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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 -
World Journal of Clinical Cases Mar 2024Postoperative pancreatic fistula (POPF) contributes significantly to morbidity and mortality after pancreaticoduodenectomy (PD). However, the underlying mechanisms...
BACKGROUND
Postoperative pancreatic fistula (POPF) contributes significantly to morbidity and mortality after pancreaticoduodenectomy (PD). However, the underlying mechanisms remain unclear. This study explored this pathology in the pancreatic stumps and elucidated the mechanisms of POPF following PD.
CASE SUMMARY
Pathological analysis and 16S rRNA gene sequencing were performed on specimens obtained from two patients who underwent complete pancreatectomy for grade C POPF after PD. Gradient inflammation is present in the pancreatic stump. The apoptosis was lower than that in the normal pancreas. