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Abdominal Radiology (New York) Jun 2024Pancreatic leaks occur when a disruption in the pancreatic ductal system results in the leakage of pancreatic enzymes such as amylase, lipase, and proteases into the... (Review)
Review
Pancreatic leaks occur when a disruption in the pancreatic ductal system results in the leakage of pancreatic enzymes such as amylase, lipase, and proteases into the abdominal cavity. While often associated with pancreatic surgical procedures, trauma and necrotizing pancreatitis are also common culprits. Cross-sectional imaging, particularly computed tomography, plays a crucial role in assessing postoperative conditions and identifying both early and late complications, including pancreatic leaks. The presence of fluid accumulation or hemorrhage near an anastomotic site strongly indicates a pancreatic fistula, particularly if the fluid is connected to the pancreatic duct or anastomotic suture line. Pancreatic fistulas are a type of pancreatic leak that carries a high morbidity rate. Early diagnosis and assessment of pancreatic leaks require vigilance and an understanding of its imaging hallmarks to facilitate prompt treatment and improve patient outcomes. Radiologists must maintain vigilance and understand the imaging patterns of pancreatic leaks to enhance diagnostic accuracy. Ongoing improvements in surgical techniques and diagnostic approaches are promising for minimizing the prevalence and adverse effects of pancreatic fistulas. In this pictorial review, our aim is to facilitate for radiologists the comprehension of pancreatic leaks and their essential imaging patterns.
PubMed: 38900317
DOI: 10.1007/s00261-024-04401-w -
ACG Case Reports Journal Jul 2023Pancreatic pseudocyst formation is a common complication of chronic pancreatitis. Rarely, a fistula develops between the pseudocyst and the portal venous system. We...
Pancreatic pseudocyst formation is a common complication of chronic pancreatitis. Rarely, a fistula develops between the pseudocyst and the portal venous system. We present a case of a 50-year-old man who was found to have a pancreatic pseudocyst-superior mesenteric vein fistula after being evaluated for several months of abdominal pain and weight loss. The patient was treated with endoscopic stenting of the pancreatic duct along with early enteral nutrition and suppressive antibiotics, which resulted in improvement in his condition. This case report highlights clinical presentation and the complexity of treatment of this rare diagnosis.
PubMed: 37441624
DOI: 10.14309/crj.0000000000001092 -
The International Journal of Medical... Aug 2023Central pancreatectomy (CP) is an ideal parenchyma-sparing procedure. The experience of r robotic central pancreatectomy (RCP) is very limited.
BACKGROUND
Central pancreatectomy (CP) is an ideal parenchyma-sparing procedure. The experience of r robotic central pancreatectomy (RCP) is very limited.
MATERIALS AND METHODS
Patients undergoing CP were included. Comparisons were made between RCP and open central pancreatectomy (OCP) groups.
RESULTS
The most common lesion in patients undergoing CP was serous cystadenoma (35.5%). The median operation time was 4.2 h for RCP versus 5.5 h for OCP. The median blood loss was significantly lower in RCP, 20 c.c. versus 170 c.c., p = 0.001. Postoperative pancreatic fistula occurred in 19.4% of all patients, with 22.1% in RCP and 15.4% in OCP. There was no significant difference regarding other surgical complications between the RCP and OCP groups. Only one patient in the OCP group developed de novo diabetes mellitus (DM), and no steatorrhoea/diarrhoea occurred after either RCP or OCP.
CONCLUSIONS
RCP is feasible and safe without compromising surgical outcomes and pancreatic functions.
PubMed: 37574857
DOI: 10.1002/rcs.2562 -
Updates in Surgery Dec 2023Postoperative pancreatic fistula (POPF) is a severe complication after distal pancreatectomy (DP); however, it is unclear how to effectively reduce the incidence. The... (Meta-Analysis)
Meta-Analysis Review
Postoperative pancreatic fistula (POPF) is a severe complication after distal pancreatectomy (DP); however, it is unclear how to effectively reduce the incidence. The purpose of this meta-analysis is to determine whether reinforced stapling reduces POPF after DP. From February 2007 to April 2023, a comprehensive search of electronic data and references was conducted in PubMed/Medline, Embase, Web of Science, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews. In this study, the perioperative outcomes were evaluated for the reinforced stapler (RS) group and the standard stapler (SS) group in DP using Review Manager Software. Using fixed- or random-effects models, pooled odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated. In total, three randomized clinical trials (RCTs) with 425 patients and five observational clinical studies (OCS) with 318 patients were included. In pooled meta-analyses from RCTs, there was no difference between the two groups in the incidence of POPF (OR = 0.79; 95% CI [0.47,1.35]; P = 0.39), intraoperative blood loss (MD = 10.66; 95% CI [- 28.83,50.16]; P = 0.6), operative time (MD = 9.88; 95% CI [- 8.92,28.67]; P = 0.3), major morbidity (OR = 1.12; 95% CI [0.67,1.90]; P = 0.66), reoperation (OR = 0.97; 95% CI [0.41,2.32]; P = 0.95), readmission (OR = 0.99; 95% CI [0.57,1.72]; P = 0.97) or hospital stay (MD = - 0.95; 95% CI [- 5.22,3.31]; P = 0.66). However, the results of POPF and readmission were favorable for RS in the OCS group.
