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Nutrients Nov 2021Numerous strategies for perioperative nutrition therapy for patients undergoing pancreaticoduodenectomy (PD) have been proposed. This systematic review aimed to... (Meta-Analysis)
Meta-Analysis
Numerous strategies for perioperative nutrition therapy for patients undergoing pancreaticoduodenectomy (PD) have been proposed. This systematic review aimed to summarize the current relevant published randomized controlled trials (RCTs) evaluating different nutritional interventions via a traditional network meta-analysis (NMA) and component network meta-analysis (cNMA). EMBASE, MEDLINE, the Cochrane Library, and ClinicalTrials.gov were searched to identify the RCTs. The evaluated nutritional interventions comprised standard postoperative enteral nutrition by feeding tube (Postop-SEN), preoperative enteral feeding (Preop-EN), postoperative immunonutrients (Postop-IM), preoperative oral immunonutrient supplement (Preop-IM), and postoperative total parenteral nutrition (TPN). The primary outcomes were general, infectious, and noninfectious complications; postoperative pancreatic fistula (POPF); and delayed gastric emptying (DGE). The secondary outcomes were mortality and length of hospital stay (LOS). The NMA and cNMA were conducted with a frequentist approach. The results are presented as odds ratios (ORs) and 95% confidence intervals (CIs). Two primary outcomes, infectious complications and POPF, were positively influenced by nutritional interventions. Preop-EN plus Postop-SEN (OR 0.11; 95% CI 0.02~0.72), Preop-IM (OR 0.22; 95% CI 0.08~0.62), and Preop-IM plus Postop-IM (OR 0.11; 95% CI 0.03~0.37) were all demonstrated to be associated with a decrease in infectious complications. Postop-TPN (OR 0.37; 95% CI 0.19~0.71) and Preop-IM plus Postop-IM (OR 0.21; 95% CI 0.06~0.77) were clinically beneficial for the prevention of POPF. While enteral feeding and TPN may decrease infectious complications and POPF, respectively, Preop-IM plus Postop-IM may provide the best clinical benefit for patients undergoing PD, as this approach decreases the incidence of both the aforementioned adverse effects.
Topics: Databases, Factual; Enteral Nutrition; Humans; Length of Stay; Network Meta-Analysis; Nutrition Therapy; Nutritional Support; Pancreatic Fistula; Pancreaticoduodenectomy; Parenteral Nutrition, Total; Postoperative Complications
PubMed: 34836308
DOI: 10.3390/nu13114049 -
Cancers Nov 2021The impact of postoperative pancreatic fistula (POPF) on survival after resection for pancreatic ductal adenocarcinoma (PDAC) remains unclear. (Review)
Review
BACKGROUND
The impact of postoperative pancreatic fistula (POPF) on survival after resection for pancreatic ductal adenocarcinoma (PDAC) remains unclear.
METHODS
The MEDLINE, Scopus, Embase, Web of Science, and Cochrane Library databases were searched for studies reporting on survival in patients with and without POPF. A meta-analysis was performed to investigate the impact of POPF on disease-free survival (DFS) and overall survival (OS).
RESULTS
Sixteen retrospective cohort studies concerning a total of 5019 patients with an overall clinically relevant POPF (CR-POPF) rate of 12.63% (n = 634 patients) were considered. Five of eleven studies including DFS data reported higher recurrence rates in patients with POPF, and one study showed a higher recurrence rate in the peritoneal cavity. Six of sixteen studies reported worse OS rates in patients with POPF. Sufficient data for a meta-analysis were available in 11 studies for DFS, and in 16 studies for OS. The meta-analysis identified a shorter DFS in patients with CR-POPF (HR 1.59, = 0.0025), and a worse OS in patients with POPF, CR-POPF (HR 1.15, = 0.0043), grade-C POPF (HR 2.21, = 0.0007), or CR-POPF after neoadjuvant therapy.
CONCLUSIONS
CR-POPF after resection for PDAC is significantly associated with worse overall and disease-free survival.
PubMed: 34830957
DOI: 10.3390/cancers13225803 -
HPB : the Official Journal of the... Mar 2022Multiple risk scores claim to predict the probability of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy. It is unclear which scores have undergone... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Multiple risk scores claim to predict the probability of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy. It is unclear which scores have undergone external validation and are the most accurate. The aim of this study was to identify risk scores for POPF, and assess the clinical validity of these scores.
