A modified alternative fistula risk score (a-FRS) obtained from the computed tomography enhancement pattern of the pancreatic parenchyma predicts pancreatic fistula after pancreatoduodenectomy

BackgroundAlternative fistula risk score (a-FRS) is useful to predict clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD).MethodsClinical data from 239 patients undergoing PD were collected. The CT value of the pancreatic parenchyma was measured in the nonenhanced (N), arterial (A), portal venous (P), and late (L) phases. The A/N, A/P, P/L and A/L ratios were calculated and their correlation with CR-POPF were analyzed. By replacing pancreatic texture with the best CT attenuation ratio, a modified a-FRS was developed.ResultsForty-seven patients developed CR-POPF. The A/P ratio (P < 0.001), P/L ratio (P = 0.002) and A/L ratio (P < 0.001) were significantly higher in the CR-POPF group. The A/L ratio performed best in predicting CR-POPF (AUC: 0.803) and the cut-off value is 1.36. A/L ratio >1.36 (P < 0.001), body mass index (P = 0.005) and duct diameter (P = 0.037) were independently associated with CR-POPF. By replacing soft texture with an A/L ratio >1.36, a modified a-FRS was developed and performed better than the a-FRS (AUC: 0.823 vs 0.748, P = 0.006) in predicting CR-POPF.ConclusionsThe modified a-FRS is an objective and preoperative model for predicting the occurrence of CR-POPF after PD.     

Pancreatic attenuation on computed tomography predicts pancreatic fistula after pancreaticoduodenectomy

BackgroundSome parameters using preoperative computed tomography (CT) have been evaluated to predict the development of pancreatic fistula (PF) after pancreaticoduodenectomy (PD). The present retrospective study evaluated the predictive value of pancreatic attenuation for PF after PD.MethodsA retrospective review was conducted of the patients who underwent PD between January 2010 and December 2014. The pancreatic attenuation was measured in unenhanced preoperative CT images. Pre- and intraoperative variables were analyzed for the risk of PF after PD.ResultsOf the 346 consecutive patients, PF occurred in 116 (34%). The pancreatic attenuation was significantly greater in patients with PF than in those without PF (median, 40.0 vs. 33.3 Hounsfield units [HU], P < 0.001). A multivariate analysis showed that a pancreatic attenuation ≥30.0 HU (odds ratio [OR], 3.72; P < 0.001), a body mass index ≥25.0 kg/m² (OR, 3.67; P < 0.001) and a diameter of the main pancreatic duct <3.0 mm (OR, 1.84; P = 0.034) were independent risk factors for PF after PD.ConclusionThe degree of pancreatic attenuation on preoperative CT images was significantly associated with PF, and a pancreatic attenuation ≥30.0 HU was an independent risk factor of PF after PD.     

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.     

External validation of alternative fistula risk score (a-FRS) for predicting pancreatic fistula after pancreatoduodenectomy

BackgroundThe utility of the proposed alternative fistula risk score (a-FRS) for predicting risk of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD) has not been validated widely.MethodsThis retrospective analysis included data of patients undergoing open and laparoscopic PD during March 2012–May 2018 in our institution. The predictive abilities of a-FRS and original-FRS were compared. Risk factors for CR-POPF were also evaluated by multivariate regression analysis.ResultsOf the 370 patients, 80 (21.62%) developed CR-POPF. The incidences of CR-POPF in patients classified as low risk, intermediate risk, and high risk by a-FRS were 5.88%, 24.38%, and 57.69%, respectively (R2 = 0.97). The incidences of CR-POPF in patients classified as negligible risk, low risk, intermediate risk, and high-risk by original-FRS were 0%, 8.62%, 21.51%, and 52.50%, respectively (R2 = 0.92). The area under the ROC curve (AUC) was 0.74 for a-FRS vs. 0.70 for original-FRS. The a-FRS performed better than original-FRS for prediction of CR-POPF in open PD patients (AUC: 0.74 vs. 0.69) and was comparable with original- FRS in laparoscopic PD patients (AUC: 0.70 vs. 0.72).ConclusionsThe a-FRS appears to be an accurate and convenient tool for predicting occurrence of CR-POPF after PD.     

