Risk factors for postoperative pancreatic fistula after pancreaticoduodenectomy: the significance of the ratio of the main pancreatic duct to the pancreas body as a predictor of leakage

Objective

Postoperative pancreatic fistula (POPF) is a severe and frequent complication after pancreaticoduodenectomy (PD). The aim of this study was to identify an independent predictor of POPF and to assess the efficacy of preoperative multidetector row computed tomography (MDCT) images as an indicator for POPF.

Methods

A total of 122 patients who underwent PD with an end-to-side, duct-to-mucosa pancreaticojejunostomy between January 2005 and May 2009 were retrospectively reviewed. The diameter of the main pancreatic duct (MPD), the diameter of the short axis of the pancreas body, and the ratio of the MPD to the pancreas body (MPD index) were digitally measured based on the curved reformatted images of preoperative MDCT.

Results

Postoperative pancreatic fistula occurred in 33 patients (27%). The operative mortality rate was 3.3% (4 patients). All four patients had grade C POPF. Three died because of hemorrhage from a pseudoaneurysm of the gastroduodenal artery stump, and one died because of sepsis due to major leakage from the pancreaticojejunostomy. In a multivariate analysis, the intraoperative blood loss (/100 ml) [odds ratio (OR), 1.1; 95% confidence interval (CI), 1.05–1.17] and MPD index (<0.2) (OR 50; 95% CI 6–41) proved to be independent predictors of POPF. In patients with an MPD index of <0.2, the incidence of POPF was 45%, and the mortality rate was 7.5%.

Conclusion

The MPD index obtained from preoperative MDCT can be a reliable predictor of POPF after PD.     

Blumgart吻合在胰十二指肠切除术后胰瘘防治中的作用

目的评价Blumgart吻合方法对胰十二指肠切除术后胰瘘及其他并发症发生的影响。方法回顾南京医科大学附属南京医院2005年1月-2011年12月实施胰十二指肠切除术的190例患者的临床资料。将患者按照不同的吻合方式为3组:Blumgart吻合组(A组)55例,胰管空肠黏膜端侧吻合组(B组)65例,套入式吻合组(C组)70例。比较不同吻合方法术后胰瘘及其他并发症的发生率。各组并发症发生率的比较采用行×列χ2检验。结果全部患者均无围手术期死亡,术后并发症发生率为48.4%(92/190),其中A组为25.5%(14/55),B组为52.3%(34/65),C组为62.9%(44/70),3组比较差异有统计学意义(χ2=17.850,P0.05)。术后胰瘘发生率20.5%(39/190),其中A组为5.5%(3/55),B组为20%(13/65),C组为32.9%(23/70)。在胰管内径3 mm的患者中,不同吻合方式的患者胰瘘发生率差异有统计学意义(χ2=6.089,P0.05),在≥3mm的患者时,不同吻合方式患者胰瘘的发生率差异无统计学意义(χ2=5.436,P0.05)。结论 Blumgart胰肠吻合方法安全、简单、省时,明显降低胰瘘的发生率,值得推广。     

Total closure of pancreatic section for end-to-side pancreaticojejunostomy decreases incidence of pancreatic fistula in pancreaticoduodenectomy

BACKGROUND: Postoperative pancreatic fistula (POPF) is a serious complication and results in prolonged hospitalization and high mortality. The present study aimed to evaluate the safety and effectiveness of total closure of pancreatic section for end-to-side pancreaticojejunostomy in pancreaticoduode-nectomy (PD).METHODS: This was a prospective randomized clinical trial comparing the outcomes of PD between patients who un-derwent total closure of pancreatic section for end-to-side pancreaticojejunostomy (Group A) vs those who underwent conventional pancreaticojejunostomy (Group B). The primary endpoint was the incidence of pancreatic fistula. Secondary endpoints were morbidity and mortality rates.RESULTS: One hundred twenty-three patients were included in this study. The POPF rate was significantly lower in Group A than that in Group B (4.8% vs 16.7%, P<0.05). About 38.3%patients in Group B developed one or more complications;this rate was 14.3% in Group A (P<0.01). The wound/abdomi-nal infection rate was also much higher in Group B than that in Group A (20.0% vs 6.3%, P<0.05). Furthermore, the average hospital stays of the two groups were 18 days in Group A, and 24 days in Group B, respectively (P<0.001). However, there was no difference in the probability of mortality, biliary leakage,delayed gastric emptying, and pulmonary infection between the two groups.CONCLUSION: Total closure of pancreatic section for end-to-side pancreaticojejunostomy is a safe and effective method for pancreaticojejunostomy in PD.     

