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.     

Association Between the Incidence of Pancreatic Fistula After Pancreaticoduodenectomy and the Degree of Pancreatic Fibrosis

Objective

The objective of this study is to investigate the association between the incidence of pancreatic fistula after pancreaticoduodenectomy (PD) and the degree of pancreatic fibrosis.

Method

Between January 2013 and December 2016, the analysis of the clinical data of 529 cases of pancreaticoduodenectomy patients of our hospital was performed in a retrospective fashion. The univariate analysis and multivariate analysis were done using the Pearson chi-squared test and binary logistic regression analysis model; correlations were analyzed by Spearman rank correlation analysis. The value of the degree of pancreatic fibrosis to predict the incidence of pancreatic fistula after pancreaticoduodenectomy was evaluated by the area under the receiver operating characteristic (ROC) curve.

Results

The total incidence of pancreatic fistula after pancreaticoduodenectomy was 28.5% (151/529). Univariate analysis and multivariate analysis showed that BMI?≥?25 kg/m², pancreatic duct size ≤?3 mm, pancreatic CT value<?30, the soft texture of the pancreas (judged during the operation), and the percent of fibrosis of pancreatic lobule ≤?25% are prognostic factors of pancreatic fistula after pancreaticoduodenectomy (P?<?0.05); the pancreatic CT value and the percent of fibrosis of pancreatic lobule in pancreatic fistula group were both lower than those in non-pancreatic fistula group (P?<?0.05). Results indicated that there is a negative correlation between the severity of pancreatic fistula and the pancreatic CT value or the percent of fibrosis of pancreatic lobule (r?=???0.297, ??0.342, respectively). The areas under the ROC curve of the percent of fibrosis of pancreatic lobule and the pancreatic CT value were 0.756 and 0.728, respectively.

Conclusion

The degree of pancreatic fibrosis is a prognostic factor which can influence the pancreatic texture and the incidence of pancreatic fistula after pancreaticoduodenectomy. The pancreatic CT value can be used as a quantitative index of the degree of pancreatic fibrosis to predict the incidence of pancreatic fistula after pancreaticoduodenectomy.

     

Perioperative Net Fluid Balance Predicts Pancreatic Fistula After Pancreaticoduodenectomy

Background

Our goal was to evaluate the relationship between perioperative fluid administration and the development of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD).

Methods

Retrospectively, we analyzed fluid balance over the first 72 h in 104 consecutive patients who underwent PD between 2013 and 2017. Patients were categorized into tertiles (low, medium, and high) by net fluid balance.

Results

POPF was identified in 17.3% of patients (n?=?18). No significant demographic differences were identified among tertiles. Similarly, there were no differences in ASA, smoking status, hemoglobin A1C, pathologic findings, operative time, blood loss, intraoperative fluid administration, use of pancreatic stents, use of epidurals, or postoperative lactate. Patients with high 72-h net fluid balance had significantly increased rates of POPF compared with those in the medium and low tertiles (31.4% vs. 11.4% vs. 8.8%, p?=?0.02). On multivariate analysis, increasing net fluid balance remained associated with CR-POPF (OR 1.26, CI 1.03–1.55, p?=?0.03).

Conclusion

High net 72-h fluid balance is an independent predictor of POPF after PD. Given ongoing efforts to minimize PD morbidity, net fluid balance may represent a clinical predictor and, possibly, a modifiable target for prevention of POPF.

     

胰漏危险度评分系统用于预测胰十二指肠切除术后胰漏低风险患者的价值

目的探讨胰漏危险度评分系统(Fistula Risk Score,FRS)预测胰十二指肠切除术后临床相关胰漏(clinically relevant pancreatic fistula,CRPF)低风险患者的价值。方法回顾性分析2015年1月~2017年6月我科90例胰十二指肠切除术的临床资料,使用剂量-反应关系及诊断效能四格表法分析FRS在预测胰十二指肠切除术后CRPF低风险患者中的价值。结果共19例发生CRPF,其中B、C级胰漏分别为17、2例;发生时间:2例术后第8天发生,2例术后第10天发生,5例术后第14天发生,2例术后第16天发生,8例术后第21天发生。对90例进行FRS评分与CRPF发生的剂量-反应关系分析显示,FRS<4分的25例均无CRPF发生,敏感性100.0%(19/19),阴性预测值100.0%(25/25)。结论FRS对于发生CRPF风险低的患者预测价值较好,对于FRS<4分的患者可尝试采取更为积极的快速康复方案。     

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.     

A Cohort Study for Derivation and Validation of Early Detection of Pancreatic Fistula After Pancreaticoduodenectomy

Background

Pancreatic fistula (PF) remains the most important morbidity after pancreaticoduodenectomy (PD). Early drain removal was recently recommended. However, this is not applicable to all cases because the development of severe PF may not be obvious until a later postoperative day (POD). This study aimed to discover ways to detect clinically relevant PF early during the postoperative stage after PD.