Surgical management of the grade C pancreatic fistula after pancreatoduodenectomy

BackgroundSurgical management of severe pancreatic fistula after pancreatoduodenectomy remains challenging, and carries high mortality. The aim of this retrospective study was to compare different surgical techniques used at relaparotomy for pancreatic fistula after pancreatoduodenectomy, and to identify factors predictive of failure to rescue.MethodsA total of 43 patients after pancreatoduodenectomy developed a pancreatic fistula requiring relaparotomy. The perioperative data and outcomes were reviewed retrospectively.ResultsCompletion pancreatectomy, simple drainage of the pancreatic anastomosis and external wirsungostomy were performed in 17, 16, and 10 cases, respectively. The mortality rate for completion pancreatectomy was 47.1%, compared with 56.3% for simple drainage (p = 0.598) and 50.0% for external wirsungostomy (p = 0.883). Simple drainage was associated with a higher rate of further relaparotomies (56.3%) in comparison with completion pancreatectomy (23.5%, p = 0.055) and external wirsungostomy (0%, p = 0.003). A rescue resection of the pancreatic remnant after failed simple drainage resulted invariably in death. On multivariate analysis, the factors predictive of mortality after relaparotomy for pancreatic fistula were organ failure on the day of reoperation (p = 0.001) and need of further surgical reintervention (p = 0.007).ConclusionTimely reintervention and appropriate surgical technique are essential for reducing mortality after reoperation for pancreatic fistula after pancreatoduodenectomy.     

Histological pancreatic findings correlate with computed tomography attenuation and predict postoperative pancreatic fistula following pancreatoduodenectomy

BackgroundAlthough a soft pancreas is a widely-accepted reliable risk factor for postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD), there is no established preoperative evaluation of pancreatic texture.MethodsTwo hundred thirty-seven patients who underwent PD with histological pancreatic assessment were retrospectively enrolled. The degree of fibrosis and fatty infiltration was scored histologically as seven grades and five grades, respectively. Computed tomography (CT) attenuation of the pancreas was measured on preoperative unenhanced CT images. Correlations between the CT attenuation of the pancreas and the histological pancreatic findings, and the development of POPF were analyzed.ResultsThe fibrosis grade was significantly higher for hard pancreas than for soft pancreas (p < 0.001), whereas the fatty infiltration grade was similar between the two types (p = 0.161). CT attenuation of the pancreas was inversely correlated with both fibrosis grade (Spearman's rank correlation coefficient ([r] = ?0.609, p < 0.001) and fatty infiltration grade (r = ?0.382, p < 0.001). Multivariate analysis showed that body mass index ≥25 kg/m² (odds ratio [OR]: 5.64, p < 0.001) and fibrosis grade ≤2 (OR: 18.0, p < 0.001) were independent risk factors for clinically significant POPF.ConclusionHistological pancreatic texture can be evaluated with CT attenuation and might be helpful in preoperatively predicting the development of POPF after PD.     

Combination of postoperative C-reactive protein value and computed tomography imaging can predict severe pancreatic fistula after pancreatoduodenectomy

BackgroundRecent management after pancreatoduodenectomy recommends either omission of prophylactic drainage or early removal. This potentially makes the diagnosis of postoperative pancreatic fistula (POPF) difficult because the diagnosis is based on the amylase value of drain effluent. The aim of this study was to determine if severe POPF could be predicted independent of drainage information.MethodsRecords of consecutive patients who underwent pancreatoduodenectomy between 2012 and 2018 were included for further analysis. The presence of a peripancreatic collection (PC) on routine postoperative (day7) computed tomography (early CT) and perioperative characteristics were analyzed.ResultsPC appeared in 82/211 patients (39%) and was associated with clinically relevant POPF (p < 0.001). The C-reactive protein (CRP) on postoperative day5 was a good predictor of severe POPF (needing interventional therapy or Grade C) (area under the receiver operating characteristics curve, 0.802; 95% confidence interval, 0.702–0.875). Presence of a PC and a high CRP value were independent risk factors for severe POPF following multivariate analysis. The combination of CRP<5.0 mg/dL on postoperative day 5 and the absence of a PC had 98% negative predictive value.ConclusionThe combination of CRP measurement and PC evaluation by early CT was useful in predicting severe POPF after pancreatoduodenectomy.     

Treatment of pancreatic fistula after pancreatoduodenectomy using a hand-made T-tube

Background/Purpose

To describe a technique for the treatment of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) using a hand-made T-tube.

Methods

Reconstruction after PD was performed by a modified Child’s method. A 3-mm tube and a 2-mm tube were connected in a ‘T’ shape. This hand-made T-tube was inserted into both the pancreatic duct and the jejunal limb, using two guidewires through a sinus tract of POPF. After a few days, the external end of the T-tube was closed with a metallic tip, and the internal pancreatic drainage was completed.

