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Zentralblatt Fur Chirurgie Jun 2018The pancreatic anastomosis may be the Achilles heel in pancreatic surgery. When a postoperative pancreatic fistula develops, be it mild or severe, in some cases... (Review)
Review
BACKGROUND
The pancreatic anastomosis may be the Achilles heel in pancreatic surgery. When a postoperative pancreatic fistula develops, be it mild or severe, in some cases life-threatening, POPF-associated complications can occur.
OBJECTIVES
Possibilities for the prophylaxis, diagnosis and therapy of POPF and POPF-associated complications in an interdisciplinary setting.
RESULTS
Differentiated diagnostic and therapeutic management of POPF grade A - C is supported by recent studies to reduce morbidity and mortality. Depending on time and severity of POPF and POPF-associated complications, a conservative/interventional or surgical approach is indicated.
CONCLUSION
With the precise classification of POPF and POPF-associated complications, interdisciplinary diagnostic and therapeutic management can reduce morbidity and mortality after pancreatic surgery.
Topics: Humans; Pancreas; Pancreatic Fistula; Pancreaticoduodenectomy; Pancreaticojejunostomy; Postoperative Complications
PubMed: 29126330
DOI: 10.1055/s-0043-119896 -
HPB : the Official Journal of the... Nov 2021Biliary anastomotic stricture (BAS) is an uncommon complication of pancreaticoduodenectomy (PD). As PDs are performed more frequently, BAS may become a more common...
BACKGROUND
Biliary anastomotic stricture (BAS) is an uncommon complication of pancreaticoduodenectomy (PD). As PDs are performed more frequently, BAS may become a more common pathologic entity requiring clinical engagement. The aim of this study was to report the incidence of BAS in the modern era of pancreatic surgery and identify risk factors associated with it.
METHODS
Patients undergoing PD at the Johns Hopkins Hospital between 2007 and 2016 were identified using an institutional registry and clinicopathological features were analyzed to identify risk factors associated with BAS.
RESULTS
Of 2125 patients identified, 103 (4.9%) developed BAS. Factors independently associated with BAS included laparoscopic approach (HR:2.83,95%CI:1.35-5.92, p = 0.006), postoperative pancreatic fistula (HR:2.45,95%CI:1.56-4.16,p < 0.001), postoperative bile leak (BL) (HR:5.26,95%CI:2.45-11.28,p < 0.001), and administration of adjuvant radiation therapy (HR:6.01,95%CI:3.19-11.34,p < 0.001). Malignant pathology was associated with lower rates of BAS (HR:0.52,95%CI:0.30-0.92, p = 0.025). BL was associated with higher rates of early-BAS (HR:16.49,95%CI:3.28-82.94, p = 0.001) while use of Vicryl suture for biliary enteric anastomosis was associated with lower rates of early-BAS (HR:0.20,95%CI:0.05-0.93, p = 0.041).
CONCLUSION
Approximately 5% of patients undergoing PD experience BAS. Multiple factors are associated with the development and timing of BAS.
Topics: Anastomosis, Surgical; Constriction, Pathologic; Humans; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; Retrospective Studies
PubMed: 34016543
DOI: 10.1016/j.hpb.2021.04.008 -
Gut and Liver Mar 2019The International Study Group for Pancreatic Fistula (ISGPF) made the first attempt to standardize the outcome measure of fistulas in the field of pancreatic surgery by... (Review)
Review
The International Study Group for Pancreatic Fistula (ISGPF) made the first attempt to standardize the outcome measure of fistulas in the field of pancreatic surgery by publishing the definition and classification of postoperative pancreatic fistulas (POPFs) in 2005. POPFs were determined by any measurable volume of fluid output via an operatively placed drain with amylase activity greater than three times the upper normal serum value. Taking into account more than 10 years of reported experience worldwide, the updated definition published in 2016 by the reconvened International Study Group for Pancreatic Surgery (ISGPS) attempted to overcome the limits of the previous classification. The crucial concept of POPF clinical significance was introduced by eliminating grade A from the fistula scenario. The wider use of interventional procedures has also made it necessary to recode grade C POPFs, which now have clearer boundaries, toward the worst end of the severity scale. Grade B still represents the most prevalent and heterogeneous category of POPFs, both in terms of clinical burden and management. In the near future, further efforts will be required to better stratify grade B POPFs to standardize treatment strategies and compare outcomes among institutions.
