-
JAMA May 2023Despite improvements in perioperative mortality, the incidence of postoperative surgical site infection (SSI) remains high after pancreatoduodenectomy. The effect of...
IMPORTANCE
Despite improvements in perioperative mortality, the incidence of postoperative surgical site infection (SSI) remains high after pancreatoduodenectomy. The effect of broad-spectrum antimicrobial surgical prophylaxis in reducing SSI is poorly understood.
OBJECTIVE
To define the effect of broad-spectrum perioperative antimicrobial prophylaxis on postoperative SSI incidence compared with standard care antibiotics.
DESIGN, SETTING, AND PARTICIPANTS
Pragmatic, open-label, multicenter, randomized phase 3 clinical trial at 26 hospitals across the US and Canada. Participants were enrolled between November 2017 and August 2021, with follow-up through December 2021. Adults undergoing open pancreatoduodenectomy for any indication were eligible. Individuals were excluded if they had allergies to study medications, active infections, chronic steroid use, significant kidney dysfunction, or were pregnant or breastfeeding. Participants were block randomized in a 1:1 ratio and stratified by the presence of a preoperative biliary stent. Participants, investigators, and statisticians analyzing trial data were unblinded to treatment assignment.
INTERVENTION
The intervention group received piperacillin-tazobactam (3.375 or 4 g intravenously) as perioperative antimicrobial prophylaxis, while the control group received cefoxitin (2 g intravenously; standard care).
MAIN OUTCOMES AND MEASURES
The primary outcome was development of postoperative SSI within 30 days. Secondary end points included 30-day mortality, development of clinically relevant postoperative pancreatic fistula, and sepsis. All data were collected as part of the American College of Surgeons National Surgical Quality Improvement Program.
RESULTS
The trial was terminated at an interim analysis on the basis of a predefined stopping rule. Of 778 participants (378 in the piperacillin-tazobactam group [median age, 66.8 y; 233 {61.6%} men] and 400 in the cefoxitin group [median age, 68.0 y; 223 {55.8%} men]), the percentage with SSI at 30 days was lower in the perioperative piperacillin-tazobactam vs cefoxitin group (19.8% vs 32.8%; absolute difference, -13.0% [95% CI, -19.1% to -6.9%]; P < .001). Participants treated with piperacillin-tazobactam, vs cefoxitin, had lower rates of postoperative sepsis (4.2% vs 7.5%; difference, -3.3% [95% CI, -6.6% to 0.0%]; P = .02) and clinically relevant postoperative pancreatic fistula (12.7% vs 19.0%; difference, -6.3% [95% CI, -11.4% to -1.2%]; P = .03). Mortality rates at 30 days were 1.3% (5/378) among participants treated with piperacillin-tazobactam and 2.5% (10/400) among those receiving cefoxitin (difference, -1.2% [95% CI, -3.1% to 0.7%]; P = .32).
CONCLUSIONS AND RELEVANCE
In participants undergoing open pancreatoduodenectomy, use of piperacillin-tazobactam as perioperative prophylaxis reduced postoperative SSI, pancreatic fistula, and multiple downstream sequelae of SSI. The findings support the use of piperacillin-tazobactam as standard care for open pancreatoduodenectomy.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT03269994.
Topics: Male; Adult; Humans; Aged; Cefoxitin; Piperacillin; Pancreaticoduodenectomy; Pancreatic Fistula; Penicillanic Acid; Anti-Bacterial Agents; Piperacillin, Tazobactam Drug Combination; Surgical Wound Infection; Sepsis
PubMed: 37078771
DOI: 10.1001/jama.2023.5728 -
World Journal of Gastroenterology Jul 2019Postoperative pancreatic fistula (POPF) is one of the most severe complications after pancreatic surgeries. POPF develops as a consequence of pancreatic juice leakage... (Review)
Review
Postoperative pancreatic fistula (POPF) is one of the most severe complications after pancreatic surgeries. POPF develops as a consequence of pancreatic juice leakage from a surgically exfoliated surface and/or anastomotic stump, which sometimes cause intraperitoneal abscesses and subsequent lethal hemorrhage. In recent years, various surgical and perioperative attempts have been examined to reduce the incidence of POPF. We reviewed several well-designed studies addressing POPF-related factors, such as reconstruction methods, anastomotic techniques, stent usage, prophylactic intra-abdominal drainage, and somatostatin analogs, after pancreaticoduodenectomy and distal pancreatectomy, and we assessed the current status of POPF. In addition, we also discussed the current status of POPF in minimally invasive surgeries, laparoscopic surgeries, and robotic surgeries.
