotic techniques.     

Cost benefit analysis of mesh reinforcement of stapled left pancreatectomy

Objectives

Pancreatic leak is a morbid complication following left pancreatectomy, which results in prolonged hospitalization, additional diagnostic testing and invasive procedures. The present authors have previously demonstrated that mesh reinforcement of stapled left pancreatectomy results in fewer pancreatic leaks. This study was conducted to investigate whether mesh reinforcement also results in cost benefits for the health care system.

Methods

A cost benefit model was developed to estimate net cost savings from the payer''s perspective. The model is based on the results of a randomized, single-blinded trial of mesh versus no mesh reinforcement of the pancreatic remnant after left pancreatectomy. A two-way sensitivity analysis was conducted to determine the model''s sensitivity to fluctuations in the cost of mesh and the effectiveness of the mesh in reducing clinically significant leaks.

Results

Average total costs for an episode of care were US$13 337 and US$15 505 for patients who did and did not receive mesh, respectively, which indicates savings of US$2168. Two-way sensitivity analysis showed that, given a probability of 1.9% for developing a clinically significant leak in patients in whom mesh reinforcement was used, the strategy would continue to save costs if mesh were priced at ≤US$1804.

Conclusions

Mesh reinforcement decreases clinically significant pancreatic leaks. Despite the additional cost of mesh reinforcement, the use of mesh reinforcement results in overall cost savings for the health care system because of the resultant decrease in the occurrence of clinically significant leaks.     

Albert-Lembert versus hybrid-layered suture in hand sewn end-to-end cervical esophagogastric anastomosis after esophageal squamous cell carcinoma resection

Background

Hand sewn cervical esophagogastric anastomosis (CEGA) is regarded as preferred technique by surgeons after esophagectomy. However, considering the anastomotic leakage and stricture, the optimal technique for performing this anastomosis is still under debate.

Methods

Between November 2010 and September 2012, 230 patients who underwent esophagectomy with hand sewn end-to-end (ETE) CEGA for esophageal squamous cell carcinoma (ESCC) were analyzed retrospectively, including 111 patients underwent Albert-Lembert suture anastomosis and 119 patients underwent hybrid-layered suture anastomosis. Anastomosis construction time was recorded during operation. Anastomotic leakage was recorded through upper gastrointestinal water-soluble contrast examination. Anastomotic stricture was recorded during follow up.

Results

The hybrid-layered suture was faster than Albert-Lembert suture (29.40±1.24 min vs. 33.83±1.41 min, P=0.02). The overall anastomotic leak rate was 7.82%, the leak rate in hybrid-layered suture group was significantly lower than that in Albert-Lembert suture group (3.36% vs. 12.61%, P=0.01). The overall anastomotic stricture rate was 9.13%, the stricture rate in hybrid-layered suture group was significantly lower than that in Albert-Lembert suture group (5.04% vs. 13.51%, P=0.04).

Conclusions

Hand sewn ETE CEGA with hybrid-layered suture is associated with lower anastomotic leakage and stricture rate compared to hand sewn ETE CEGA with Albert-Lembert suture.     

Does fibrin glue sealant decrease the rate of anastomotic leak after a pancreaticoduodenectomy? Results of a prospective randomized trial

Background

The aim of this study was to evaluate the effect of topical fibrin glue applied externally to all anastomoses after a pancreaticoduodenectomy (PD) on drain lipase levels, anastomotic leaks, complication rates and length of hospital stay.

Methods

A standardized non-pylorus preserving PD was performed with or without fibrin glue applied to each anastomosis.

Results

Fifty-seven patients were randomized: 32 with and 25 without TISSEEL. There were no statistical differences in each group with respect to drain lipase levels (high 40% versus 43%, P = 0.794), complications including gastric or biliary leaks (24% versus 28%, P = 1.00), wound infection (16% versus 9%, P = 0.28) and a Clavien score of 3 or more (16% versus 25%, P = 0.757) or hospital stay (12 versus 17 days, P = 0.777). Most patients with elevated drain lipase levels had an unaltered clinical course not predictive of adverse outcomes. However, the operative finding of a soft pancreas (27 out of 57 patients) was associated with post-operative complications (P = 0.002). There were no peri-operative deaths.