METHODS
Areas under receiving operator characteristic curve (AUROCs) were extracted from studies that performed external validation of POPF risk scores. These were pooled for each risk score, using intercept-only random-effects meta-regression models.
RESULTS
Systematic review identified 34 risk scores, of which six had been subjected to external validation, and so included in the meta-analysis, (Tokyo (N=2 validation studies), Birmingham (N=5), FRS (N=19), a-FRS (N=12), m-FRS (N=3) and ua-FRS (N=3) scores). Overall predictive accuracies were similar for all six scores, with pooled AUROCs of 0.61, 0.70, 0.71, 0.70, 0.70 and 0.72, respectively. Considerably heterogeneity was observed, with I2 statistics ranging from 52.1-88.6%.
CONCLUSION
Most risk scores lack external validation; where this was performed, risk scores were found to have limited predictive accuracy. . Consensus is needed for which score to use in clinical practice. Due to the limited predictive accuracy, future studies to derive a more accurate risk score are warranted.
Topics: Humans; Pancreas; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; Retrospective Studies; Risk Assessment; Risk Factors
PubMed: 34810093
DOI: 10.1016/j.hpb.2021.10.006 -
Frontiers in Oncology 2021To compare perioperative and oncological outcomes of pancreatic duct adenocarcinoma (PDAC) after laparoscopic open pancreaticoduodenectomy (LPD OPD), we performed a...
BACKGROUND
To compare perioperative and oncological outcomes of pancreatic duct adenocarcinoma (PDAC) after laparoscopic open pancreaticoduodenectomy (LPD OPD), we performed a meta-analysis of currently available propensity score matching studies and large-scale retrospective cohorts to compare the safety and overall effect of LPD to OPD for patients with PDAC.
METHODS
A meta-analysis was registered at PROSPERO and the registration number is CRD42021250395. PubMed, Web of Science, EMBASE, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched based on a defined search strategy to identify eligible studies before March 2021. Data on operative times, blood loss, 30-day mortality, reoperation, length of hospital stay (LOS), overall morbidity, Clavien-Dindo ≥3 complications, postoperative pancreatic fistula (POPF), blood transfusion, delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), and oncologic outcomes (R0 resection, lymph node dissection, overall survival, and long-term survival) were subjected to meta-analysis.
RESULTS
Overall, we identified 10 retrospective studies enrolling a total of 11,535 patients (1,514 and 10,021 patients underwent LPD and OPD, respectively). The present meta-analysis showed that there were no significant differences in overall survival time, 1-year survival, 2-year survival, 30-day mortality, Clavien-Dindo ≥3 complications, POPF, DGE, PPH, and lymph node dissection between the LPD and OPD groups. Nevertheless, compared with the OPD group, LPD resulted in significantly higher rate of R0 resection (OR: 1.22; 95% CI 1.06-1.40; = 0.005), longer operative time (WMD: 60.01 min; 95% CI 23.23-96.79; = 0.001), lower Clavien-Dindo grade ≥III rate ( = 0.02), less blood loss (WMD: -96.49 ml; 95% CI -165.14 to -27.83; = 0.006), lower overall morbidity rate (OR: 0.65; 95% CI 0.50 to 0.85; = 0.002), shorter LOS (MD = -2.73; 95% CI -4.44 to -1.03; = 0.002), higher 4-year survival time ( = 0.04), 5-year survival time ( = 0.001), and earlier time to starting adjuvant chemotherapy after surgery (OR: -10.86; 95% CI -19.42 to -2.30; = 0.01).
CONCLUSIONS
LPD is a safe and feasible alternative to OPD for patients with PDAC, and compared with OPD, LPD seemed to provide a similar OS.
SYSTEMATIC REVIEW REGISTRATION
https://www.crd.york.ac.uk/PROSPERO/#recordDetails.
PubMed: 34778064
DOI: 10.3389/fonc.2021.749140 -
Scandinavian Journal of Surgery : SJS :... 2022Surgical drains are widely utilized in hepatopancreaticobiliary surgery to prevent intra-abdominal collections and identify postoperative complications. Surgical drain...
