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Langenbeck's Archives of Surgery Dec 2022Emergency pancreaticoduodenectomy (EPD) is an uncommon surgical procedure; usually, it is performed in traumatic cases, with non-traumatic indications being very rare.... (Review)
Review
PURPOSE
Emergency pancreaticoduodenectomy (EPD) is an uncommon surgical procedure; usually, it is performed in traumatic cases, with non-traumatic indications being very rare. Our review aimed to offer a comprehensive descriptive overview of the characteristics of EPD in non-traumatic settings.
METHODS
Our study is a review of individual participant data. PubMed, Cochrane, Google Scholar and Embase databases were searched. The last search was conducted in March 2022; studies that reported EPD for non-traumatic indications were included in the analysis.
RESULTS
Twenty-six articles were identified, twenty-five providing individual participant data; 17 articles (68%) were case reports. One article was a large retrospective study on the NSQIP (American College of Surgeons National Surgical Quality Improvement) database, which enrolled 409 patients that underwent EPD for malignant causes. From the other studies, we extracted individual participant data for a total of 66 patients. The patients were divided in subgroups, based on the indication for surgery: malignant causes (39.39%), uncontrollable bleeding (19.69%), iatrogenic injuries (30.3%), perforations (4.54%), or ischemic causes (6.06%). The postoperative morbidity was higher for the perforation subgroup. Postoperative pancreatic fistula is the most common complication reported (21.21%); higher rates were reported in the malignant and bleeding subgroups, with no special mention of this complication in the NSQIP database study. Mortality rate was 10.3% in the NSQIP database and higher, 19.69% in the 66-patient cohort; the highest mortality rates were registered in the perforation and ischemic subgroup.
CONCLUSION
EPD is a complex surgical intervention, with important associated morbidity and mortality rates, higher than that in elective settings, although it can be a life-saving procedure in selected cases and should be performed only in high-experience centres.
Topics: Humans; Pancreaticoduodenectomy; Retrospective Studies; Pancreatectomy; Pancreatic Fistula; Postoperative Complications
PubMed: 36280612
DOI: 10.1007/s00423-022-02702-6 -
Surgical Endoscopy May 2023Pancreaticoduodenectomy is the first choice surgical intervention for the radical treatment of pancreatic tumors. However, an anastomotic fistula is a common... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Pancreaticoduodenectomy is the first choice surgical intervention for the radical treatment of pancreatic tumors. However, an anastomotic fistula is a common complication after pancreaticoduodenectomy with a high mortality rate. With the development of minimally invasive surgery, open pancreaticoduodenectomy (OPD), laparoscopic pancreaticoduodenectomy (LPD), and robotic pancreaticoduodenectomy (RPD) are gaining interest. But the impact of these surgical methods on the risk of anastomosis has not been confirmed. Therefore, we aimed to integrate relevant clinical studies and explore the effects of these three surgical methods on the occurrence of anastomotic fistula after pancreaticoduodenectomy.
METHODS
A systematic literature search was conducted for studies reporting the RPD, LPD, and OPD. Network meta-analysis of postoperative anastomotic fistula (Pancreatic fistula, biliary leakage, gastrointestinal fistula) was performed.
RESULTS
Sixty-five studies including 10,026 patients were included in the network meta-analysis. The rank of risk probability of pancreatic fistula for RPD (0.00) was better than LPD (0.37) and OPD (0.62). Thus, the analysis suggests the rank of risk of the postoperative pancreatic fistula for RPD, LPD, and OPD. The rank of risk probability for biliary leakage was similar for RPD (0.15) and LPD (0.15), and both were better than OPD (0.68).
CONCLUSIONS
This network meta-analysis provided ranking for three different types of pancreaticoduodenectomy. The RPD and LPD can effectively improve the quality of surgery and are safe as well as feasible for OPD.