Results

The indication criteria for the T-tube treatment are as follows: (1) the pancreatic drainage tube inserted during operation has been dislodged; and (2) either the main pancreatic duct or the jejunal limb can be demonstrated on fistulograms. In the 30 years between 1978 and 2007, 642 patients underwent PD (pylorus-preserving, n = 210; Whipple, n = 302; and hepatopancreatoduodenectomy, n = 130). The T-tube treatment was performed in 9 patients (pylorus-preserving, n = 5; Whipple, n = 1; and hepatopancreatoduodenectomy, n = 3). The median duration between surgery and the T-tube placement was 64 days (range, 22–107 days). The median hospital stay after the T-tube placement was 12 days (range, 7–54 days). Neither major nor minor complications associated with the T-tube treatment occurred. The T-tube was removed in 5 patients after a median of 2 months (range, 2–24 months). Of these patients, 4 are alive without recurrence of carcinoma, and 1 patient died of recurrence 56 months after surgery. The other 4 patients died of recurrence before removal of the T-tube, at 11 months after placement of the tube (range, 7–15 months) without any complications associated with the T-tube treatment.

Conclusions

T-tube treatment is a minimally invasive, simple, safe, and reliable technique that can dramatically improve grade C POPF. This procedure should be considered as a first-line treatment of choice in selected patients with refractory grade C POPF.     

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

Background/Purpose

Although the operative mortality and morbidity associated with pancreatoduodenectomy (PD) has been decreasing, pancreatic fistula remains a potentially fatal complication. The aim of this study was to identify risk factors and predictors of pancreatic fistula formation, and ways to prevent this in a consecutive series of PD patients in a single institution.

Methods

The association between pancreatic fistula formation and various clinical parameters was investigated in 50 patients who underwent PD at Kochi Medical School from January 1991 through February 2006.

Results

The incidence of pancreatic fistula in these patients was 28%. Multivariate analysis identified three independent factors correlated with the occurrence of pancreatic fistula: (1) absence of fibrotic texture of the pancreas examined intraoperatively (relative risk [RR], 1.6; 95% confidence interval [CI], 1.2–2.0; P = 0.01); (2) serum amylase concentration greater than 195?U/l (1.69 times the normal upper limit) on the first postoperative day (RR, 2.4; 95% CI, 1.0–5.7; P = 0.01); and (3) not having early postoperative enteral nutrition (RR, 3.2; 95% CI, 1.2–9.0; P = 0.004).

Conclusions

Soft texture of the pancreas and increased serum amylase the day after PD are both risk factors with predictive value for pancreatic fistula. The incidence of fistula formation is reduced by early postoperative enteral nutrition.

     

Risk prediction platform for pancreatic fistula after pancreatoduodenectomy using artificial intelligence

BACKGROUND Despite advancements in operative technique and improvements in postoperative managements,postoperative pancreatic fistula(POPF) is a life-threatening complication following pancreatoduodenectomy(PD).There are some reports to predict POPF preoperatively or intraoperatively,but the accuracy of those is questionable.Artificial intelligence(AI) technology is being actively used in the medical field,but few studies have reported applying it to outcomes after PD.AIM To develop a risk prediction platform for POPF using an AI model.METHODS Medical records were reviewed from 1769 patients at Samsung Medical Center who underwent PD from 2007 to 2016.A total of 38 variables were inserted into AI-driven algorithms.The algorithms tested to make the risk prediction platform were random forest(RF) and a neural network(NN) with or without recursive feature elimination(RFE).The median imputation method was used for missing values.The area under the curve(AUC) was calculated to examine the discriminative power of algorithm for POPF prediction.RESULTS The number of POPFs was 221(12.5%) according to the International Study Group of Pancreatic Fistula definition 2016.After median imputation,AUCs using 38 variables were 0.68 ± 0.02 with RF and 0.71 ± 0.02 with NN.The maximal AUC using NN with RFE was 0.74.Sixteen risk factors for POPF were identified by AI algorithm:Pancreatic duct diameter,body mass index,preoperative serum albumin,lipase level,amount of intraoperative fluid infusion,age,platelet count,extrapancreatic location of tumor,combined venous resection,co-existing pancreatitis,neoadjuvant radiotherapy,American Society of Anesthesiologists' score,sex,soft texture of the pancreas,underlying heart disease,and preoperative endoscopic biliary decompression.We developed a web-based POPF prediction platform,and this application is freely available at http://popfrisk.smchbp.org.CONCLUSION This study is the first to predict POPF with multiple risk factors using AI.This platform is reliable(AUC 0.74),so it could be used to select patients who need especially intense therapy and to preoperatively establish an effective treatment strategy.     