Methods

We studied 120 patients who underwent PD. Grades B/C PF classified according to the International Study Group of Pancreatic Surgery guidelines were defined as clinically relevant PF. Logistic regression was used to identify detection factors for clinically relevant PF. Receiver operating characteristic curves were used to identify the optimal cutoff value for clinically relevant PF, and the k-fold cross-validation model to validate the cutoff value.

Results

Drain amylase on POD 1 and C-reactive protein (CPR) on POD 2 were independent factors for clinically relevant PF. Drain amylase >1300 IU/l on POD 1 and CRP >12.8 g/dl on POD 2 were the best cutoff values for clinically relevant PF detection and were confirmed by k-fold cross-validation. The sensitivity and specificity values were 79 and 81 %, respectively.

Conclusions

Values of drain amylase and CRP combined were useful to distinguish clinically relevant PF.

     

Pancreatic Fibrosis Correlates With Delayed Gastric Emptying After Pylorus-Preserving Pancreaticoduodenectomy With Pancreaticogastrostomy

OBJECTIVE: To show that residual pancreatitis delays gastric emptying, the authors used surgical specimens and studied gastric stasis after pylorus-preserving pancreaticoduodenectomy (PPPD). SUMMARY BACKGROUND DATA: Delayed gastric emptying is a leading cause of complications after PPPD, occurring in 30% of patients. The pathogenesis of delayed gastric emptying remains unclear. METHODS: Surgical specimens of the pancreas from 25 patients undergoing PPPD and pancreaticogastrostomy were collected and examined by microscopy according to progressive pancreatic fibrosis and divided into three groups: no fibrosis, periductal fibrosis, and intralobular fibrosis. The authors then measured gastric output from the nasogastric tube, pancreatic output from the pancreatic tube, and the time until patients tolerated a solid diet. RESULTS: Pancreatic juice output was significantly related to the degree of pathologic findings, and gastric output was inversely related to them. A significant prolongation of postoperative solid diet tolerance correlated with increased pancreatic fibrosis and gastric fluid production. CONCLUSIONS: Pancreatic fibrosis and increased gastric fluid production correlate with delayed gastric emptying after PPPD with pancreaticogastrostomy.     

Preoperative Sarcopenia Strongly Influences the Risk of Postoperative Pancreatic Fistula Formation After Pancreaticoduodenectomy

Background

Postoperative pancreatic fistula (POPF) is a serious complication of pancreaticoduodenectomy (PD). Sarcopenia is a newly identified marker of frailty. We performed this study to assess whether preoperative sarcopenia has an impact on clinically relevant POPF formation.

Methods

A total of 266 consecutive patients who underwent a PD between 2010 and 2014 were enrolled in this retrospective study. Skeletal muscle mass was measured using preoperative computed tomography images. The impact of preoperative sarcopenia on clinically relevant POPF formation was analyzed using univariate and multivariate analyses.

Results

Of the 266 patients, 132 (49.6 %) were classified as having preoperative sarcopenia. The rate of clinically relevant POPF formation was significantly higher in the sarcopenia group (22.0 vs. 10.4 %; P?=?0.011). A multivariate logistic regression analysis showed that sarcopenia (odds ratio, 2.869; P?=?0.007) was an independent risk factor for the development of clinically relevant POPF, along with a soft pancreas and a parenchymal thickness at the pancreatic resection site of ≥8 mm.

Conclusions

Preoperative sarcopenia was identified as a strong and independent risk factor for clinically relevant POPF formation after PD. Perioperative rehabilitation and nutrition therapy may contribute to the prevention of POPF formation and a safer PD.

     

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.     

胰十二指肠切除术后胰瘘的防治近况

目的总结胰十二指肠切除术后胰瘘的防治近况.方法综合近年来国内外文献有关胰瘘防治的方法和进展,对各种预防胰瘘方法进行评价.结果胰腺残端的处理是预防胰瘘的关键,各种胰肠吻合术预防胰瘘作用有不同结果,胰胃和胰肠吻合术胰瘘的发生率分别为12.3%和11.1%左右.捆绑式胰肠吻合术,在连续100例的临床应用中,其胰瘘率为0,效果独特.结论各种胰腺残端的处理方法各有利弊,其中胰肠吻合为最常用的方法,捆绑式胰肠吻合术对预防胰瘘的发生有确切效果,值得推广应用.     