Conclusions

1. Fibrin glue application to all anastomoses does not alter drain lipase levels.
2. Drain lipase levels are not a significant surrogate marker for clinically significant anastomotic leaks or complications.
3. Fibrin glue application did not reduce the incidence of an anastomotic leak or complications.

     

Isolated Roux loop pancreaticojejunostomy versus pancreaticogastrostomy after pancreaticoduodenectomy: a prospective randomized study

Objectives

The optimal strategy for the reconstruction of the pancreas following pancreaticoduodenectomy (PD) is still debated. The aim of this study was to compare the outcomes of isolated Roux loop pancreaticojejunostomy (IRPJ) with those of pancreaticogastrostomy (PG) after PD.

Methods

Consecutive patients submitted to PD were randomized to either method of reconstruction. The primary outcome measure was the rate of postoperative pancreatic fistula (POPF). Secondary outcomes included operative time, day to resumption of oral feeding, postoperative morbidity and mortality, and exocrine and endocrine pancreatic functions.

Results

Ninety patients treated by PD were included in the study. The median total operative time was significantly longer in the IRPJ group (320 min versus 300 min; P = 0.047). Postoperative pancreatic fistula developed in nine of 45 patients in the IRPJ group and 10 of 45 patients in the PG group (P = 0.796). Seven IRPJ patients and four PG patients had POPF of type B or C (P = 0.710). Time to resumption of oral feeding was shorter in the IRPJ group (P = 0.03). Steatorrhea at 1 year was reported in nine of 42 IRPJ patients and 18 of 41 PG patients (P = 0.029). Albumin levels at 1 year were 3.6 g/dl in the IRPJ group and 3.3 g/dl in the PG group (P = 0.001).

Conclusions

Isolated Roux loop PJ was not associated with a lower rate of POPF, but was associated with a decrease in the incidence of postoperative steatorrhea. The technique allowed for early oral feeding and the maintenance of oral feeding even if POPF developed.     

Relaparotomy for a pancreatic fistula after a pancreaticoduodenectomy: a comparison of different surgical strategies

Introduction

A relaparotomy for a pancreatic fistula (PF) after a pancreaticoduodenectomy (PD) is a formidable operation, and the appropriate treatment of anastomotic leakage is under debate. The objective of this study was to compare the outcomes of different strategies in managing the pancreatic remnant during a relaparotomy for PF after a PD.

Methods

In this retrospective study on prospectively collected data, 669 PD were performed between 2004 and 2011. The study group comprised 31 patients requiring a relaparotomy, because of delayed haemorrhage (n = 19) or sepsis (n = 12). The pancreatic stump was treated either using pancreas-preserving techniques (simple drainage or duct occlusion) or completion of a pancreatectomy (CP). In 2008, autologous islet transplantation (AIT) was introduced for endocrine tissue rescue of CP.

Results

The mortality rate, blood loss and transfusion requirement were similar for all techniques. Patients undergoing a CP required a further relaparotomy less frequently than patients with pancreas preservation (7% versus 59%, P < 0.01), and the intensive care unit (ICU) stay was reduced after CP (P = 0.058). PF persisted at discharge in 66% of patients after pancreas-preserving techniques. AIT was associated with CP in 7 patients, of whom one died post-operatively. Long-term graft function was maintained in four out of six surviving patients, with one insulin-independent patient at 36 months after transplantation.

Conclusions

When a PF requires a relaparotomy, CP has become our favoured technique. AIT can reduce the metabolic impact of the procedure.     

An end-to-side suspender pancreaticojejunostomy: A new invagination pancreaticojejunostomy