Pancreatic fistula after pancreaticoduodenectomy: the conservative treatment of choice

Background:

A pancreatic fistula (PF) is the most common complication after pancreaticoduodenectomy (PD), and its reported incidence varies from 2% to 28%. The aim of the present study was to analyse the treatment of a complicated PF comparing the surgical approach with conservative techniques.

Methods:

From January 2000 through to August 2006, 121 patients were submitted for PD. The study consisted of 70 men and 47 women, with a median age of 60 years (SD ± 12). The main indications for PD were pancreatic duct carcinoma in 52 patients (44.5%), ampullary carcinoma or adenoma in 18 (15.4%) and islet cell tumour in 11 (9.4%). Reconstruction by pancreatogastrostomy was performed in 65 patients (55.6%), and pancreatojejunostomy in 52 patients (44%).

Results:

Thirty-five patients (30%) developed a PF. Amongst these, 20 were managed conservatively and 14 were reoperated. These two groups of patients were compared with patients without a PF for analysis. There was no significant difference in the mean age, the gender ratio, American Society of Anesthesiologists (ASA) classification, surgical time and blood replacement, number of associated procedures, vascular resection and type of reconstruction between the three groups. There were five post-operative deaths (4.2%), three patients (21.4%) in the surgical treatment group (P < 0.01). Mean total number of complications (P= 0.02) and mean length of hospital stay (P < 0.001) were greater in the surgical group. The medium delay between the pancreatic resection and reoperation was 10 days (range, 3–32 days). Completion splenopancreatectomy was required in five patients whereas conservative treatment including debridement and drainage was applied in nine patients.

Conclusion:

The surgical approach for a PF is associated with a higher mortality and morbidity. There is no advantage in performing completion pancreatectomy (CP) instead of extensive drainage as a result of the same mortality and morbidity rates and the risk of endocrine insufficiency. In cases of complicated PF, radiological or surgical conservative treatment is recommended.     

Tailored pancreatic reconstruction after pancreaticoduodenectomy: a single-center experience of 892 cases

BACKGROUND: Pancreatic reconstruction following pancre-aticoduodenectomy (PD) is still debatable even for pancreatic surgeons. Ideally, pancreatic reconstruction after PD should reduce the risk of postoperative pancreatic fistula (POPF) and its severity if developed with preservation of both exo-crine and endocrine pancreatic functions. It must be tailored to control the morbidity linked to the type of reconstruction. This study was to show the best type of pancreatic reconstruc-tion according to the characters of pancreatic stump. METHODS: We studied all patients who underwent PD in our center from January 1993 to December 2015. Patients were categorized into three groups depending on the presence of risk factors of postoperative complications: low-risk group (ab-sent risk factor), moderate-risk group (presence of one risk fac-tor) and high-risk group (presence of two or more risk factors). RESULTS: A total of 892 patients underwent PD for resection of periampullary tumor. BMI >25 kg/m2, cirrhotic liver, soft pancreas, pancreatic duct diameter <3 mm, and pancreatic duct location from posterior edge <3 mm are risk variables for development of postoperative complications. POPF de-veloped in 128 (14.3%) patients. Delayed gastric emptying occurred in 164 (18.4%) patients, biliary leakage developed in 65 (7.3%) and pancreatitis presented in 20 (2.2%). POPF in low-, moderate- and high-risk groups were 26 (8.3%), 65 (15.7%) and 37 (22.7%) patients, respectively. Postoperative morbidity and mortality were significantly lower with pan-creaticogastrostomy (PG) in high-risk group, while pancre-aticojejunostomy (PJ) decreases incidence of postoperative steatorrhea in all groups. CONCLUSIONS: Selection of proper pancreatic reconstruc-tion according to the risk factors of patients may reduce POPF and postoperative complications and mortality. PG is superior to PJ as regards short-term outcomes in high-risk group but PJ provides better pancreatic function in all groups and therefore, PJ is superior in low- and moderate-risk groups.     