Topics: Drainage; Humans; Laparoscopy; Pancreas; Pancreatectomy; Pancreatic Fistula; Pancreatic Juice; Pancreatic Neoplasms; Pancreaticoduodenectomy; Pancreaticojejunostomy; Postoperative Care; Postoperative Complications; Risk Factors; Robotic Surgical Procedures; Somatostatin; Stents; Treatment Outcome
PubMed: 31391768
DOI: 10.3748/wjg.v25.i28.3722 -
Annals of Surgery Mar 2023The aim of this study was to develop a classification system for pancreas-associated risk factors in pancreatoduodenectomy (PD). (Meta-Analysis)
Meta-Analysis
A Simple Classification of Pancreatic Duct Size and Texture Predicts Postoperative Pancreatic Fistula: A classification of the International Study Group of Pancreatic Surgery.
OBJECTIVE
The aim of this study was to develop a classification system for pancreas-associated risk factors in pancreatoduodenectomy (PD).
SUMMARY BACKGROUND DATA
Postoperative pancreatic fistula (POPF) is the most relevant PD-associated complication. A simple standardized surgical reporting system based on pancreas-associated risk factors is lacking.
METHODS
A systematic literature search was conducted to identify studies investigating clinically relevant (CR) POPF (CR-POPF) and pancreas-associated risk factors after PD. A meta-analysis of CR-POPF rate for texture of the pancreas (soft vs not-soft) and main pancreatic duct (MPD) diameter was performed using the Mantel-Haenszel method. Based on the results, the International Study Group of Pancreatic Surgery (ISGPS) proposes the following classification: A, not-soft (hard) texture and MPD >3 mm; B, not-soft (hard) texture and MPD ≤3 mm; C, soft texture and MPD >3 mm; D, soft texture and MPD ≤3 mm. The classification was evaluated in a multi-institutional, international cohort.
RESULTS
Of the 2917 articles identified, 108 studies were included in the analyses. Soft pancreatic texture was significantly associated with the development of CR-POPF [odds ratio (OR) 4.24, 95% confidence interval (CI) 3.67-4.89, P < 0.01) following PD. Similarly, MPD diameter ≤3 mm significantly increased CR-POPF risk compared with >3 mm diameter MPDs (OR 3.66, 95% CI 2.62-5.12, P < 0.01). The proposed 4-stage system was confirmed in an independent cohort of 5533 patients with CR-POPF rates of 3.5%, 6.2%, 16.6%, and 23.2% for type A-D, respectively ( P < 0.001).
CONCLUSION
For future pancreatic surgical outcomes studies, the ISGPS recommends reporting these risk factors according to the proposed classification system for better comparability of results.
Topics: Humans; Pancreatic Fistula; Pancreas; Pancreatic Ducts; Pancreaticoduodenectomy; Risk Factors; Postoperative Complications
PubMed: 33914473
DOI: 10.1097/SLA.0000000000004855 -
Indian Journal of Cancer 2023Postoperative pancreatic fistula (POPF) is the most feared complication following pancreatic resection. Octreotide, a synthetic somatostatin analog, has been widely used... (Review)
Review
Postoperative pancreatic fistula (POPF) is the most feared complication following pancreatic resection. Octreotide, a synthetic somatostatin analog, has been widely used by pancreatic surgeons worldwide after pancreatic resections, often as per surgeon's discretion, to prevent POPF especially in cases at high risk of developing POPF. We herein analyze the data available till date of the subject. A PubMed search with keywords "somatostatin OR octreotide OR somatostatin analogues AND postoperative pancreatic fistula" was made. Further filters were applied in the search "Clinical Trial, Meta-Analysis, Randomized Controlled Trial, Systematic Review, from 1990 - 2021," and the 68 results thus obtained were analyzed and included in this narrative review. There is considerable heterogeneity among the studies assessing the role of octreotide in the prevention of POPF making data comparison difficult, and hence results remain inconclusive. Most of the earlier studies used different definitions of POPF and other complications; included patients with varied pancreatic pathologies such as cancer, chronic pancreatitis, and benign lesions; surgical techniques such as pancreaticoduodenectomy, distal pancreatectomy, and other procedures; use of somatostatin and its analogs such as octreotide, lanreotide, pasireotide, and vapreotide; varied surgeon and institutional volume; and so on. Besides, pancreatic surgery is per se a complex surgical procedure and has its own inherent biases related to patient and the pancreas itself affecting the overall outcome. Data indicate favorable role of newer somatostatin analogs, and further studies are urgently needed. The question about the efficacy of prophylactic octreotide to reduce POPF after pancreaticoduodenectomy remains open to debate.