Effect of Blumgart anastomosis in reducing the incidence rate of pancreatic fistula after pancreatoduodenectomy

BACKGROUND Pancreatic fistula is one of the most serious complications after pancreatoduodenectomy for treating any lesions at the pancreatic head. For years, surgeons have tried various methods to reduce its incidence. AIM To investigate and emphasize the clinical outcomes of Blumgart anastomosis compared with traditional anastomosis in reducing postoperative pancreatic fistula. METHODS In this observational study, a retrospective analysis of 291 patients who underwent pancreatoduodenectomy, including Blumgart anastomosis (201 patients) and traditional embedded pancreaticojejunostomy (90 patients), was performed in our hospital. The preoperative and perioperative courses and longterm follow-up status were analyzed to compare the advantages and disadvantages of the two methods. Moreover, 291 patients were then separated by the severity of postoperative pancreatic fistula, and two methods of pancreaticojejunostomy were compared to detect the features of different anastomosis. Six experienced surgeons were involved and all of them were proficient in both surgical techniques.RESULTS The characteristics of the patients in the two groups showed no significant differences, nor the preoperative information and pathological diagnoses. The operative time was significantly shorter in the Blumgart group (343.5 ± 23.0 vs 450.0 ± 40.1 min, P = 0.028), as well as the duration of pancreaticojejunostomy drainage tube placement and postoperative hospital stay (12.7 ± 0.9 d vs 17.4 ± 1.8 d, P = 0.031;and 21.9 ± 1.3 d vs 28.9 ± 1.3 d, P = 0.020, respectively). The overall complications after surgery were much less in the Blumgart group than in the embedded group (11.9% vs 26.7%, P = 0.002). Patients who underwent Blumgart anastomosis would suffer less from severe pancreatic fistula (71.9% vs 50.0%, P = 0.006), and this pancreaticojejunostomy procedure did not have worse influences on long-term complications and life quality. Thus, Blumgart anastomosis is a feasible pancreaticojejunostomy procedure in pancreatoduodenectomy surgery. It is safe in causing less postoperative complications, especially pancreatic fistula, and thus shortens the hospitalization duration. CONCLUSION Surgical method should be a key factor in reducing pancreatic fistula, and Blumgart anastomosis needs further promotion.     

Comparative analysis of the sarcopenia and HALP score on postoperative outcomes in pancreatic cancer patients after pancreatoduodenectomy

BackgroundSarcopenia and HALP (Hemoglobin, Albumin, Lymphocyte, and Platelet) scores are factors commonly associated with postoperative outcomes used in cancer patients. This study aims to evaluate the effect of these two prognostic factors on postoperative outcomes in operated pancreatic cancer patients and their correlation with each other.MethodsThe study is a single-center, retrospective study conducted with 179 patients diagnosed with pancreatic adenocarcinoma after pancreatoduodenectomy (PD) between January 2012 and January 2022. The Psoas muscular index (PMI) and HALP scores of the patients were calculated. Cut-off values were determined in order to determine the nutritional status of the patients and to group them. The cut-off value of the HALP score was determined according to survival status. In addition, the clinical data and pathological findings of tumors were collected. These two parameters were evaluated in terms of length of hospital stay, postoperative complication rates, fistula development, and overall survival, and their correlations with each other were examined.ResultsOf the patients, 74 (41.3%) were female, and 105 (58.7%) were male. According to PMI cut-off values, 83 (46.4%) patients were in the sarcopenia group. According to the HALP score cut-off values, 77 (43.1%) patients were in the low HALP group. Sarcopenia and Low HALP group had a higher risk of death (respectively Hazard ratio:5.67, CI:3.58–8.98, Hazard ratio:5.95, CI: 3.72–9.52) (p < 0.001). There was a moderate correlation between PMI and HALP score (rs = 0.34, p = 0.01). The correlation in these values was higher in the female gender.ConclusionsIn line with the data obtained from our study, HALP score and sarcopenia are among the important parameters used to evaluate postoperative complications and provide information about survival. Patients with a low HALP score and sarcopenic have an increased likelihood of developing postoperative complications and a lower survival.     