胰十二指肠切除术后胰瘘的相关因素分析及防治策略

虽然胰十二指肠切除术技术不断改进,但胰瘘仍然是术后难以避免的最严重的并发症,本文针对胰瘘的定义、影响胰瘘的相关因素及胰瘘防治措施的研究进展作进一步的综述。     

胰管内径对胰十二指肠切除术后胰瘘发生率的影响

目的 分析胰管内径对胰十二指肠切除术后胰瘘发生率的影响.方法 选取1995年1月至2008年12月期间在我院行胰十二指肠切除术的患者256例,根据胰肠吻合方式分为胰管空肠端侧黏膜吻合组(n=115)、胰管空肠端端黏膜吻合组(n=71)、胰管空肠端端套入组(n=43)和胰胃吻合组(n=27).另外,将238例患者根据不同引流方式分为支撑内引流组(n=132)和支撑外引流组(n=106),比较各组胰瘘的发生率;将223例患者根据胰管内径大小分为≤0.2 cm组(n=54)、0.2～0.4 cm组(n=93)和≥0.4 cm组(n=76),比较不同胰管内径对胰瘘发生率的影响.结果 本组胰瘘发生率为8.20%(21/256).各吻合方式的胰瘘发生率为: 胰管空肠端侧黏膜吻合组为7.83%(9/115),胰管空肠端端黏膜吻合组为7.04%(5/71),胰管空肠端端套入组为13.95%(6/43),胰胃吻合组为3.70%(1/27),4组间差异无统计学意义(χ2=2.763,P=0.430);胰管支撑内引流组和支撑外引流组的胰瘘发生率分别为9.10%(12/132)和8.49%(9/106),差异无统计学意义(χ2=0.126,P=0.722).胰管内径≥0.4 cm者无胰瘘发生,胰管内径在0.2～0.4 cm与胰管内径≤0.2 cm的胰瘘发生率分别为15.05%(14/93)和11.11%(6/54),3组间差异有统计学意义(χ2=12.009,P=0.002).不同胰管内径的胰瘘发生率与胰肠吻合方式无关(χ2=1.878,P=0.598). 结论胰肠吻合方式对胰瘘发生率无影响,胰管内径是影响胰瘘发生的重要因素.     

No Mortality or Pancreatic Fistula After Full-Thickness Suture Pancreaticogastrostomy in 39 Patients Who Underwent Pancreaticoduodenectomy

Pancreaticoduodenectomy is considered the standard operation for periampullary tumors. Despite major advances in pancreatic surgery, pancreatic fistula is still an important cause of morbidity and mortality after pancreaticoduodenectomy. Meticulous surgical technique and proper reconstruction of the pancreas are essential to prevent pancreatic fistula. Pancreaticogastrostomy is a safe method for reconstruction of the pancreas after pancreaticoduodenectomy. Regardless of pancreatic texture or duct diameter, the reconstruction is performed by passing full-thickness sutures through both the anterior and posterior sides of the pancreas. In this study, we report 39 cases of reconstruction with pancreaticogastrostomy after pancreaticoduodenectomy without mortality or pancreatic fistula.Key words: Pancreaticogastrostomy, Pancreatic fistula, Pancreaticoduodenectomy, Full-thickness suturesPancreaticoduodenectomy (PD) is considered the standard treatment for periampullary tumors. Despite major advances in pancreatic surgery, overall postoperative morbidity after PD is high, even in high-volume centers.¹ While the operation-associated mortality rate of pancreatic surgery has decreased to less than 4%, the operation-associated morbidity rate is reported to be as high as 50%, largely due to the pancreaticoenteric anastomosis, the “Achilles'' heel” of pancreatic surgery.^2–4Pancreatic fistula (PF) is the most important cause of morbidity and mortality after PD. Soft pancreatic tissue texture and small pancreatic duct diameter have been identified as risk factors for PF. Pancreatic fistula may cause life-threatening complications, such as postoperative hemorrhage and peritonitis.⁵ We report the first cases without mortality or PF in 39 patients who were reconstructed with pancreaticogastrostomy (PG) after PD. In this study, we performed the PG by passing full-thickness sutures through the pancreas wall from both the anterior and posterior sides of the gland regardless of pancreatic tissue texture or pancreatic duct diameter.     

A Preoperative Predictive Scoring System for Postoperative Pancreatic Fistula after Pancreaticoduodenectomy

Background  

Postoperative pancreatic fistula (POPF) remains a leading cause of morbidity after pancreaticoduodenectomy (PD). In the present study we sought to establish a preoperative scoring system with which to predict this complication.     

Pancreatic Islet Autotransplantation After Completion Pancreatectomy for Pancreatic Fistula After Hemipancreatoduodenectomy for Carcinoma

Objective

Pancreatic islet autotransplantation (IAT) has a potential to prevent brittle diabetes in patients after total pancreatectomy. Because of the fear of tumor spread, IAT has rarely been used in case of malignancy. We report our experience with patients who underwent hemipancreatoduodenectomy for carcinoma and later completion pancreatectomy for pancreatic fistula with islet autotransplantation at our institution.