Topics: Humans; Octreotide; Pancreas; Pancreatectomy; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; Randomized Controlled Trials as Topic; Risk Factors; Somatostatin; Treatment Outcome
PubMed: 37530235
DOI: 10.4103/ijc.IJC_280_21 -
Langenbeck's Archives of Surgery Feb 2020Pancreaticojejunal anastomosis is one of the most demanding procedures in surgery. Up to now, no technique has been proven to reduce the incidence of POPF when compared... (Review)
Review
BACKGROUND
Pancreaticojejunal anastomosis is one of the most demanding procedures in surgery. Up to now, no technique has been proven to reduce the incidence of POPF when compared to the other methods.
PURPOSE
The aim of this review was to provide a concise and illustrated description of the most recent methods of pancreaticojejunostomy. Their development was directly related to the still ongoing search by surgeons for such a technique of anastomosis that would eliminate the problem of POPF.
CONCLUSIONS
Knowledge of various techniques of anastomosis may help the surgeon to find the most suitable and optimal method of pancreatic-intestinal anastomosis for the patient.
Topics: Humans; Pancreas; Pancreatic Fistula; Pancreaticojejunostomy
PubMed: 31975148
DOI: 10.1007/s00423-020-01855-6 -
Journal of Clinical Medicine Jul 2022Postoperative pancreatic fistula (POPF) is one of the most critical complications after pancreatic surgery. The relationship between sarcopenia and outcomes following... (Review)
Review
Postoperative pancreatic fistula (POPF) is one of the most critical complications after pancreatic surgery. The relationship between sarcopenia and outcomes following this type of surgery is debated. The aim of this review was to assess the impact of sarcopenia on the risk of POPF. A literature search was performed using the PubMed database and the reference lists of relevant articles to identify papers about the impact of sarcopenia on POPF in pancreatic surgery. Twenty-one studies published between 2016 and 2021 with a total of 4068 patients were included. Some studies observed a significant difference in the incidence of POPF between the sarcopenic and non-sarcopenic patients undergoing pancreatoduodenectomy. Interestingly, there was a trend of a lower POPF rate in sarcopenic patients than in non-sarcopenic patients. Only one study included patients undergoing distal pancreatectomy specifically. The role of sarcopenia in surgical outcomes is still unclear. A combination of objective CT measurements could be used to predict POPF. It could be assessed by routine preoperative staging CT and could improve preoperative risk stratification in patients undergoing pancreatic surgery.
PubMed: 35887908
DOI: 10.3390/jcm11144144 -
Journal of the American College of... May 2023Minimally invasive, robotic techniques for hepatobiliary procedures offer the potential for accelerated recovery and reduced opioid usage. Robotic...
BACKGROUND:
Minimally invasive, robotic techniques for hepatobiliary procedures offer the potential for accelerated recovery and reduced opioid usage. Robotic pancreaticoduodenectomy is a technically challenging procedure with a complex reconstruction. In this regard, standardization of the pancreaticojejunostomy technique is critical for safe adoption of robotic technology in pancreatic surgery.
STUDY DESIGN:
In this video, we demonstrate the primary steps and associated principles to perform a robotic pancreaticojejunostomy using a modified Blumgart/Nagakawa technique.