Background: Postoperative pancreatic fistula(POPF) is a severe complication of the pancreaticoduodenectomy(PD). Recently, we introduced a method of suspender pancreaticojejunostomy(PJ) to the PD. In this study, we retrospectively analyzed various risk factors for complications after PD. We also introduced and assessed the suspender PJ to demonstrate its advantages.Methods: Data from 335 patients with various periampullary lesions, who underwent the Whipple procedure(classic Whipple procedure or pylorus-preserving) PD by either traditional end-to-side invagination PJ or suspender PJ, were analyzed. The correlation between either perioperative or postoperative complications and corresponding PD approaches was evaluated by univariate analysis.Results: A total of 147 patients received the traditional end-to-side invagination PJ, and 188 patients were given the suspender PJ. Overall, 51.9% patients had various complications after PD. The mortality rate was 2.4%. The POPF incidence in patients who received the suspender PJ was 5.3%, which was significantly lower than those who received the traditional end-to-side invagination PJ(18.4%)(P 0.001).Univariate analysis showed that PJ approach and the pancreas texture were significantly associated with the POPF incidence rate(P 0.01). POPF was a risk factor for both postoperative abdominal cavity infection(OR = 8.34, 95% CI: 3.99–17.42, P 0.001) and abdominal cavity hemorrhage(OR = 4.86, 95% CI:1.92–12.33, P = 0.001).Conclusions: Our study showed that the impact of the pancreas texture was a major risk factor for pancreatic leakage after a PD. The suspender PJ can be easily accomplished and widely applied and can effectively decrease the impact of the pancreas texture on pancreatic fistula after a PD and leads to a lower POPF incidence rate.     

Side-branch intraductal papillary mucinous neoplasms of the pancreatic head/uncinate: resection or enucleation?

Introduction

Side-branch intraductal papillary mucinous neoplasms (IPMN) of the pancreatic head/uncinate are an increasingly common indication for pancreaticoduodenectomy (PD). However, enucleation (EN) may be an alternative to PD in selected patients to improve outcomes and preserve pancreatic parenchyma.

Aim

To determine peri-operative outcomes in patients with side-branch IPMN of the pancreatic head/uncinate undergoing EN or PD compared with a cohort of patients with pancreatic adenocarcinoma (PA) undergoing PD.

Methods

Retrospective review of a prospectively collected, combined, academic institutional series from 2005 to 2008. Of 107 pancreatic head/uncinate IPMN, enucleation was performed in 7 (IPMN EN) and PD was performed in 100 (IPMN PD) with 17 of these radiographically amenable to EN (IPMN PD^en). During the same time period, 281 patients underwent PD for PA (Control PD).

Results

Operative time was shorter (p < 0.05) and blood loss (p < 0.05) was less in the IPMN EN group compared with all other groups. Peri-operative mortality and morbidity of all IPMN groups (IPMN EN, IPMN PD^en) were similar to the Control PD group. Overall pancreatic fistulae rate in the IPMN EN group was higher than in the IPMN PD^en and Control PD groups; however, the rate of grade C pancreatic fistulae was the same in all groups.

Conclusions

Pancreaticoduodenectomy for side-branch IPMNs can be performed safely. Compared with PD, enucleation for IPMN has less blood loss, shorter operative time and similar morbidity, mortality, hospital length of stay (LOS) and readmission rate. Enucleation should be considered more frequently as an option for patients with unifocal side-branch IPMN.     

A preoperative predictive score of pancreatic fistula following pancreatoduodenectomy

Background

Various factors are related to the occurrence of postoperative pancreatic fistula (POPF) following pancreatoduodenectomy (PD). Some of the strongest are identified intra- or postoperatively, which limits their utility in predicting this complication. The preoperative prediction of POPF permits an individualized approach to patient consent and selection, and may influence postoperative management. This study sought to develop and test a score to predict POPF.

Methods

A post hoc analysis of a prospectively maintained database was conducted. Consecutive patients were randomly selected to modelling and validation sets at a ratio of 2 : 1, respectively. Patient data, preoperative blood tests and physical characteristics of the gland (assessed from preoperative computed tomography images) were subjected to univariate and multivariate analysis in the modelling set of patients. A score predictive of POPF was designed and tested in the validation set.

Results

Postoperative pancreatic fistula occurred in 77 of 325 (23.7%) patients. The occurrence of POPF was associated with 12 factors. On multivariate analysis, body mass index and pancreatic duct width were independently associated with POPF. A risk score to predict POPF was designed (area under the receiver operating characteristic curve: 0.832, 95% confidence interval 0.768–0.897; P < 0.001) and successfully tested upon the validation set.

Conclusions

Preoperative assessment of a patient''s risk for POPF is possible using simple measurements. The present risk score is a valid tool with which to predict POPF in patients undergoing PD.     

Preoperative computed tomography measurements of pancreatic steatosis and visceral fat: prognostic markers for dissemination and lethality of pancreatic adenocarcinoma

Background

Increased visceral fat and pancreatic steatosis promote lymphatic metastases and decreased survival in patients with pancreatic adenocarcinoma after pancreatoduodenectomy (PD).