Pancreaticojejunostomy after pancreaticoduodenectomy: Suture material and incidence of post-operative pancreatic fistula

PurposePancreatic fistula represents the most important complication in terms of clinical management and costs after pancreaticoduodenectomy. A lot of studies have investigated several techniques in order to reduce pancreatic fistula, but data on the effect of sutures material on pancreatic fistula are not available. The analysis investigated the role of suture material in influencing pancreatic fistula rate and severity.MethodsResults from 130 consecutive pancreaticoduodenectomy with pancreaticojejunostomy performed between March 2013 and September 2014 were prospectively collected and analyzed. In 65 cases pancreaticojejunostomy was performed with absorbable sutures, in the other 65 cases using non-absorbable sutures (polyester, silk and polybutester).ResultsPancreaticojejunostomy with non-absorbable sutures had the same incidence of pancreatic fistula, but less severe and with less episodes of post-operative bleeding if compared with absorbable sutures. A sub-analysis was carried out comparing polydioxanone with polyester: the latter was associated with a lower pancreatic fistula rate (11.9% vs. 31.7%; p = 0,01) and less severe pancreatic anastomosis dehiscence (grade C - 0% vs. 30%; p = 0.05). Univariate and multivariate analysis confirmed that hard pancreatic texture, pancreatic ductal adenocarcinoma at final histology and the use of polyester for pancreaticojejunostomy were associated with a lower pancreatic fistula rate (p < 0.05).ConclusionFurther studies are needed to investigate the effects of pancreatic juice and bile on different sutures and pancreatic tissue response to different materials. However, pancreaticojejunostomy performed with polyester sutures is safe and feasible and is associated to a lower incidence of pancreatic fistula with less severe clinical impact.     

Risk factors and managements of hemorrhage associated with pancreatic fistula after pancre-aticoduodenectomy

BACKGROUND: Post-pancreaticoduodenectomy pancreatic fistula associated hemorrhage(PPFH) is one of the leading lethal complications. Our study was to analyze the risk factors and managements of hemorrhage associated with pancreatic fistula after pancreaticoduodenectomy, and to evaluate treatment options.METHOD: We analyzed 445 patients who underwent pancreaticoduodenectomy or pylorus-preserving pancreaticoduodenectomy and evaluated the relevance between clinical data and PPFH.RESULTS: The incidence of postoperative pancreatic fistula(POPF) was 27.42%(122/445), and the incidence of PPFH was 4.49%(20/445). Among the 20 patients with PPFH, 7died and 13 were cured. Interventional angiographic therapy was performed for 10 patients and 5 were successfully treated. Relaparotomy was performed for 5 patients and 2 were successfully cured. Univariate logistic regression analysis indicated that several risk factors were related to PPFH: the nature of tumor(carcinoid/low-grade or high-grade malignancy), preoperative day 1 serum prealbumin, preoperative day 1 total bilirubin(TBIL), operative time, blood loss in the operation, operative method(vascular resection and revascularization), postoperative day 3 TBIL, biliary fistula, and the grade of POPF. The multivariate stepwise logistic regression analysis demonstrated that the nature of tumor and the grade of POPF were independently risk factors of PPFH. Receiver operating characteristic curve indicated that preoperative day 1 serum prealbumin level 173 mg/L and postoperative day 3 TBIL level ≥168 μmol/L were the risk factors of PPFH.CONCLUSIONS: The risk of PPFH was found to be increased with high potential malignancy and high grade of POPF. Angiography-embolization is one of the major and effective therapies for PPFH. Extraluminal-intraluminal PPFH is more serious and needs more aggressive treatments.     