Topics: Amylases; Humans; Pancreas; Pancreatic Fistula; Postoperative Complications; Practice Guidelines as Topic; Severity of Illness Index
PubMed: 30419630
DOI: 10.5009/gnl18229 -
Frontiers of Medicine Jun 2020Postoperative pancreatic fistula (POPF) is the most common and critical complication after pancreatic body and tail resection. How to effectively reduce the occurrence... (Review)
Review
Postoperative pancreatic fistula (POPF) is the most common and critical complication after pancreatic body and tail resection. How to effectively reduce the occurrence of pancreatic fistula and conduct timely treatment thereafter is an urgent clinical issue to be solved. Recent research standardized the definition of pancreatic fistula and stressed the correlation between POPF classification and patient prognosis. According to the literature, identification of the risk factors for pancreatic fistula contributed to lowering the rate of the complication. Appropriate management of the pancreatic stump and perioperative treatment are of great significance to reduce the rate of POPF in clinical practice. After the occurrence of POPF, the treatment of choice should be determined according to the classification of the pancreatic fistula. However, despite the progress and promising treatment approaches, POPF remains to be a clinical issue that warrants further studies in the future.
Topics: Disease Management; Humans; Pancreatectomy; Pancreatic Fistula; Postoperative Complications; Risk Assessment; Risk Factors
PubMed: 31840199
DOI: 10.1007/s11684-019-0727-3 -
Cirugia Espanola Feb 2022
Topics: Abdominal Injuries; Humans; Pancreas; Pancreatic Diseases; Pancreatic Fistula
PubMed: 34973915
DOI: 10.1016/j.cireng.2021.12.001 -
ANZ Journal of Surgery May 2021Many studies have explored factors relating to post-operative pancreatic fistula (POPF); however, the original definition (All-POPF) was revised to include only... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Many studies have explored factors relating to post-operative pancreatic fistula (POPF); however, the original definition (All-POPF) was revised to include only 'clinically relevant' (CR) POPF. This study identified variables associated with the two International Study Group on Pancreatic Surgery definitions to identify which variables are more strongly associated with CR-POPF.
METHODS
A systematic review identified all studies reporting risk factors for POPF (using both International Study Group on Pancreatic Fistula definitions) following pancreatoduodenectomy. The primary outcome was factors associated with CR-POPF. Meta-analyses (random effects models) of pre-, intra- and post-operative factors associated with POPF in more than two studies were included.
RESULTS
Among 52 774 patients All-POPF (n = 69 studies) and CR-POPF (n = 53 studies) affected 27% (95% confidence interval (CI ) 23-30) and 19% (CI 17-22), respectively. Of the 176 factors, 24 and 17 were associated with All- and CR-POPF, respectively. Absence of pre-operative pancreatitis, presence of renal disease, no pre-operative neoadjuvant therapy, use of post-operative somatostatin analogues, absence of associated venous or arterial resection were associated with CR-POPF but not All-POPF.
CONCLUSION
In conclusion this study demonstrates wide variation in reported rates of POPF and that several risk factors associated with CR-POPF are not used within risk prediction models. Data from this study can be used to shape future studies, research and audit across ethnic and geographic boundaries in POPF following pancreatoduodenectomy.
Topics: Humans; Pancreas; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; Retrospective Studies; Risk Factors
PubMed: 33135873
DOI: 10.1111/ans.16408 -
Polski Przeglad Chirurgiczny Apr 2018Pancreatic fistula is one of the most severe complications after pancreatic surgeries. The risk of pancreatic fistula after distal pancreatectomy is up to 60%. Effective... (Review)
Review
Pancreatic fistula is one of the most severe complications after pancreatic surgeries. The risk of pancreatic fistula after distal pancreatectomy is up to 60%. Effective methods to prevent pancreatic fistula are still sought. A unified definition of pancreatic fistula, which was introduced in 2005 by the International Study Group of Pancreatic Surgery (ISGPS), has allowed for an easier diagnosis and determination of fistula severity, as well as for a reliable inter-center comparison of data. Furthermore, a number of publications point out the risk factors of pancreatic fistula, which may be classified into patient-related risk factors, such as MBI, gender, smoking tobacco or pancreatic structure; and surgery-related risk factors, such as blood loss, prolonged surgery and non-underpinning of the major pancreatic duct. The analysis of risk factors and the use of different methods for the prevention of pancreatic fistula, including novel surgical techniques, may reduce both, the formation and severity of fistula. This will, in turn, lead to reduced secondary complications and mortality, as well as a shorter hospital stay. We present a literature review on different strategies used to prevent pancreatic fistula. It seems, however, that multicenter, prospective, randomized studies in two large groups of patients after pancreatectomy are necessary to establish clear recommendations for the preventive management.