A simple preoperative stratification tool predicting the risk of postoperative pancreatic fistula after pancreatoduodenectomy

BackgroundPostoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) can be associated with severe postoperative morbidity. This study aims to develop a preoperative POPF risk calculator that can be easily implemented in clinical routine.MethodsPatients undergoing PD were identified from a prospectively-maintained database. A total of 11 preoperative baseline and CT-based radiological parameters were used in a binominal logistic regression model. Parameters remaining predictive for grade B/C POPF were entered into the risk calculator and diagnostic accuracy measures and ROC curves were calculated for a training and a test patient cohort. The risk calculator was transformed into a simple nomogram.ResultsA total of 242 patients undergoing PD in the period from 2012 to 2018 were included. CT-imaging-based maximum main pancreatic duct (MPD) diameter (p = 0.047), CT-imaging-based pancreatic gland diameter at the anticipated resection margin (p = 0.002) and gender (p = 0.058) were the parameters most predictive for grade B/C POPF. Based on these parameters, a risk calculator was developed to identify patients at high risk of developing grade B/C POPF. In a training cohort of PD patients this risk calculator was associated with an AUC of 0.808 (95%CI 0.726–0.874) and an AUC of 0.756 (95%CI 0.669-0-830) in the independent test cohort. A nomogram applicable as a visual risk scale for quick assessment of POPF grade B/C risk was developed.ConclusionThe preoperative POPF risk calculator provides a simple tool to stratify patients planned for PD according to the risk of developing postoperative grade B/C POPF. The nomogram visual risk scale can be easily integrated into clinical routine and may be a valuable model to select patients for POPF-preventive therapy or as a stratification tool for clinical trials.     

Postoperative negative-pressure drainage through a PEG tube can prevent pancreatic fistula after pancreatoduodenectomy

Postoperative pancreatic fistula(POPF)is a well-known complication after pancreatoduodenectomy[1].It is difficult to prevent due to a number of factors.The very placement and tightening of sutures in pancreatic tissue is challenging.Perfusion of the anastomosis edges is unpredictable.Another risk factor is the large amounts of fluids(comprising gastric and intestinal secretions,bile,and pancreatic juice)collected in the intestine near the pancreatic anastomosis,which increase the pressure in the first loop of the anastomosed intestine,and may ultimately rupture the pancreatoenteric anastomosis.Effective peristalsis,required to pass these fluids to subsequent sections of the intestine,takes time to return after such an extensive procedure.Increased pressure in the intestinal loop may also contribute to ischemia,by increasing the tension of the intestinal wall,constricting or even blocking its blood vessels.All these are aggravated by the chemical effects of intestinal contents.Any surgical errors may add the risk of POPF.     

Somatostatin analogues for the prevention of pancreatic fistula after open pancreatoduodenectomy: A nationwide analysis

BackgroundSomatostatin analogues (SA) are currently used to prevent postoperative pancreatic fistula (POPF) development. However, its use is controversial. This study investigated the effect of different SA protocols on the incidence of POPF after pancreatoduodenectomy in a nationwide population.MethodsAll patients undergoing elective open pancreatoduodenectomy were included from the Dutch Pancreatic Cancer Audit (2014–2017). Patients were divided into six groups: no SA, octreotide, lanreotide, pasireotide, octreotide only in high-risk (HR) patients and lanreotide only in HR patients. Primary endpoint was POPF grade B/C. The updated alternative Fistula Risk Score was used to compare POPF rates across various risk scenarios.Results1992 patients were included. Overall POPF rate was 13.1%. Lanreotide (10.0%), octreotide-HR (9.4%) and no protocol (12.7%) POPF rates were lower compared to the other protocols (varying from 15.1 to 19.1%, p = 0.001) in crude analysis. Sub-analysis in patients with HR of POPF showed a significantly lower rate of POPF when treated with lanreotide (10.0%) compared to no protocol, octreotide and pasireotide protocol (21.6–26.9%, p = 0.006). Octreotide-HR and lanreotide-HR protocol POPF rates were comparable to lanreotide protocol, however not significantly different from the other protocols. Multivariable regression analysis demonstrated lanreotide protocol to be positively associated with a low odds-ratio (OR) for POPF (OR 0.387, 95% CI 0.180–0.834, p = 0.015). In-hospital mortality rates were not affected.ConclusionUse of lanreotide in all patients undergoing pancreatoduodenectomy has a potential protective effect on POPF development. Protocols for HR patients only might be favorable too. However, future studies are warranted to confirm these findings.