胰十二指肠切除术后胰肠吻合口瘘临床分析

目的：回顾分析胰十二指肠切除术后发生胰肠吻合口瘘病例以减少手术并发症。方法：对1986年1月－2001年6月62例胰十二指肠切除术病例资料行回顾性分析。结果：62例中，发生胰肠吻合口瘘9例，发生率14．5％，其中1986年1月－1991年12月发生胰肠吻合口瘘5例，发生率62．5％（5／8）；1992年1月－2001年6月发生胰肠吻合口瘘4例，发生率7．4％（4／54）。围手术期死亡2例，死亡率3．2％，占胰瘘的22．2％。死因为胰瘘致全身衰竭。结论：要降低胰肠吻合口瘘的发生率，重点在于手术技巧及方式的改进。手术前后的支持治疗、应用生长抑制、控制感染、有效的胃肠减压是必须的。一旦发生胰瘘，若早期诊断，及时采取综合治疗，可以使绝大部分的胰肠吻合口瘘得到治愈。     

Determination of factors predictive of outcome for patients undergoing a pancreaticoduodenectomy of pancreatic head ductal adenocarcinomas

Introduction

A pancreaticoduodenectomy is the reference treatment for a resectable pancreatic head ductal adenocarcinoma. The probability of 5-year survival in patients undergoing such treatment is 5–25% and is associated with relatively high peri-operative morbidity and mortality. The objective of the present study was to evaluate risk factors predictive of outcome for patients undergoing a pancreaticoduodenectomy for a pancreatic adenocarcinoma.

Methods

This retrospective analysis incorporated data from the Vancouver General Hospital and the British Columbia Cancer Agency (BCCA) from 1999–2007.

Results

The 5-year survival of 100 patients was 12% with a median survival of 16.5 months. Ninety-day mortality was 7%. Predictors of 90-day mortality included age ≥ 80 years (P < 0.001) and an American Society of Anesthesiologists (ASA) score = 3 (P = 0.012) by univariate analysis and age ≥80 years (P < 0.001) by multivariate analysis. The identifiable predictive factor for poor 5-year survival was an ASA score = 3 (P = 0.043) whereas a Dindo–Clavien surgical complication grade ≥ 3 was associated with a worse outcome (P = 0.013). Referral to the BCCA was associated with a favourable 5-year survival (P = 0.001).

Conclusions

The present study identifies risk factors for patient selection to enhance survival benefit in this patient population.     

Complications after pancreaticoduodenectomy: the problem of current definitions

Pancreaticoduodenectomy nowadays represents a complex procedure and a challenge for the surgeon. Even though mortality is reported to be below 5% for experienced surgeons, morbidity is still around 30%–50%, often leading to prolongation of hospital stay, demanding postoperative investigations and procedures, and outpatient monitoring of the patients with complications. In the literature there is no agreement on the definitions of postoperative complications following pancreaticoduodenectomy, leading to a wide range of complication rates in different specialist units, particularly regarding the source of every complication, postoperative pancreatic fistula, and others such as delayed gastric emptying. Some authors have demonstrated that applying different definitions in homogeneous, single-center series, the incidence of a complication varied with statistical significance, implying the impossibility of correctly comparing different experiences. It seems essential to organize a Consensus Meeting among expert surgeons to prepare world-wide accepted definitions. The aim of this article is to review the current controversial definitions and to suggest a new clinical-based approach to the problem of the feasibility and reliability of the definitions themselves.     

Correlation of apparent diffusion coefficient measured by diffusion-weighted MRI and clinicopathologic features in pancreatic cancer patients

Background/purpose

The aim of this study was to evaluate the clinical usefulness of diffusion-weighted magnetic resonance imaging (DWI) in patients with pancreatic cancer by comparing the apparent diffusion coefficient (ADC) value with clinicopathologic features.

Methods

Twenty-two consecutive patients (12 men, 10 women; mean age 64.4 years) with pancreatic cancer underwent DWI before surgery. We retrospectively investigated the correlations between tumor ADC value and clinicopathologic features.

Results

Apparent diffusion coefficient value was significantly lower for pancreatic cancer than for noncancerous tissue (P < 0.001). Receiver operating characteristic analysis yielded an optimal ADC cutoff value of 1.21 × 10^?3 mm²/s to distinguish pancreatic cancer from noncancerous tissue. There was a significant negative correlation between ADC value and tumor size (r = ?0.59, P = 0.004) and between ADC value and number of metastatic lymph nodes (r = ?0.56, P = 0.007). Tumors with low ADC value had a significant tendency to show high portal venous system invasion (P = 0.02) and extrapancreatic nerve plexus invasion (P = 0.01).