Topics: Humans; Pancreaticoduodenectomy; Pancreatic Fistula; Network Meta-Analysis; Pancreatectomy; Pancreatic Neoplasms; Anastomosis, Surgical; Postoperative Complications; Laparoscopy; Retrospective Studies; Robotic Surgical Procedures; Length of Stay
PubMed: 36627536
DOI: 10.1007/s00464-022-09832-4 -
Scandinavian Journal of Gastroenterology Oct 2016Pancreas surgery has developed into a fairly safe procedure in terms of mortality, but is still hampered by considerable morbidity. Among the most frequent and dreaded... (Review)
Review
BACKGROUND
Pancreas surgery has developed into a fairly safe procedure in terms of mortality, but is still hampered by considerable morbidity. Among the most frequent and dreaded complications are the development of a post-operative pancreatic fistula (POPF). The prediction and prevention of POPF remains an area of debate with several questions yet to be firmly addressed with solid answers.
METHODS
A systematic review of systematic reviews/meta-analyses and randomized trials in the English literature (PubMed/MEDLINE, Cochrane library, EMBASE) covering January 2005 to December 2015 on risk factors and preventive strategies for POPF.
RESULTS
A total of 49 systematic reviews and meta-analyses over the past decade discussed patient, surgeon, pancreatic disease and intraoperative related factors of POPF. Non-modifiable factors (age, BMI, comorbidity) and pathology (histotype, gland texture, duct size) that indicates surgery are associated with POPF risk. Consideration of anastomotic technique and use of somatostatin-analogs may slightly modify the risk of fistula. Sealant products appear to have no effect. Perioperative bleeding and transfusion enhance risk, but is modifiable by focus on technique and training. Drains may not prevent fistulae, but may help in early detection. Early drain-amylase may aid in detection. Predictive scores lack uniform validation, but may have a role in patient information if reliable pre-operative risk factors can be obtained.
CONCLUSIONS
Development of POPF occurs through several demonstrated risk factors. Anastomotic technique and use of somatostatin-analogs may slightly decrease risk. Drains may aid in early detection of leaks, but do not prevent POPF.
Topics: Digestive System Surgical Procedures; Drainage; Humans; Morbidity; Pancreas; Pancreatic Fistula; Postoperative Complications; Predictive Value of Tests; Randomized Controlled Trials as Topic; Risk Factors
PubMed: 27216233
DOI: 10.3109/00365521.2016.1169317 -
International Journal of Surgery... May 2018Laparoscopic pancreatic surgery (LPS) has been widely used in the treatment of benign and low-grade pancreatic diseases. It is necessary to expand the current knowledge... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Laparoscopic pancreatic surgery (LPS) has been widely used in the treatment of benign and low-grade pancreatic diseases. It is necessary to expand the current knowledge on the feasibility and safety of LPS for pancreatic ductal adenocarcinoma (PDAC) by systematic reviewing the published studies and analyzing them by meta-analysis.
METHODS
Original articles compared LPS with open pancreatic surgery (OPS) for PDAC, published from January 1994 to August 2017 were searched in medical databases. Postoperative pancreatic fistula (POPF), morbidity, mortality, operation time, blood loss, transfusion, hospital stay, retrieved lymph nodes (RLNs), and survival outcomes were compared.
RESULTS
Fourteen studies with a total of 13174 patients (1705 in LPS and 11469 in OPS) were included for the meta-analysis. LPS showed less morbidity (RR = 0.78, 95%CI: 0.66-0.92, P < .01), blood loss (WMD = -298.05 ml, 95% CI, -482.98∼-113.12 ml; P < .01), shorter hospital stay (WMD = -2.86, 95%CI, -3.85∼-1.87; P < .01), more RLNs (WMD = 1.47, 95%CI: 0.15-2.78; P = .03) and comparable POPF (RR = 1.12, 95%CI: 0.82-1.53, P = .50), operation time (WMD = 22.23 min; 95%CI: -19.56-64.01, P = .30), and 5-year overall survival (HR = 0.92, 95%CI: 0.80-1.06; P = .23) compared to OPS.
CONCLUSION
LPS can be performed safely in carefully selected patients with PADC and would improve the surgical outcomes. Considering the limitation of study design, the conclusions should be interpret cautiously and warrant to be confirmed by randomized controlled studies.