Objectives

We aim to determine the utility of preoperative computed tomography (CT) measurements of pancreatic steatosis and visceral fat as prognostic indicators in patients with pancreatic adenocarcinoma.

Methods

High-resolution CT scans of 42 patients undergoing PD for pancreatic adenocarcinoma were reviewed. Attenuation in CT of the pancreas, liver and spleen were measured in Hounsfield units and scored by two blinded investigators. Perirenal adipose tissue was measured in mm.

Results

Lymphatic metastases were present in 57% of patients. Age, gender, tumour size and margin status were similar in patients with and without nodal metastases. Node-positive patients had increased visceral but not subcutaneous fat pads compared with node-negative patients and decreased CT attenuation of the pancreatic body and tail and liver. Node-positive patients stratified by visceral adiposity (≥10 mm vs. <10 mm) demonstrated poorer survival (7 ± 1 months vs. 16 ± 2 months; P < 0.01).

Conclusions

In resected pancreatic adenocarcinoma, increased pancreatic steatosis and increased visceral fat stores are associated with lymphatic metastases. Furthermore, increased visceral fat is associated with abbreviated survival in patients with lymphatic metastases. Hence, increased visceral fat may be a causative factor of abbreviated survival and serves a prognostic role in patients with pancreatic malignancies.     

Drain data to predict clinically relevant pancreatic fistula

Background

Post-operative pancreatic fistula (POPF) is a common and potentially devastating complication of pancreas resection. Management of this complication is important to the pancreas surgeon.

Objective

The aim of the present study was to evaluate whether drain data accurately predicts clinically significant POPF.

Methods

A prospectively maintained database with daily drain amylase concentrations and output volumes from 177 consecutive pancreatic resections was analysed. Drain data, demographic and operative data were correlated with POPF (ISGPF Grade: A – clinically silent, B – clinically evident, C – severe) to determine predictive factors.

Results

Twenty-six (46.4%) out of 56 patients who underwent distal pancreatectomy and 52 (43.0%) out of 121 patients who underwent a Whipple procedure developed a POPF (Grade A-C). POPFs were classified as A (24, 42.9%) and C (2, 3.6%) after distal pancreatectomy whereas they were graded as A (35, 28.9%), B (15, 12.4%) and C (2, 1.7%) after Whipple procedures. Drain data analysis was limited to Whipple procedures because only two patients developed a clinically significant leak after distal pancreatectomy.The daily total drain output did not differ between patients with a clinical leak (Grades B/C) and patients without a clinical leak (no leak and Grade A) on post-operative day (POD) 1 to 7. Although the median amylase concentration was significantly higher in patients with a clinical leak on POD 1–6, there was no day that amylase concentration predicted a clinical leak better than simply classifying all patients as ‘no leak’ (maximum accuracy =86.1% on POD 1, expected accuracy by chance =85.6%, kappa =10.2%).

Conclusion

Drain amylase data in the early post-operative period are not a sensitive or specific predictor of which patients will develop clinically significant POPF after pancreas resection.     

Peri-operative outcomes for pancreatoduodenectomy in India: a multi-centric study

Background:

There have been an increasing number of reports world-wide relating improved outcomes after pancreatic resections to high volumes thereby supporting the idea of centralization of pancreatic resectional surgery. To date there has been no collective attempt from India at addressing this issue. This cohort study analysed peri-operative outcomes after pancreatoduodenectomy (PD) at seven major Indian centres.

Materials and Methods:

Between January 2005 and December 2007, retrospective data on PDs, including intra-operative and post-operative factors, were obtained from seven major centres for pancreatic surgery in India.

Results:

Between January 2005 and December 2007, a total of 718 PDs were performed in India at the seven centres. The median number of PDs performed per year was 34 (range 9–54). The median number of PDs per surgeon per year was 16 (range 7–38). Ninety-four per cent of surgeries were performed for suspected malignancy in the pancreatic head and periampullary region. The median mortality rate per centre was four (range 2–5%). Wound infections were the commonest complication with a median incidence per centre of 18% (range 9.3–32.2%), and the median post-operative duration of hospital stay was 16 days (range 4–100 days).

Conclusions:

This is the first multi-centric report of peri-operative outcomes of PD from India. The results from these specialist centers are very acceptable, and appear to support the thrust towards centralization.