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Annals of Surgery Aug 2023To develop a fistula risk score for auditing, to be able to compare postoperative pancreatic fistula (POPF) after pancreatoduodenectomy among hospitals.
OBJECTIVE
To develop a fistula risk score for auditing, to be able to compare postoperative pancreatic fistula (POPF) after pancreatoduodenectomy among hospitals.
BACKGROUND
For proper comparisons of outcomes in surgical audits, case-mix variation should be accounted for.
METHODS
This study included consecutive patients after pancreatoduodenectomy from the mandatory nationwide Dutch Pancreatic Cancer Audit. Derivation of the score was performed with the data from 2014 to 2018 and validation with 2019 to 2020 data. The primary endpoint of the study was POPF (grade B or C). Multivariable logistic regression analysis was performed for case-mix adjustment of known risk factors.
RESULTS
In the derivation cohort, 3271 patients were included, of whom 479 (14.6%) developed POPF. Male sex [odds ratio (OR)=1.34; 95% confidence interval (CI): 1.09-1.66], higher body mass index (OR=1.07; 95% CI: 1.05-1.10), a final diagnosis other than pancreatic ductal adenocarcinoma/pancreatitis (OR=2.41; 95% CI: 1.90-3.06), and a smaller duct diameter (OR=1.43/mm decrease; 95% CI: 1.32-1.55) were independently associated with POPF. Diabetes mellitus (OR=0.73; 95% CI: 0.55-0.98) was independently associated with a decreased risk of POPF. Model discrimination was good with a C -statistic of 0.73 in the derivation cohort and 0.75 in the validation cohort (n=913). Hospitals differed in particular in the proportion of pancreatic ductal adenocarcinoma/pancreatitis patients, ranging from 36.0% to 58.1%. The observed POPF risk per center ranged from 2.9% to 25.4%. The expected POPF rate based on the 5 risk factors ranged from 11.6% to 18.0% among hospitals.
CONCLUSIONS
The auditing fistula risk score was successful in case-mix adjustment and enables fair comparisons of POPF rates among hospitals.
Topics: Humans; Male; Pancreaticoduodenectomy; Risk Assessment; Risk Factors; Pancreatic Fistula; Pancreatic Neoplasms; Carcinoma, Pancreatic Ductal; Pancreatitis; Postoperative Complications; Retrospective Studies
PubMed: 35837978
DOI: 10.1097/SLA.0000000000005532 -
Journal of Hepato-biliary-pancreatic... Feb 2022Drain management is important for the detection and treatment of clinically relevant postoperative pancreatic fistula (CR-POPF). We previously established the...
BACKGROUND
Drain management is important for the detection and treatment of clinically relevant postoperative pancreatic fistula (CR-POPF). We previously established the triple-checked criteria for drain removal: drain fluid amylase (DFA) <5000 U/L on postoperative day (POD) 1 and DFA <3000 U/L on POD 3, or C-reactive protein <15 mg/dL on POD 3. This study aimed to validate the efficacy of the triple-checked criteria.
METHODS
In this study, 681 patients who underwent pancreatectomy were included. Drains were removed according to our previous criteria (sequentially checked criteria: DFA <5000 U/L on POD 1 and DFA <3000 U/L on POD 3) from 2012 to 2016 (control group) and the triple-checked criteria from 2017 to 2019 (intervention group).
RESULTS
The control group included 406 patients, and the intervention group included 275 patients. Significantly more patients (n = 237, 86.2%) met the triple-checked criteria in the intervention group, relative to the sequentially checked criteria for early drain removal policy (n = 309, 76.1%; P = .001). Sensitivity, accuracy, and negative predictive value were significantly higher in the intervention group than in the control group (P < .001). The incidence of CR-POPF was not significantly different (11.1% vs 13.8%, P = .285).
CONCLUSIONS
The triple-checked criteria contributed to effective drain removal after pancreatectomy without increasing CR-POPF.
Topics: Amylases; Drainage; Humans; Pancreatectomy; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; Risk Factors
PubMed: 34330147
DOI: 10.1002/jhbp.1030 -
Medicine Aug 2023Laparoscopic pancreaticoduodenectomy (LPD) is a classic surgical method for diseases, such as tumors at the lower end of the common bile duct, pancreatic head, and...