Conclusions

Apparent diffusion coefficient value appears to be a promising parameter for detecting pancreatic cancer and evaluating the degree of malignancy of pancreatic cancer.     

Novel interventional treatment technique for intractable pancreatic fistula due to dehiscence of pancreatico-jejunal anastomosis following pancreaticoduodenectomy

Despite recent technological advances in the treatment of hepatobiliary pancreatic disease, intractable external pancreatic fistula is still a major critical complication after pancreaticoduodenectomy, and the treatment strategy is not well defined. We report here a case that was successfully treated by our novel interventional internal drainage technique. A 62-year-old woman underwent pylorus-preserving pancreaticoduodenectomy for carcinoma of the papilla of Vater, with reconstruction by a modified Child’s procedure. One year later, she was readmitted to our hospital because of external pancreatic fistula. Both computed tomography and fistulography demonstrated a pancreatic fistula derived from dehiscence of the pancreatico-jejunal anastomosis. The pancreatic fistula persisted for 1 week with conservative management. Therefore, we performed repeated fistulography and cannulation, using two comparatively stiff guidewires introduced into the main pancreatic duct and stenotic anastomosed jejunal lumen, respectively, and we placed an endoprosthesis, using bilateral guidewires to connect the two lumens. Consequently, the pancreatic fistula was successfully closed within a few days. Our novel technique is simple, rapid, and not costly. Therefore, it should be considered an effective treatment strategy for persistent pancreatic fistula following pancreaticoduodenectomy that fails to respond to initial conservative management and an endoscopic approach. Also, this technique is applicable to other intractable fistulous situations.     

Pancreatic reconstruction techniques after pancreaticoduodenectomy: a review of the literature

ABSTRACT

Introduction: Postoperative pancreatic fistula is the most troublesome complication after pancreaticoduodenectomy, and is an on-going area of concern for pancreatic surgeons. The specific pancreatic reconstruction technique is an important factor influencing the development of postoperative pancreatic fistula after pancreaticoduodenectomy.

Areas covered: In this paper, we briefly introduced the definition and relevant influencing factors of postoperative pancreatic fistula. We performed a search of all meta-analyses published in the last 5 years and all published randomized controlled trials comparing different pancreatic anastomotic techniques, and we evaluated the advantages and disadvantages of different techniques.

Expert opinion: No individual anastomotic method can completely avoid postoperative pancreatic fistula. Selecting specific techniques tailored to the patient’s situation intraoperatively may be key to reducing the incidence of postoperative pancreatic fistula.     

胰腺吻合新理念与新技术

胰十二指肠切除术的手术方式存在许多争议,其术中消化道重建,特别是胰腺的吻合方式一直以来是其难点之一。介绍了目前国际上各种胰十二指肠切除术的消化道重建方式,并提出自己的观点,即根据胰管大小和胰腺质地对胰腺进行分类,以此提出新的"个体化"的消化道重建方式,进一步的指导外科医生选择恰当的手术方式以减少胰瘘等术后并发症的发生。     

RETRACTED ARTICLE: Preoperative endoscopic pancreatic stenting: a novel prophylactic measure against pancreatic fistula after distal pancreatectomy

Background/Purpose

The prevention of pancreatic fistula is still a major problem in distal pancreatectomy (DP). We have recently adopted preoperative endoscopic pancreatic stenting with the aim of preventing the leakage of pancreatic juice from the resection plane of the remnant pancreas after DP. We reviewed ten patients who underwent this intervention.

Methods

One to 6 days before surgery, the patients underwent an endoscopic transpapillary pancreatic stent (7 Fr., 3 cm) placement. The perioperative short-term outcomes were assessed.

Results

Preoperative endoscopic pancreatic stenting was successfully performed in all ten patients. Two (20%) patients, both with intraductal papillary mucinous tumor, developed mild acute pancreatitis after the stent placement. None of the ten patients developed pancreatic fistula. The pancreatic stent was removed 8–28 days (mean, 11 days) postoperatively.