Topics: Blood Loss, Surgical; Blood Transfusion; Carcinoma, Pancreatic Ductal; Humans; Laparoscopy; Length of Stay; Operative Time; Pancreatectomy; Pancreatic Fistula; Pancreatic Neoplasms; Postoperative Complications; Treatment Outcome
PubMed: 29337177
DOI: 10.1016/j.ijsu.2017.12.032 -
Pancreatology : Official Journal of the... 2015Potential benefits of local extirpation of benign pancreatic head tumors are tissue conservation of pancreas, stomach, duodenum and common bile duct (CBD) and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Potential benefits of local extirpation of benign pancreatic head tumors are tissue conservation of pancreas, stomach, duodenum and common bile duct (CBD) and maintenance of pancreatic functions.
METHODS
Medline/PubMed, Embase and Cochrane Library databases were searched to identify studies applying duodenum-preserving total or partial pancreatic-head resection (DPPHRt/p) and reporting short- and long-term outcomes. Twenty-four studies, including 416 patients who underwent DPPHRt/p, were identified for systematic analysis. The meta-analysis was based on 10 prospective controlled and 4 retrospective controlled cohort studies, comparing 293 DPPHRt/p resections with 372 pancreato-duodenectomies (PD).
RESULTS, SYSTEMATIC ANALYSIS
Of 416 patients, 75.7% underwent total and 24.3% partial head resection, while 47.1% included segmentectomy of duodenum and CBD. The most common pathology was cystic neoplasm (65.8%) and endocrine tumors (13.4%). The frequencies of severe postoperative complications of 8.8%, pancreatic fistula of 19.2%, re-operation of 1.7% and hospital mortality of 0.48%, indicate a low level of early post-operative complications.
META-ANALYSIS
DPPHRt/p significantly preserved the level of exocrine (IV = -0.67, 95% CI -0.98 to -0.35, p = 0.0001) and endocrine (IV = 18.20, fixed, 95% CI -0.92 to 25.48, p = 0.0001) pancreatic functions compared to PD when the pre- and postoperative functional status in both groups are analyzed. There were no significant differences between DPPHRt/p and PD in frequency of pancreatic fistula, delayed gastric emptying or hospital mortality.
CONCLUSION
DPPHRt/p for benign neoplasms and neuro-endocrine tumors of the pancreatic head is associated with a low level of early-postoperative complications and a better conservation of exocrine and endocrine functions.
Topics: Common Bile Duct; Duodenum; Humans; Pancreas; Pancreatic Function Tests; Pancreatic Neoplasms
PubMed: 25732271
DOI: 10.1016/j.pan.2015.01.009 -
Pancreatology : Official Journal of the... 2016Enucleation of pancreatic tumors is rarely performed. The aim of this study was to evaluate the published evidence for its short- and long-term outcomes. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND AND OBJECTIVE
Enucleation of pancreatic tumors is rarely performed. The aim of this study was to evaluate the published evidence for its short- and long-term outcomes.
METHODS
PubMed (MEDLINE) and EMBASE databases were searched from 1990 to March 2016. Studies including at least ten patients who underwent enucleation of pancreatic lesions were included. Data on the outcomes were synthesized and meta-analyzed where appropriate.
RESULTS
Twenty-seven studies involving 1316 patients were included in the systematic review. The postoperative mortality was 0.3%, and the postoperative morbidity was 50.3%, mainly represented by pancreatic fistula (38.1%). Endocrine insufficiency, exocrine insufficiency and tumor recurrence was observed in 2.4%, 1.1% and 2.3% of the patients respectively. Compared with typical resection, the operation time, blood loss, length of hospital stay, and the incidence of endocrine and exocrine insufficiency were all significantly reduced after enucleation. The occurrence of pancreatic fistula was significantly higher in enucleation group, but overall morbidity, the reoperation rate and mortality were comparable between the two groups. There was no significant difference in disease recurrence between the two groups. Compared with central pancreatectomy, enucleation had a shorter operation time, lower blood loss, less morbidity, and better pancreatic function. Compared with open enucleation, minimally invasive enucleation had a shorter operation time and a shorter length of hospital stay.
CONCLUSIONS
Enucleation is an appropriate surgical procedure in selected patients with benign or low-malignant lesions of the pancreas. The benefits of minimally invasive approach need to be validated in further investigations with larger groups of patients.