Laparoscopic pancreaticoduodenectomy (LPD) is a classic surgical method for diseases, such as tumors at the lower end of the common bile duct, pancreatic head, and benign and malignant tumors of the duodenum. Postoperative pancreatic fistula (POPF) is one of the most serious complications of LPD. To reduce the incidence of grade B or C POPF and other complications after LPD, we applied a split pancreatic duct stent combined with the characteristics of internal and external stent drainage. Between September 2020 and September 2022,12 patients underwent placement of the Split pancreatic duct stent during LPD. Data on basic characteristics of patients, surgical related indicators and postoperative POPF incidence were collected and analyzed. The results showed that the average operation time was 294.2 ± 36 minutes, average time for pancreaticojejunostomy was 35.9 ± 4.1 minutes, and average estimated blood loss was 204.2 ± 58.2 mL. Biochemical leakage occurred in 2 patients (16.7%), whereas no grade B or C POPF, 1 case (8.3%) had postoperative bleeding, and no death occurred within 30 days after the operation. Preliminary experience shows that the split pancreatic duct stent can effectively reduce the incidence of complications after LPD, especially grade B or C POPF.
Topics: Humans; Pancreaticoduodenectomy; Pancreatic Ducts; Pancreas; Pancreaticojejunostomy; Pancreatic Fistula; Postoperative Complications; Laparoscopy; Stents; Retrospective Studies
PubMed: 37543786
DOI: 10.1097/MD.0000000000034049 -
European Journal of Radiology Jun 2021To develop a radiomics model and a combined model for preoperative prediction of clinically relevant postoperative pancreatic fistula (CR-POPF) in patients undergoing...
OBJECTIVES
To develop a radiomics model and a combined model for preoperative prediction of clinically relevant postoperative pancreatic fistula (CR-POPF) in patients undergoing pancreaticoduodenectomy and to compare the predictive performance of the two models with the traditional Fistula Risk Score system.
METHODS
A total of 250 patients who underwent pancreaticoduodenectomy (PD) with preoperative computed tomography (CT) were divided into a training set (n = 175) and validation set (n = 75). The pancreatic area was automatically segmented on the portal venous phase CT images using a 3D U-Net segmentation model. A radiomics model was developed using radiomics features extracted from the volume of interest (VOI) and a combined model was developed using radiomics features, demographic information and radiological features. The FRS was also used to predict POPF. The predictive performance of the prediction models was assessed using receiver operating characteristic (ROC) curves, calibration curves and decision curve analysis (DCA).
RESULTS
Eleven and 18 features were extracted for the radiomics model and combined model, respectively. The combined model showed excellent predictive value, with an AUC of 0.871 (95 %CI 0.816,0.926) and 0.869 (95 %CI 0.779,0.958) in the training cohort and validation cohort, respectively. Calibration curves and DCA showed that the combined model outperformed the traditional FRS system and radiomics model.
CONCLUSION
The combined model exhibited excellent predictive performance and outperformed the traditional FRS system and radiomics model in the preoperative prediction of CR-POPF.
Topics: Humans; Pancreas; Pancreatic Fistula; Pancreaticoduodenectomy; ROC Curve; Retrospective Studies; Risk Assessment
PubMed: 33857829
DOI: 10.1016/j.ejrad.2021.109693 -
Clinical Journal of Gastroenterology Aug 2020Pancreatic pseudocyst and portal vein thrombosis are common conditions resulting from acute and chronic pancreatitis. However, pancreatic pseudocyst-portal vein fistula... (Review)
Review
Pancreatic pseudocyst and portal vein thrombosis are common conditions resulting from acute and chronic pancreatitis. However, pancreatic pseudocyst-portal vein fistula (PPVF) is a rare and life-threatening complication. In PPVF patients, drainage or operative therapy is necessary under certain conditions, including communication between the pseudocyst and pancreatic duct, pancreatic duct stricture, pancreatic duct stone, and infection that is difficult to control with antibiotics. We describe the case of a 78-year-old woman who presented with an infected pancreatic pseudocyst invading the portal venous system with obstruction due to thromboembolization. Conservative therapy with antibiotics was insufficient. We, therefore, performed endoscopic ultrasound-guided cyst-drainage (EUS-CD). During EUS-CD, PPVF and pseudocyst-pancreatic duct fistula were confirmed by contrast medium injection. Despite the presence of the pseudocyst-pancreatic duct fistula, the pancreatic duct was not visualized in the pancreatic head, suggesting stricture in the main pancreatic duct. We, therefore, performed endoscopic retrograde pancreatography, which revealed pancreatic stone in the main pancreatic duct. Then, we added a 7-Fr pancreatic stent. She was discharged after 89 days of hospitalization. We reviewed the literature on the management of PPVF formation, and EUS-CD is considered to be a good treatment option for PPVF patients without portal vein patency.