BACKGROUND AND OBJECTIVE
Surgical drains are widely utilized in hepatopancreaticobiliary surgery to prevent intra-abdominal collections and identify postoperative complications. Surgical drain monitoring ranges from simple-output measurements to specific analysis for constituents such as amylase. This systematic review aimed to determine whether surgical drain monitoring can detect postoperative complications and impact on patient outcomes.
METHODS
A systematic review was performed, and the following databases searched between 02/03/20 and 26/04/20: MEDLINE, EMBASE, The Cochrane Library, and Clinicaltrials.gov. All studies describing surgical drain monitoring of output and content in adult patients undergoing hepatopancreaticobiliary surgery were considered. Other invasive methods of intra-abdominal sampling were excluded.
RESULTS
The search returned 403 articles. Following abstract review, 390 were excluded and 13 articles were included for full review. The studies were classified according to speciality and featured 11 pancreatic surgery and 2 hepatobiliary surgery studies with a total sample of 3262 patients. Postoperative monitoring of drain amylase detected pancreatic fistula formation and drain bilirubin testing facilitated bile leak detection. Both methods enabled early drain removal. Improved patient outcomes were observed through decreased incidence of postoperative complications (pancreatic fistulas, intra-abdominal infections, and surgical-site infections), length of stay, and mortality rate. Isolated monitoring of drain output did not confer any clinical benefits.
CONCLUSIONS
Surgical drain monitoring has advantages in the postoperative care for selected patients undergoing hepatopancreaticobiliary surgery. Enhanced surgical drain monitoring involving the testing of drain amylase and bilirubin improves the detection of complications in the immediate postoperative period.
Topics: Amylases; Bilirubin; Device Removal; Digestive System Surgical Procedures; Drainage; Humans; Pancreatic Fistula; Postoperative Complications
PubMed: 34749548
DOI: 10.1177/14574969211030118 -
Gland Surgery Sep 2021Digestive endoscopy and surgery are the primary invasive methods for the clinical treatment of necrotizing pancreatitis. However, there are relatively few studies...
BACKGROUND
Digestive endoscopy and surgery are the primary invasive methods for the clinical treatment of necrotizing pancreatitis. However, there are relatively few studies evaluating the effectiveness and safety of these two methods.
METHODS
Randomized controlled trials (RCTs) on endoscopic and surgical treatment of necrotizing pancreatitis published from January 2000 to December 2020 were searched in the PubMed, Medline, Embase, China Biology Medicine Disc (CBM), and WanFang databases. The was adopted to evaluate the quality of the included literature, and Review Manager 5.3 was used for data analysis.
RESULTS
Ten articles were included in this meta-analysis, involving a total of 401 patients, including 188 in the endoscopy group and 213 in the surgery group. Meta-analysis results revealed that the clinical remission rate (CRR) [odds ratio (OR) =1.30, 95% confidence interval (CI): 0.58-2.92, P=0.52], new organ failure rate (OFR) (OR =0.53, 95% CI: 0.26-1.09, P=0.08), abdominal bleeding rate (ABR) (OR =0.62, 95% CI: 0.33-1.15, P=0.13), and intensive care unit (ICU) stay time (IST) [mean deviation (MD) =-7.33, 95% CI: -16.76 to 2.11, P=0.13] were not significantly different between the endoscopy and surgery groups. In the endoscopy group, the mortality rate (OR =0.56, 95% CI: 0.31-1.02, P=0.05), intestinal fistula rate (IFR) or gastrointestinal perforation rate (GPR) (OR =0.50, 95% CI: 0.26-0.99, P=0.05), and pancreatic fistula rate (PFR) (OR =0.09, 95% CI: 0.04-0.23, P<0.00001) were markedly lower compared to the surgery group.
DISCUSSION
There was no obvious difference in the clinical efficacy of endoscopic and surgical treatment of necrotizing pancreatitis. However, endoscopy can greatly reduce the incidence of postoperative death and major complications in patients.