Topics: Adult; Aged; Aged, 80 and over; Female; Humans; Male; Middle Aged; Pancreas; Pancreatectomy; Pancreatic Fistula; Postoperative Complications; Prospective Studies; Risk Factors
PubMed: 29773760
DOI: 10.5604/01.3001.0011.7491 -
HPB : the Official Journal of the... Nov 2015A post-operative pancreatic fistula (POPF) is a major cause of morbidity and mortality after a pancreaticoduodenectomy (PD). This systematic review aimed to identify all... (Review)
Review
BACKGROUND
A post-operative pancreatic fistula (POPF) is a major cause of morbidity and mortality after a pancreaticoduodenectomy (PD). This systematic review aimed to identify all scoring systems to predict POPF after a PD, consider their clinical applicability and assess the study quality.
METHOD
An electronic search was performed of Medline (1946-2014) and EMBASE (1996-2014) databases. Results were screened according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and quality assessed according to the QUIPS (quality in prognostic studies) tool.
RESULTS
Six eligible scoring systems were identified. Five studies used the International Study Group on Pancreatic Fistula (ISGPF) definition. The proposed scores feature between two and five variables and of the 16 total variables, the majority (12) featured in only one score. Three scores could be fully completed pre-operatively whereas 1 score included intra-operative and two studies post-operative variables. Four scores were internally validated and of these, two scores have been subject to subsequent multicentre review. The median QUIPS score was 38 out of 50 (range 16-50).
CONCLUSION
These scores show potential in calculating the individualized patient risk of POPF. There is, however, much variation in current scoring systems and further validation in large multicentre cohorts is now needed.
Topics: Global Health; Humans; Incidence; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; Prognosis; Risk Assessment; Risk Factors
PubMed: 26456948
DOI: 10.1111/hpb.12503 -
Trials Sep 2022Prophylactic abdominal drainage is current standard practice after distal pancreatectomy (DP), with the aim to divert pancreatic fluid in case of a postoperative... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Prophylactic abdominal drainage is current standard practice after distal pancreatectomy (DP), with the aim to divert pancreatic fluid in case of a postoperative pancreatic fistula (POPF) aimed to prevent further complications as bleeding. Whereas POPF after pancreatoduodenectomy, by definition, involves infection due to anastomotic dehiscence, a POPF after DP is essentially sterile since the bowel is not opened and no anastomoses are created. Routine drainage after DP could potentially be omitted and this could even be beneficial because of the hypothetical prevention of drain-induced infections (Fisher, Surgery 52:205-22, 2018). Abdominal drainage, moreover, should only be performed if it provides additional safety or comfort to the patient. In clinical practice, drains cause clear discomfort. One multicenter randomized controlled trial confirmed the safety of omitting abdominal drainage but did not stratify patients according to their risk of POPF and did not describe a standardized strategy for pancreatic transection. Therefore, a large pragmatic multicenter randomized controlled trial is required, with prespecified POPF risk groups and a homogeneous method of stump closure. The objective of the PANDORINA trial is to evaluate the non-inferiority of omitting routine intra-abdominal drainage after DP on postoperative morbidity (Clavien-Dindo score ≥ 3), and, secondarily, POPF grade B/C.