Topics: Aged; Drainage; Endosonography; Female; Humans; Pancreatic Fistula; Pancreatic Pseudocyst; Portal Vein
PubMed: 32215857
DOI: 10.1007/s12328-020-01105-8 -
Tomography (Ann Arbor, Mich.) Jul 2023Transdiaphragmatic fistulae are rare conditions characterized by pathological communication between two epithelium-lined surfaces. Hepato-thoracic fistula consists of...
Transdiaphragmatic fistulae are rare conditions characterized by pathological communication between two epithelium-lined surfaces. Hepato-thoracic fistula consists of abnormal communication between the liver and/or the biliary system and the thorax; while the pancreaticopleural fistula consists of abnormal communication between the pancreas and the thorax, the pleuro-biliary fistula represents the more common type. Clinical symptoms and laboratory findings are generally non-specific (e.g., thoracic and abdominal pain, dyspnea, cough, neutrophilia, elevated CPR, and bilirubin values) and initially, first-level investigations, such as chest RX and abdominal ultrasound, are generally inconclusive for the diagnosis. Contrast-enhanced CT represents the first two-level radiological imaging technique, usually performed to identify and evaluate the underlying pathology sustained by transdiaphragmatic fistulae, their complications, and the evaluation of the fistulous tract. When the CT remains inconclusive, other techniques such as MRI and MRCP can be performed. A prompt and accurate diagnosis is crucial because the recognition of fistulae and the precise definition of the fistulous tract have a major impact on the management acquisition process.
Topics: Humans; Pancreatic Fistula; Magnetic Resonance Imaging; Biliary Tract; Tomography, X-Ray Computed
PubMed: 37489476
DOI: 10.3390/tomography9040108 -
Langenbeck's Archives of Surgery May 2023Pancreatic fistula following distal pancreatectomies still remains a relevant problem. The present study describes our first series with a new method of pancreatic...
PURPOSE
Pancreatic fistula following distal pancreatectomies still remains a relevant problem. The present study describes our first series with a new method of pancreatic remnant closure.
METHODS
A free fascia-peritoneum graft - harvested from the internal rectus sheet - was fixed onto the pancreatic stump by one circular stitch. The method was applied in 18 cases.
RESULTS
The postoperative hospital stay was 8 days in average. No clinically relevant postoperative pancreatic fistula (CR-POPF) developed. The morbidity rate was 39%, mostly Clavien-Dindo Grade II types. There was no reoperation or mortality.
CONCLUSION
The first series showed advantageous results with our method. Certainly, further studies are needed for the evaluation of this new and promising technique.
Topics: Humans; Pancreatectomy; Pancreatic Fistula; Pancreas; Suture Techniques; Postoperative Complications; Retrospective Studies
PubMed: 37140674
DOI: 10.1007/s00423-023-02916-2 -
ANZ Journal of Surgery Jun 2024Clinically relevant postoperative pancreatic fistula (CR-POPF) is a significant complication after pancreaticoduodenectomy. CR-POPF is associated with various adverse... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Clinically relevant postoperative pancreatic fistula (CR-POPF) is a significant complication after pancreaticoduodenectomy. CR-POPF is associated with various adverse outcomes, including high mortality rates. Identifying complication predictors for CR-POPF, such as preoperative CT scan features, including pancreatic attenuation index (PAI) and pancreatic duct diameter (PDD), is critical. This systematic review and meta-analysis consolidate existing literature to assess the impact of these variables on CR-POPF risk.
METHODS
Our comprehensive search, conducted in May 2023, covered PubMed, Scopus, Embase, and Web of Science databases. Inclusion criteria encompassed peer-reviewed cohort studies on pancreaticoduodenectomy, focusing on preoperative CT scan data. Case reports, case series, and studies reporting distal pancreatectomy were excluded. The quality assessment of included articles was done using New-Castle Ottawa Scale for cohort studies. Statistical analysis was carried out using Review Manager 5. This study was registered at the International Prospective Register of Systematic Reviews database (PROSPERO) on 12 May 2023 (registration number: CRD42023414139).
RESULTS
We conducted a detailed analysis of 38 studies with 7393 participants. The overall incidence of CR-POPF was 24%. Multiple linear regression analyses revealed that PDD and pancreatic parenchymal thickness were significantly associated with CR-POPF.
CONCLUSION
Our systematic review and meta-analysis shed light on CT scan findings for predicting CR-POPF after Whipple surgery. Age, PDD, and pancreatic parenchymal thickness significantly correlate with CR-POPF.