PubMed: 34733725
DOI: 10.21037/gs-21-516 -
HPB : the Official Journal of the... Feb 2022Central pancreatectomy is usually performed to excise lesions of the neck or proximal body of the pancreas. In the last decade, thanks to the advent of novel... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Central pancreatectomy is usually performed to excise lesions of the neck or proximal body of the pancreas. In the last decade, thanks to the advent of novel technologies, surgeons have started to perform this procedure robotically. This review aims to appraise the results and outcomes of robotic central pancreatectomies (RCP) through a systematic review and meta-analysis.
METHODS
A systematic search of MEDLINE, Embase, and Web Of Science identified studies reporting outcomes of RCP. Pooled prevalence rates of postoperative complications and mortality were computed using random-effect modelling.
RESULTS
Thirteen series involving 265 patients were included. In all cases but one, RCP was performed to excise benign or low-grade tumours. Clinically relevant post-operative pancreatic fistula (POPF) occurred in 42.3% of patients. While overall complications were reported in 57.5% of patients, only 9.4% had a Clavien-Dindo score ≥ III. Re-operation was necessary in 0.7% of the patients. New-onset diabetes occurred postoperatively in 0.3% of patients and negligible mortality and open conversion rates were observed.
CONCLUSION
RCP is safe and associated with low perioperative mortality and well preserved postoperative pancreatic function, although burdened by high overall morbidity and POPF rates.
Topics: Humans; Pancreas; Pancreatectomy; Pancreatic Fistula; Pancreatic Neoplasms; Postoperative Complications; Robotic Surgical Procedures
PubMed: 34625342
DOI: 10.1016/j.hpb.2021.09.014 -
The British Journal of Surgery Nov 2021Despite the fact that primary percutaneous catheter drainage has become standard practice, some patients with pancreatic fistula after pancreatoduodenectomy ultimately... (Meta-Analysis)
Meta-Analysis
Completion pancreatectomy or a pancreas-preserving procedure during relaparotomy for pancreatic fistula after pancreatoduodenectomy: a multicentre cohort study and meta-analysis.
BACKGROUND
Despite the fact that primary percutaneous catheter drainage has become standard practice, some patients with pancreatic fistula after pancreatoduodenectomy ultimately undergo a relaparotomy. The aim of this study was to compare completion pancreatectomy with a pancreas-preserving procedure in patients undergoing relaparotomy for pancreatic fistula after pancreatoduodenectomy.
METHODS
This retrospective cohort study of nine institutions included patients who underwent relaparotomy for pancreatic fistula after pancreatoduodenectomy from 2005-2018. Furthermore, a systematic review and meta-analysis were performed according to the PRISMA guidelines.
RESULTS
From 4877 patients undergoing pancreatoduodenectomy, 786 (16 per cent) developed a pancreatic fistula grade B/C and 162 (3 per cent) underwent a relaparotomy for pancreatic fistula. Of these patients, 36 (22 per cent) underwent a completion pancreatectomy and 126 (78 per cent) a pancreas-preserving procedure. Mortality was higher after completion pancreatectomy (20 (56 per cent) versus 40 patients (32 per cent); P = 0.009), which remained after adjusting for sex, age, BMI, ASA score, previous reintervention, and organ failure in the 24 h before relaparotomy (adjusted odds ratio 2.55, 95 per cent c.i. 1.07 to 6.08). The proportion of additional reinterventions was not different between groups (23 (64 per cent) versus 84 patients (67 per cent); P = 0.756). The meta-analysis including 33 studies evaluating 745 patients, confirmed the association between completion pancreatectomy and mortality (Mantel-Haenszel random-effects model: odds ratio 1.99, 95 per cent c.i. 1.03 to 3.84).
CONCLUSION
Based on the current data, a pancreas-preserving procedure seems preferable to completion pancreatectomy in patients in whom a relaparotomy is deemed necessary for pancreatic fistula after pancreatoduodenectomy.
Topics: Cohort Studies; Drainage; Global Health; Humans; Incidence; Intraoperative Period; Laparotomy; Multicenter Studies as Topic; Pancreatectomy; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; Reoperation; Survival Rate
PubMed: 34608941
DOI: 10.1093/bjs/znab273 -
Frontiers in Surgery 2021Although laparoscopic pancreaticoduodenectomy (LPD) is a safe and feasible treatment compared with open pancreaticoduodenectomy (OPD), surgeons need a relatively long...