METHODS/DESIGN
Binational multicenter randomized controlled non-inferiority trial, stratifying patients to high and low risk for POPF grade B/C and incorporating a standardized strategy for pancreatic transection. Two groups of 141 patients (282 in total) undergoing elective DP (either open or minimally invasive, with or without splenectomy). Primary outcome is postoperative rate of morbidity (Clavien-Dindo score ≥ 3), and the most relevant secondary outcome is grade B/C POPF. Other secondary outcomes include surgical reintervention, percutaneous catheter drainage, endoscopic catheter drainage, abdominal collections (not requiring drainage), wound infection, delayed gastric emptying, postpancreatectomy hemorrhage as defined by the international study group for pancreatic surgery (ISGPS) (Wente et al., Surgery 142:20-5, 2007), length of stay (LOS), readmission within 90 days, in-hospital mortality, and 90-day mortality.
DISCUSSION
PANDORINA is the first binational, multicenter, randomized controlled non-inferiority trial with the primary objective to evaluate the hypothesis that omitting prophylactic abdominal drainage after DP does not worsen the risk of postoperative severe complications (Wente etal., Surgery 142:20-5, 2007; Bassi et al., Surgery 161:584-91, 2017). Most of the published studies on drain placement after pancreatectomy focus on both pancreatoduodenectomy and DP, but these two entities present are associated with different complications and therefore deserve separate evaluation (McMillan et al., Surgery 159:1013-22, 2016; Pratt et al., J Gastrointest Surg 10:1264-78, 2006). The PANDORINA trial is innovative since it takes the preoperative risk on POPF into account based on the D-FRS and it warrants homogenous stump closing by using the same graded compression technique and same stapling device (de Pastena et al., Ann Surg 2022; Asbun and Stauffer, Surg Endosc 25:2643-9, 2011).
Topics: Abdomen; Drainage; Humans; Pancreas; Pancreatectomy; Pancreatic Fistula; Postoperative Complications; Retrospective Studies
PubMed: 36153559
DOI: 10.1186/s13063-022-06736-5 -
Surgery Feb 2023Early stratification of postoperative pancreatic fistula according to severity and/or need for invasive intervention may improve outcomes after pancreaticoduodenectomy....
BACKGROUND
Early stratification of postoperative pancreatic fistula according to severity and/or need for invasive intervention may improve outcomes after pancreaticoduodenectomy. This study aimed to identify the early postoperative variables that may predict postoperative pancreatic fistula severity.
METHODS
All patients diagnosed with biochemical leak and clinically relevant-postoperative pancreatic fistula based on drain fluid amylase >300 U/L on the fifth postoperative day after pancreaticoduodenectomy were identified from a consecutive cohort from Birmingham, UK. Demographics, intraoperative parameters, and postoperative laboratory results on postoperative days 1 through 7 were retrospectively extracted. Independent predictors of clinically relevant-postoperative pancreatic fistula were identified using multivariable binary logistic regression and converted into a risk score, which was applied to an external cohort from Verona, Italy.
RESULTS
The Birmingham cohort had 187 patients diagnosed with postoperative pancreatic fistula (biochemical leak: 99, clinically relevant: 88). In clinically relevant-postoperative pancreatic fistula patients, the leak became clinically relevant at a median of 9 days (interquartile range: 6-13) after pancreaticoduodenectomy. Male sex (P = .002), drain fluid amylase-postoperative day 3 (P < .001), c-reactive protein postoperative day 3 (P < .001), and albumin-postoperative day 3 (P = .028) were found to be significant predictors of clinically relevant-postoperative pancreatic fistula on multivariable analysis. The multivariable model was converted into a risk score with an area under the receiver operating characteristic curve of 0.78 (standard error: 0.038). This score significantly predicted the need for invasive intervention (postoperative pancreatic fistula grades B3 and C) in the Verona cohort (n = 121; area under the receiver operating characteristic curve: 0.68; standard error = 0.06; P = .006) but did not predict clinically relevant-postoperative pancreatic fistula when grades B1 and B2 were included (area under the receiver operating characteristic curve 0.52; standard error = 0.07; P = .802).
CONCLUSION
We developed a novel risk score based on early postoperative laboratory values that can accurately predict higher grades of clinically relevant-postoperative pancreatic fistula requiring invasive intervention. Early identification of severe postoperative pancreatic fistula may allow earlier intervention.
Topics: Humans; Male; Pancreaticoduodenectomy; Pancreatic Fistula; Retrospective Studies; Risk Factors; Risk Assessment; Drainage; Postoperative Complications; Amylases
PubMed: 37530481
DOI: 10.1016/j.surg.2022.09.008