Topics: Adult; Aged; Digestive System Surgical Procedures; Evidence-Based Medicine; Female; Guidelines as Topic; Humans; Male; Middle Aged; Pancreatectomy; Pancreatic Neoplasms; Pancreaticoduodenectomy; Treatment Outcome
PubMed: 27423534
DOI: 10.1016/j.pan.2016.07.006 -
Digestive Surgery 2016Different scoring systems to predict the occurrence of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy have been described, but the considered risk... (Review)
Review
BACKGROUND/AIM
Different scoring systems to predict the occurrence of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy have been described, but the considered risk factors often suffer subjective scaling. The aim of this review is to evaluate and compare all published risk metrics predictive of POPF.
METHODS
All existing scores were retrieved by literature web search. Inclusion criteria were ISGPF classification of POPF and the development of a risk score metric.
RESULTS
From a total of 286 publications, 10 studies were selected. Most of them were retrospective and single center. The models considered a median number of 3 items (range from 2 to 5); in 5 of 10 trials only pre or intraoperative variables were included. The median number of patients/study was 186 (IQR 111.1-229.0). External validation was performed in 6 of 10 studies. The most recurrent items were abdominal fat (4/10), main pancreatic duct diameter (in 4/10), and pancreatic texture (3/10).
CONCLUSION
POPF risk estimation should be easy, accurate, and objective. It should consider preoperative patient-related and gland-related features, and intraoperative events. None of the published systems completely adhere to these principles. Large heterogeneous multicentric validations should be endorsed, to account for the case-mix and evaluate the reproducibility of each scoring system.
Topics: Abdominal Fat; Humans; Pancreatic Ducts; Pancreatic Fistula; Pancreaticoduodenectomy; Predictive Value of Tests; Risk Factors
PubMed: 27160158
DOI: 10.1159/000445068 -
Scientific Reports May 2017The feasible of minimally invasive pancreaticoduodenectomy (MIPD) remains controversial when compared with open pancreaticoduodenectomy (OPD). We conducted a systemic... (Meta-Analysis)
Meta-Analysis Review
The feasible of minimally invasive pancreaticoduodenectomy (MIPD) remains controversial when compared with open pancreaticoduodenectomy (OPD). We conducted a systemic review and meta-analysis to summarise the available evidence to compare MIPD vs OPD. We systemically searched PubMed, EMBASE and Web of Science for studies published through February 2016. The primary endpoint was postoperative pancreatic fistula (POPF, grade B/C). A total of 27 studies involving 14,231 patients (2,377 MIPD and 11,854 OPD) were included. MIPD was associated with longer operative times (P < 0.01) and increased mortality (P < 0.01), but decreased estimated blood loss (P < 0.01), decreased delayed gastric emptying (P < 0.01), increased R0 resection rate (P < 0.01), decreased wound infection (P = 0.03) and shorter hospital stays (P < 0.01). There were no significant differences in BMI (P = 0.43), tumor size (P = 0.17), lymph nodes harvest (P = 0.57), POPF (P = 0.84), reoperation (P = 0.25) and 5-year survival rates (P = 0.82) for MIPD compared with OPD. Although there was an increased operative cost (P < 0.01) for MIPD compared with OPD, the postoperative cost was less (P < 0.01) with the similar total costs (P = 0.28). MIPD can be a reasonable alternative to OPD with the potential advantage of being minimally invasive. However, MIPD should be performed in high-volume centers and more randomized-controlled trials are needed to evaluate the appropriate indications of MIPD.
Topics: Humans; Neoplasms; Odds Ratio; Pancreaticoduodenectomy; Treatment Outcome
PubMed: 28533536
DOI: 10.1038/s41598-017-02488-4 -
Surgical Endoscopy Oct 2019Pancreatic enucleation (pEN) as parenchyma-sparing procedure for small pancreatic neoplasms is quickly becoming the most common surgical option in such setting....
BACKGROUND
Pancreatic enucleation (pEN) as parenchyma-sparing procedure for small pancreatic neoplasms is quickly becoming the most common surgical option in such setting. Nowadays, pEN is frequently carried out through a minimally invasive approach either laparoscopic or robotic. Its impact on overall perioperative complications and pancreatic fistula (POPF) is still under evaluation. The scope of our systematic review is to assess pEN's perioperative outcomes and to evaluate the effect of the minimally invasive techniques over POPF and other surgical complications.