Although laparoscopic pancreaticoduodenectomy (LPD) is a safe and feasible treatment compared with open pancreaticoduodenectomy (OPD), surgeons need a relatively long training time to become technically proficient in this complex procedure. In addition, the incidence of complications and mortality of LPD will be significantly higher than that of OPD in the initial stage. This meta-analysis aimed to compare the safety and overall effect of LPD to OPD after learning curve based on eligible large-scale retrospective cohorts and randomized controlled trials (RCTs), especially the difference in the perioperative and short-term oncological outcomes. PubMed, Web of Science, EMBASE, Cochrane Central Register, and ClinicalTrials.gov databases were searched based on a defined search strategy to identify eligible studies before March 2021. Only clinical studies reporting more than 40 cases for LPD were included. Data on operative times, blood loss, and 90-day mortality, reoperation, length of hospital stay (LOS), overall morbidity, Clavien-Dindo ≥III complications, postoperative pancreatic fistula (POPF), blood transfusion, delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), and oncologic outcomes (R0 resection, lymph node dissection, positive lymph node numbers, and tumor size) were subjected to meta-analysis. Overall, the final analysis included 13 retrospective cohorts and one RCT comprising 2,702 patients (LPD: 1,040, OPD: 1,662). It seems that LPD has longer operative time (weighted mean difference (WMD): 74.07; 95% CI: 39.87-108.26; < 0.0001). However, compared with OPD, LPD was associated with a higher R0 resection rate (odds ratio (OR): 1.43; 95% CI: 1.10-1.85; = 0.008), lower rate of wound infection (OR: 0.35; 95% CI: 0.22-0.56; < 0.0001), less blood loss (WMD: -197.54 ml; 95% CI -251.39 to -143.70; < 0.00001), lower blood transfusion rate (OR: 0.58; 95% CI 0.43-0.78; = 0.0004), and shorter LOS (WMD: -2.30 day; 95% CI -3.27 to -1.32; < 0.00001). No significant differences were found in 90-day mortality, overall morbidity, Clavien-Dindo ≥ III complications, reoperation, POPF, DGE, PPH, lymph node dissection, positive lymph node numbers, and tumor size between LPD and OPD. Comparative studies indicate that after the learning curve, LPD is a safe and feasible alternative to OPD. In addition, LPD provides less blood loss, blood transfusion, wound infection, and shorter hospital stays when compared with OPD.
PubMed: 34568416
DOI: 10.3389/fsurg.2021.715083 -
Journal of Clinical Medicine Jul 2021The mortality rate following pancreaticoduodenectomy (PD) has been decreasing over the past few years; nonetheless, the morbidity rate remains elevated. The most common...
BACKGROUND
The mortality rate following pancreaticoduodenectomy (PD) has been decreasing over the past few years; nonetheless, the morbidity rate remains elevated. The most common complications after PD are post-operative pancreatic fistula (POPF) and delayed gastric emptying (DGE) syndrome. The issue as to which is the best reconstruction method for the treatment of the pancreatic remnant after PD is still a matter of debate. The aim of this study was to retrospectively analyze the morbidity rate in 100 consecutive PD reconstructed with Wirsung-Pancreato-Gastro-Anastomosis (WPGA), performed by a single surgeon applying a personal modification of the pancreatic reconstruction technique.
METHODS
During an 8-year period (May 2012 to March 2020), 100 consecutive patients underwent PD reconstructed with WPGA. The series included 57 males and 43 females (M/F 1.32), with a mean age of 68 (range 41-86) years. The 90-day morbidity and mortality were retrospectively analyzed. Additionally, a systematic review was conducted, comparing our technique with the existing literature on the topic.
RESULTS
We observed eight cases of clinically relevant POPF (8%), three cases of "primary" DGE (3%) and four patients suffering "secondary" DGE. The surgical morbidity and mortality rate were 26% and 6%, respectively. The median hospital stay was 13.6 days. The systematic review of the literature confirmed the originality of our modified technique for Wirsung-Pancreato-Gastro-Anastomosis.
CONCLUSIONS
Our modified double-layer WPGA is associated with a very low incidence of POPF and DGE. Also, the technique avoids the risk of acute hemorrhage of the pancreatic parenchyma.
PubMed: 34300229
DOI: 10.3390/jcm10143064