Conclusions

Preoperative endoscopic pancreatic stenting may be an effective prophylactic measure against pancreatic fistula development following DP.

     

胰十二指肠切除术后胰瘘发生的危险因素分析

目的 分析胰十二指肠切除术后胰瘘发生的危险因素,为临床有效降低术后并发症提供理论依据.方法 回顾性分析2009年9月至2012年9月上海交通大学医学院附属仁济医院收治的352例因癌症行胰十二指肠切除术患者的临床资料,根据术后有无发生胰瘘将患者分为胰瘘组和非胰瘘组进行对列研究.对围手术期可能影响术后发生胰瘘的多种因素进行单因素分析及多变量Logistic回归分析.结果 共49例胰十二指肠切除术后发生胰瘘,胰瘘发生率为13.9％ (49/352).经单因素及多因素分析,术后胰瘘的发生与患者性别和年龄、糖尿病病史、手术时间、术中出血量、是否血管切除重建、胰管是否留置支撑管、胰肠吻合时间、消化道重建方式等均无关;而胰腺质地脆、胰管直径＜3 mm、术前血清总胆红素水平＞ 171 μmol/L、术前黄疸持续时间超过8周、术前血清白蛋白水平＜30 g/L是影响术后胰瘘发生的独立危险因素(P值均＜0.05).结论 胰腺质地、胰管直径、术前黄疸程度、黄疸持续时间及低蛋白血症是影响胰十二指肠切除术后胰瘘发生的危险因素.     

硬脊膜动静脉瘘磁共振成像的特点

目的分析硬脊膜动静脉瘘(SDAVF)脊髓病变的MRI特点,探讨脊髓病变与畸形血管和临床症状的关系。方法经DSA证实的SDAVF患者32例,应用场强3.0T超导型MRI扫描仪于术前行常规脊髓MRI平扫和增强扫描。按照脊髓病变的范围,分为局限(1～4个椎体)、中度(5～7个椎体)和广泛(8～10个椎体)病变三组。按照改良的Aminoff和Logue步态与排尿障碍法,于术前对患者进行临床评分,<6分为轻症者,≥6分为重症者。结果①30例病变中心位于下胸段(94%,30/32)。32例中病变局限组8例(25%),临床轻症者6例,重症者2例;中度组19例(59%),临床轻症者5例,重症者14例;广泛组5例(16%),轻症者1例,重症者4例。②32例患者髓内均可见T2WI高信号,31例高信号位于脊髓中心,呈"铅笔样"改变,1例呈弥散状分布;2例髓内可见T1WI低信号。增强扫描后,31例脊髓强化,1例未见强化。③瘘口位于脊髓病变范围内12例,位于脊髓病变范围外20例。④31例引流静脉范围≥相应脊髓病变范围,且引流静脉与脊髓病变部位一致;1例脊髓病变>引流静脉范围,引流静脉与脊髓病变部位部分一致。结论①SDAVF脊髓病变范围...     

Transection using bipolar scissors reduces pancreatic fistula after distal pancreatectomy

Background/Purpose

Various methods and technique for treating the surgical stump of the remnant pancreas have been reported to reduce pancreatic fistula after distal pancreatectomy (DP). However, appropriate surgical stump closure after DP is still controversial. We aimed to clarify whether using bipolar scissors in DP reduces pancreatic fistula compared to hand-sewn suture of surgical stump closure.

Methods

Between January 1989 and December 2005, handsewn suture of surgical stump closure was performed (n = 49), and bipolar scissors was prospectively performed between January 2006 and July 2007 (n = 26).

Results

The overall rate of pancreatic fistula after DP was 22 patients (29%). There were significant differences between the hand-sewn suture group (41%) and bipolar scissors group (8%) concerning pancreatic fistula (P = 0.0164). A multivariate logistic regression analysis revealed that two factors, soft pancreas and hand-sewn suture compared to bipolar scissors, were independent risk factors of pancreatic fistula after DP (P = 0.011 and 0.0361, respectively).

Conclusions

Bipolar scissors for transection of the pancreas is a useful device to reduce pancreatic fistula after DP.