Topics: Humans; Pancreatectomy; Pancreatic Fistula; Pancreas; Postoperative Complications; Reoperation; Risk Factors; Randomized Controlled Trials as Topic
PubMed: 37950142
DOI: 10.1007/s13304-023-01691-5 -
Pancreatology : Official Journal of the... Jun 2024Postoperative pancreatic fistula (POPF) is a major cause of morbidity and mortality after pancreatoduodenectomy (PD), and previous research has focused on... (Review)
Review
Postoperative pancreatic fistula (POPF) is a major cause of morbidity and mortality after pancreatoduodenectomy (PD), and previous research has focused on patient-related risk factors and comparisons between anastomotic techniques. However, it is recognized that surgeon experience is an important factor in POPF outcomes, and that there is a significant learning curve for the pancreatic anastomosis. The aim of this study was to review the current literature on training models for the pancreatic anastomosis, and to explore areas for future research. It is concluded that research is needed to understand the mechanical properties of the human pancreas in an effort to develop a synthetic model that closely mimics its mechanical properties. Virtual reality (VR) is an attractive alternative to synthetic models for surgical training, and further work is needed to develop a VR pancreatic anastomosis training module that provides both high fidelity and haptic feedback.
Topics: Humans; Anastomosis, Surgical; Pancreas; Pancreaticoduodenectomy; Pancreatic Fistula; Virtual Reality; Models, Anatomic
PubMed: 38580492
DOI: 10.1016/j.pan.2024.03.020 -
Annals of Surgery Jul 2023The objective of this study was to identify the indications for and report the outcomes of completion pancreatectomy (CPLP) in the postoperative course after...
OBJECTIVE
The objective of this study was to identify the indications for and report the outcomes of completion pancreatectomy (CPLP) in the postoperative course after pancreatoduodenectomy (PD).
BACKGROUND
CPLP may be considered or even inevitable for damage control after PD.
METHODS
A prospectively maintained database of all patients undergoing PD between 2001 and 2019 was searched for patients who underwent CPLP in the postoperative course after PD. Baseline characteristics, perioperative details, and outcomes of CPLP patients were analyzed and specific indications for CPLP were identified.
RESULTS
A total of 3953 consecutive patients underwent PD during the observation period. CPLP was performed in 120 patients (3%) after a median of 10 days following PD. The main indications for CPLP included postpancreatectomy acute necrotizing pancreatitis [n=47 (39%)] and postoperative pancreatic fistula complicated by hemorrhage [n=41 (34%)] or associated with uncontrollable leakage of the pancreatoenteric anastomosis [n=23 (19%)]. The overall 90-day mortality rate of all 3953 patients was 3.5% and 37% for patients undergoing CPLP.
CONCLUSIONS
Our finding that only very few patients (3%) need CPLP suggests that conservative, interventional, and organ-preserving surgical measures are the mainstay of complication management after PD. Postpancreatectomy acute necrotizing pancreatitis, uncontrollable postoperative pancreatic fistula, and fistula-associated hemorrhage are highly dangerous and represent the main indications for CPLP after PD.
Topics: Humans; Pancreatectomy; Pancreaticoduodenectomy; Pancreatic Fistula; Pancreatitis, Acute Necrotizing; Pancreas; Postoperative Complications; Retrospective Studies
PubMed: 35781509
DOI: 10.1097/SLA.0000000000005494 -
Anticancer Research Aug 2023Postoperative pancreatic fistula (POPF) may cause severe complications. In this study, risk factors for postoperative pancreatic fluid leakage after...