Topics: Humans; Pancreaticoduodenectomy; Pancreatic Fistula; Postoperative Complications; Tomography, X-Ray Computed; Risk Factors; Preoperative Period; Incidence
PubMed: 38837835
DOI: 10.1111/ans.19033 -
Langenbeck's Archives of Surgery Nov 2020Pancreatic fistula following pancreatic resections is still a relevant complication. The present work shows the efforts of a single institute to decrease this problem.
PURPOSE
Pancreatic fistula following pancreatic resections is still a relevant complication. The present work shows the efforts of a single institute to decrease this problem.
METHODS
A total of 130 patients (63 men, 67 women) with a mean age of 60 (range: 23-81) years were operated on between January 2013 and March 2020. The most frequent type of pancreatic resection was a Whipple procedure with partial antrectomy. During all operations, an innovative method was used, namely a modification of the purse-string suture pancreatojejunostomy. Moreover, an early drain removal policy was applied, based on the drain amylase level on the first and subsequent postoperative days.
RESULTS
Mean postoperative hospital stay was 13 days (range: 7-75). The overall morbidity rate was 43.8%; the clinically relevant (grade B/C) pancreatic fistula (CR-POPF) rate was 6.9%. Delayed gastric emptying (DGE) was observed in 4% of the patients. The ratio of operative mortality was 0.7%; the reoperation rate was 5.3%. Based on the drain amylase level on the first postoperative day, two groups could be established. In the first one, the drain was removed early, on the fourth day in average (range: 2-6). In the other group, the drain was left in situ protractedly or reinserted later on.
CONCLUSION
A single center's experience proves that the refinement of the technique can improve the results of pancreatic surgery.
Topics: Adult; Aged; Aged, 80 and over; Drainage; Female; Humans; Male; Middle Aged; Pancreas; Pancreatectomy; Pancreatic Fistula; Pancreaticoduodenectomy; Pancreaticojejunostomy; Postoperative Complications; Young Adult
PubMed: 32737588
DOI: 10.1007/s00423-020-01942-8 -
BMC Surgery Jun 2020The mortality following pancreaticoduodenectomy has markedly decreased but remains an important challenge for the complexity of operation and technical skills involved....
BACKGROUND
The mortality following pancreaticoduodenectomy has markedly decreased but remains an important challenge for the complexity of operation and technical skills involved. The present study aimed to clarify the impact of individualized pancreaticoenteric anastomosis and management to postoperative pancreatic fistula.
METHODS
Data from 529 consecutive pancreaticoduodenectomies were retrospectively analysed from the Hepatobiliary and Pancreatic Surgery Unit I, Peking Cancer Hospital. The pancreaticoenteric anastomosis was determined based on the pancreatic texture and diameter of the main pancreatic duct. The amylase value of the drainage fluid was dynamically monitored postoperatively on days 3, 5 and 7. A low speed intermittent irrigation was performed in selected patients. Intraoperative and postoperative results were collected and compared between the pancreaticogastrostomy (PG) group and pancreaticojejunostomy (PJ) group.
RESULTS
From 2010 to 2019, 529 consecutive patients underwent pancreaticoduodenectomy. Pancreaticogastrostomy was performed in 364 patients; pancreaticojejunostomy was performed in 150 patients respectively. The clinically relevant pancreatic fistula (CR-POPF) was 9.8% and mortality was zero. The soft pancreas, diameter of main pancreatic duct≤3 mm, BMI ≥ 25, operation time > 330 min and pancreaticogastrostomy was correlated with postoperative pancreatic fistula significantly. The CR-POPF of PJ was significantly higher than that of PG in soft pancreas patients; the operation time of PJ was shorter than that of PG significantly in hard pancreas patients. Intraoperative blood loss and operation time of PG was less than that of PJ significantly in normal pancreatic duct patients (p < 0.05).
CONCLUSIONS
Individualized pancreaticoenteric anastomosis should be determined based on the pancreatic texture and pancreatic duct diameter. The appropriate anastomosis and postoperative management could prevent mortality.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Amylases; Anastomosis, Surgical; Drainage; Female; Humans; Male; Middle Aged; Pancreas; Pancreatic Diseases; Pancreatic Ducts; Pancreatic Fistula; Pancreaticoduodenectomy; Pancreaticojejunostomy; Retrospective Studies; Stomach; Therapeutic Irrigation; Young Adult
PubMed: 32571289
DOI: 10.1186/s12893-020-00791-y