Methods

From August 2007 to December 2012, 5 patients underwent IAT after completion pancreatectomy for pancreatic fistula after hemipancreatoduodenectomy for carcinoma. Islets were isolated from the pancreatic tail with the use of digestion with collagenase. Nonpurified islet suspension was infused into the portal vein during surgery.

Results

The median number of islets transplanted was 175,000 islet equivalents (range, 70,000–365,000). One patient died after surgery for reasons unrelated to IAT. Another 3 patients had stable diabetes with partial graft function (fasting C-peptide levels 0.23, 0.41, and 0.61 nmol/L and Hb_A1c 4.8%, 4.6%, and 6.9% at 24, 24 and 9 months after IAT, respectively). The 1st patient, with pancreatic head carcinoma, was alive 28 months after IAT with lymph node and liver recurrence since 18 months after IAT. The 2nd patient, with gall bladder and distal bile duct carcinoma, died 47 months after IAT with tumor recurrence. The 3rd patient, with ampullary carcinoma, died 12 months after IAT with local recurrence and solitary liver metastasis. The last patient had been off insulin 9 months after IAT without tumor recurrence (fasting C-peptide, 0.89 nmol/L; HbA1c, 4.2%).

Conclusions

Autotransplantation of pancreatic islets isolated from the residual pancreatic tissue in patients who previously underwent hemipancreatoduodenectomy for cancer may provide stable glucose control and thus improve quality of life. In this small series we did not observe early development of multiple liver metastases caused by islet suspension contamination with malignant cells. Oncologic outcome of the patients was not worse than what would be expected without IAT.     

Comment on: Preoperative Sarcopenia Strongly Influences the Risk of Postoperative Pancreatic Fistula Formation After Pancreaticoduodenectomy

Journal of Gastrointestinal Surgery -     

Anatomy-Specific Pancreatic Stump Management to Reduce the Risk of Pancreatic Fistula After Pancreatic Head Resection

Background  

The anatomical status of the pancreatic remnant after a pancreatic head resection varies greatly among patients. The aim of the present study was to improve management of the pancreatic remnant for reducing pancreatic fistula after pancreatic head resection.     

Jejunum or Stomach for the Pancreatic Anastomosis After Pancreaticoduodenectomy

Objective: The authors hypothesized that pancreaticogastrostomy is safer than pancreaticojejunostomy after pancreaticoduodenectomy and less likely to be associated with a postoperative pancreatic fistula.Summary Background Data: Pancreatic fistula is a leading cause of morbidity and mortality after pancreaticoduodenectomy, occurring in 10% to 20% of patients. Nonrandomized reports have suggested that pancreaticogastrostomy is less likely than pancreaticojejunostomy to be associated with postoperative complications.Methods: Between May 1993 and January 1995, the findings for 145 patients were analyzed in this prospective trial at The Johns Hopkins Hospital. After giving their appropriate preoperative informed consent, patients were randomly assigned to pancreaticogastrostomy or pancreaticojejunostomy after completion of the pancreaticoduodenal resection. All pancreatic anastomoses were performed in two layers without pancreatic duct stents and with closed suction drainage. Pancreatic fistula was defined as drainage of greater than 50 mL of amylase-rich fluid on or after postoperative day 10.Results: The pancreaticogastrostomy (n=73) and pancreaticojejunostomy (n=72) groups were comparable with regard to multiple parameters, including demographics, medical history, preoperative laboratory values, and intraoperative factors, such as operative time, blood transfusions, pancreatic texture, length of pancreatic remnant mobilized, and pancreatic duct diameter. The overall incidence of pancreatic fistula after pancreaticoduodenectomy was 11.7% (171145). The incidence of pancreatic fistula was similar for the pancreaticogastrostomy (12.3%) and pancreaticojejunostomy (11.1%) groups. Pancreatisc fistula was associated with a significant prolongation of postoperative hospital stay (36±5 vs. 15±1 days) (p<0.001). Factors significantly increasing the risk of pancreatic fistula by univariate logistic regression analysis included ampullary or duodenal disease, soft pancreatic texture, longer operative time, greater intraoperative red blood cell transfusions, and lower surgical volume (p<0.05). A multivariate logistic regression analysis revealed the factors most highly associated with pancreatic fistula to be lower surgical volume and ampullary or duodenal disease in the resected specimen.Conclusions: Pancreatic fistula is a common complication after pancreaticoduodenectomy, with an incidence most strongly associated with surgical volume and underlying disease. These data do not support the hypothesis that pancreaticogastrostomy is safer than pancreaticojejunostomy or is associated with a lower incidence of pancreatic fistula.