BACKGROUND/AIM
Postoperative pancreatic fistula (POPF) may cause severe complications. In this study, risk factors for postoperative pancreatic fluid leakage after pancreaticoduodenectomy (PD) were investigated, with a particular focus on preoperative pancreatic exocrine function and pathological evaluations of the resected pancreas.
PATIENTS AND METHODS
A total of 67 patients underwent the N-benzoyl-L-tyrosyl-para-aminobenzoic acid (BT-PABA) test and PD in our department between June 2003 and March 2018. The endpoint was the development of POPF. Patients' clinical characteristics, preoperative test results, surgery-related parameters, and pathological evaluations of the resected samples were investigated. Preoperative pancreatic exocrine function was evaluated by the BT-PABA test, and the proportion of residual acinar tissue and the fibrosis rate of the resected pancreatic tissue were assessed.
RESULTS
17 (25.4%) patients with Grade B and C POPF were compared with 50 patients without POPF. On univariate analysis, pancreatic carcinoma (p=0.028), BT-PABA test results higher than 66.3% (p=0.030), and main pancreatic duct (MPD) diameter lower than 5.0 mm (p=0.006) were identified as risk factors for postoperative pancreatic fluid leakage. On multivariate analysis, pancreatic carcinoma (p=0.008), BT-PABA test results higher than 66.3% (p=0.036), MPD diameter lower than 5.0mm (p=0.029) were significant risk factors. BT-PABA test results have a moderate correlation with both the proportion of pancreatic acinar tissue (r=0.421, p=0.028) and the pancreatic fibrosis rate (r=-0.443, p=0.021).
CONCLUSION
The preoperative BT-PABA test results higher than 66.3% were an independent risk factor for POPF. This suggests that the development of POPF may be attenuated by diminished exocrine function with poor pancreatic fluid flow and the progression of fibrosis.
Topics: Humans; Pancreaticoduodenectomy; Pancreatic Fistula; 4-Aminobenzoic Acid; Pancreas; Risk Factors; Fibrosis; Postoperative Complications; Retrospective Studies; Pancreatic Neoplasms
PubMed: 37500133
DOI: 10.21873/anticanres.16534 -
DEN Open Apr 2024Postoperative pancreatic fistula (POPF) is a major cause of morbidity after pancreatic surgery. Recently, endoscopic ultrasound-guided transmural drainage (EUS-TD) has...
OBJECTIVES
Postoperative pancreatic fistula (POPF) is a major cause of morbidity after pancreatic surgery. Recently, endoscopic ultrasound-guided transmural drainage (EUS-TD) has been widely used to manage pancreatic pseudocysts after acute pancreatitis. Several studies have reported the effectiveness of EUS-TD for POPF, although there is insufficient evidence regarding the performance of EUS-TD for POPF. We herein report on the safety, efficacy, and appropriate timing of EUS-TD for POPF compared with conventional percutaneous intervention.
METHODS
Eight patients who underwent EUS-TD of POPF and 36 patients who underwent percutaneous intervention were retrospectively enrolled. Clinical outcomes, including technical success, clinical success, and complications, were analyzed among the two groups.
RESULTS
In terms of clinical outcomes between the EUS-TD and percutaneous intervention groups, significant differences were observed in the number of interventions (1 vs. 4, = 0.011), period of clinical success (6 days vs. 11 days, = 0.001), incidence of complications (0 vs. 3, = 0.021), postoperative hospital stays (27 days vs. 34 days, = 0.027), and recurrence of POPF (0 vs. 5, = 0.001).
CONCLUSIONS
EUS-TD for POPF appears to be safe and technically feasible. This approach should be considered a therapeutic option in patients with POPF after pancreatic surgery.
PubMed: 37404728
DOI: 10.1002/deo2.270 -
JAMA Surgery Sep 2023Understanding the learning curve of a new complex surgical technique helps to reduce potential patient harm. Current series on the learning curve of minimally invasive...
IMPORTANCE
Understanding the learning curve of a new complex surgical technique helps to reduce potential patient harm. Current series on the learning curve of minimally invasive distal pancreatectomy (MIDP) are mostly small, single-center series, thus providing limited data.
OBJECTIVE
To evaluate the length of pooled learning curves of MIDP in experienced centers.