RESULTS:
Key steps to this procedure include: 1) exposure and positioning of the pancreatic remnant and jejunal limb; 2) transpancreatic suture placement using augmented sutures with bulldog clamps for organization; 3) duct-to-mucosa anastomosis with well-defined order of suture placement and knot-tying for optimal exposure, tissue handling, and technical ease; 4) completion of the anterior row of transpancreatic sutures using Lapra-TY clips for gentle, but firm tissue apposition; and 5) placement of omental flap and surgical drains in proximity to the reconstruction.
CONCLUSION:
We described our technique for performing a robotic pancreaticojejunostomy, which compensates for the technical limitations of the robotic approach. These adjustments in combination with the magnified surgical vision and augmented skill associated with the robotic platform allow for safe and reliable performance of the pancreaticojejunostomy technique.
Topics: Humans; Pancreaticojejunostomy; Robotic Surgical Procedures; Robotics; Pancreatitis, Chronic; Pancreaticoduodenectomy; Postoperative Complications; Pancreatic Fistula
PubMed: 36729595
DOI: 10.1097/XCS.0000000000000485 -
Updates in Surgery Aug 2021Postoperative pancreatic fistula (POPF) still represents the major driver of surgical morbidity after pancreaticoduodenectomy. The purpose of this narrative review was... (Review)
Review
Postoperative pancreatic fistula (POPF) still represents the major driver of surgical morbidity after pancreaticoduodenectomy. The purpose of this narrative review was to critically analyze current evidence supporting the use of total pancreatectomy (TP) to prevent the development of POPF in patients with high-risk pancreas, and to explore the role of completion total pancreatectomy (CP) in the management of severe POPF. Considering the encouraging perioperative outcomes, TP may represent a promising tool to avoid the morbidity related to an extremely high-risk pancreatic anastomosis in selected patients. Surgical management of severe POPF is only required in few critical scenarios. In this context, even if anecdotal, CP might play a role as last resort in expert hands.
Topics: Humans; Pancreas; Pancreatectomy; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; Retrospective Studies; Risk Factors
PubMed: 34363601
DOI: 10.1007/s13304-021-01130-3 -
PloS One 2021Postoperative pancreatic fistula (POPF) with reported incidence rates up to 45% contributes substantially to overall morbidity. In this study, we conducted a...
PURPOSE
Postoperative pancreatic fistula (POPF) with reported incidence rates up to 45% contributes substantially to overall morbidity. In this study, we conducted a retrospective evaluation of POPF along with its potential perioperative clinical risk factors and its effect on tumor recurrence.
METHODS
Clinical data on patients who had received pancreatoduodenectomy (PD), distal pancreatectomy (DP), or duodenum-preserving pancreatic head resection (DPPHR) were prospectively collected between 2007 and 2016. A Picrosirius red staining score was developed to enable morphological classification of the resection margin of the pancreatic stump. The primary end point was the development of major complications. The secondary end points were overall and recurrence-free survival.
RESULTS
340 patients underwent pancreatic resection including 222 (65.3%) PD, 87 (25.6%) DP, and 31 (9.1%) DPPHR. Postoperative major complications were observed in 74 patients (21.8%). In multivariable logistic regression analysis, POPF correlated with body mass index (BMI) (p = 0.025), prolonged stay in hospital (p<0.001), high Picrosirius red staining score (p = 0.049), and elevated postoperative levels of amylase or lipase in drain fluid (p≤0.001). Multivariable Cox regression analysis identified UICC stage (p<0.001), tumor differentiation (p<0.001), depth of invasion (p = 0.001), nodal invasion (p = 0.001), and the incidence of POPF grades B and C (p = 0.006) as independent prognostic markers of recurrence-free survival.
CONCLUSION
Besides the known clinicopathological risk factors BMI and amylase in the drain fluid, the incidence of POPF correlates with high Picrosirius red staining score in the resection margins of the pancreatic stumps of curatively resected pancreatic ductal adenocarcinoma (PDAC). Furthermore, clinically relevant POPF seems to be a prognostic factor for tumor recurrence in PDAC.
Topics: Adult; Aged; Humans; Incidence; Middle Aged; Pancreatic Fistula; Pancreatic Neoplasms; Postoperative Period; Retrospective Studies; Risk Factors
PubMed: 34086792
DOI: 10.1371/journal.pone.0252727