METHODS
We performed a systematic literature search (time-frame January 1999-September 2018), considering exclusively those studies which included at least 5 cases of either open or minimally invasive pEN. Data regarding postoperative outcome and POPF were extracted and analyzed. We defined postoperative morbidities by the Clavien-Dindo classification while POPF according to the International Study Group of Pancreatic Fistula (ISGPF) definition.
RESULTS
Sixty-three studies met the criteria selected, accounting for a study population of 2485 patients. 27.7% had a minimally invasive pEN. The overall postoperative morbidity rate was 46.1% with 11.9% rated as severe (Clavien-Dindo ≥ 3). Mortality rate was 0.69%. The minimally invasive approach to pEN led to a statistically significant reduction of both the overall POPF rate (28.7% vs. 45.9%, p < 0.001), and clinically significant B-C POPF (p < 0.027). The postoperative overall morbidity rate was clearly in favor of the minimally invasive approach (27.6% vs. 55.2%, p < 0.001).
CONCLUSIONS
Our review confirms that pEN is a safe and feasible technique for the treatment of small benign or low-grade pancreatic neoplasms and it can be implemented with an acceptable morbidity rate along with low mortality. The minimally invasive approach is gaining widespread acceptance due to its supposed non-inferiority compared with the traditional open approach. In our review, it showed to be even better in terms of POPF incidence rate and short-term postoperative outcome. Still, such data need to be corroborated by randomized clinical trials.
Topics: Humans; Laparoscopy; Neoplasm Recurrence, Local; Pancreatectomy; Pancreatic Neoplasms; Postoperative Complications; Robotic Surgical Procedures
PubMed: 31363894
DOI: 10.1007/s00464-019-06967-9 -
Medicina (Kaunas, Lithuania) Jan 2023: Postoperative pancreatic fistula (POPF) is one of the most challenging complications after pancreatic resections, associated with prolonged hospital stay and high... (Review)
Review
: Postoperative pancreatic fistula (POPF) is one of the most challenging complications after pancreatic resections, associated with prolonged hospital stay and high mortality. Early identification of pancreatic fistula is necessary for the treatment to be effective. Several prognostic factors have been identified, although it is unclear which one is the most crucial. Some studies show that post-pancreatectomy hypophosphatemia may be associated with the development of POPF. The aim of this systematic review was to determine whether postoperative hypophosphatemia can be used as a prognostic factor for postoperative pancreatic fistula. : The systematic literature review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations (PRISMA) and was registered in the International Prospective Register of Systematic Reviews (PROSPERO). The PubMed, ScienceDirect, and Web of Science databases were systematically searched up to the 31st of January 2022 for studies analyzing postoperative hypophosphatemia as a prognostic factor for POPF. Data including study characteristics, patient characteristics, operation type, definitions of postoperative hypophosphatemia and postoperative pancreatic fistula were extracted. : Initially, 149 articles were retrieved. After screening and final assessment, 3 retrospective studies with 2893 patients were included in this review. An association between postoperative hypophosphatemia and POPF was found in all included studies. Patients undergoing distal pancreatectomy were more likely to develop severe hypophosphatemia compared to patients undergoing proximal pancreatectomy. Serum phosphate levels on postoperative day 4 (POD 4) and postoperative day 5 (POD 5) remained significantly lower in patients who developed leak-related complications showing a slower recovery of hypophosphatemia from postoperative day 3 (POD 3) through postoperative day 7 (POD 7). Moreover, body mass index (BMI) higher than 30 kg/m, soft pancreatic tissue, abnormal white blood cell count on postoperative day 3 (POD 3), and shorter surgery time were associated with leak-related complications (LRC) and lower phosphate levels. : Early postoperative hypophosphatemia might be used as a prognostic biomarker for early identification of postoperative pancreatic fistula. However, more studies are needed to better identify significant cut-off levels of postoperative hypophosphatemia and development of hypophosphatemia in the postoperative period.
Topics: Humans; Pancreatic Fistula; Prognosis; Retrospective Studies; Hypophosphatemia; Postoperative Complications; Phosphates; Postoperative Period; Risk Factors
PubMed: 36837475
DOI: 10.3390/medicina59020274