DESIGN, SETTING, AND PARTICIPANTS
This international, multicenter, retrospective cohort study included MIDP procedures performed from January 1, 2006, through June 30, 2019, in 26 European centers from 8 countries that each performed more than 15 distal pancreatectomies annually, with an overall experience exceeding 50 MIDP procedures. Consecutive patients who underwent elective laparoscopic or robotic distal pancreatectomy for all indications were included. Data were analyzed between September 1, 2021, and May 1, 2022.
EXPOSURES
The learning curve for MIDP was estimated by pooling data from all centers.
MAIN OUTCOMES AND MEASURES
The learning curve was assessed for the primary textbook outcome (TBO), which is a composite measure that reflects optimal outcome, and for surgical mastery. Generalized additive models and a 2-piece linear model with a break point were used to estimate the learning curve length of MIDP. Case mix-expected probabilities were plotted and compared with observed outcomes to assess the association of changing case mix with outcomes. The learning curve also was assessed for the secondary outcomes of operation time, intraoperative blood loss, conversion to open rate, and postoperative pancreatic fistula grade B/C.
RESULTS
From a total of 2610 MIDP procedures, the learning curve analysis was conducted on 2041 procedures (mean [SD] patient age, 58 [15.3] years; among 2040 with reported sex, 1249 were female [61.2%] and 791 male [38.8%]). The 2-piece model showed an increase and eventually a break point for TBO at 85 procedures (95% CI, 13-157 procedures), with a plateau TBO rate at 70%. The learning-associated loss of TBO rate was estimated at 3.3%. For conversion, a break point was estimated at 40 procedures (95% CI, 11-68 procedures); for operation time, at 56 procedures (95% CI, 35-77 procedures); and for intraoperative blood loss, at 71 procedures (95% CI, 28-114 procedures). For postoperative pancreatic fistula, no break point could be estimated.
CONCLUSION AND RELEVANCE
In experienced international centers, the learning curve length of MIDP for TBO was considerable with 85 procedures. These findings suggest that although learning curves for conversion, operation time, and intraoperative blood loss are completed earlier, extensive experience may be needed to master the learning curve of MIDP.
Topics: Humans; Male; Female; Middle Aged; Pancreatectomy; Pancreatic Neoplasms; Learning Curve; Pancreatic Fistula; Retrospective Studies; Blood Loss, Surgical; Treatment Outcome; Laparoscopy; Postoperative Complications; Surgeons
PubMed: 37378968
DOI: 10.1001/jamasurg.2023.2279 -
Annals of Surgery Mar 2024This study aimed to investigate the clinical significance and risk factors of postoperative pancreatic fistula (POPF) after post-pancreatectomy acute pancreatitis (PPAP)...
OBJECTIVE
This study aimed to investigate the clinical significance and risk factors of postoperative pancreatic fistula (POPF) after post-pancreatectomy acute pancreatitis (PPAP) in patients who underwent pancreaticoduodenectomy (PD).
SUMMARY BACKGROUND DATA
PPAP has been recognized as a critical factor in the pathophysiology of POPF after PD.
METHODS
A total of 817 consecutive patients who underwent elective PD between January 2020 and June 2022 were included. PPAP and POPF were defined in accordance with the International Study Group for Pancreatic Surgery (ISGPS) definitions. Multivariate logistic analyses were performed to investigate the risk factors for POPF. Comparisons between PPAP-associated POPF and non-PPAP-associated POPF were made to further characterize this intriguing complication.
RESULTS
Overall, 159 (19.5%) patients developed POPF after PD, of which 73 (45.9%) occurred following PPAP, and the remaining 86 (54.1%) had non-PPAP-associated POPF. Patients with PPAP-associated POPF experienced significantly higher morbidity than patients without POPF. Multivariate analyses revealed distinct risk factors for each POPF type. For PPAP-associated POPF, independent risk factors included estimated blood loss >200 mL (OR 1.93), MPD ≤3 cm (OR 2.88), and soft pancreatic texture (OR 2.01), largely overlapping with FRS (Fistula Risk Score) elements. On the other hand, non-PPAP-associated POPF was associated with age >65 years (OR 1.95), male (OR 2.10), and MPD ≤3 cm (OR 2.57). Notably, among patients with PPAP, the incidence of POPF consistently hovered around 50% regardless of the FRS stratification.
CONCLUSIONS
PPAP-associated POPF presents as a distinct pathophysiology in the development of POPF after PD, potentially opening doors for future prevention strategies targeting the early postoperative period.
PubMed: 38501245
DOI: 10.1097/SLA.0000000000006277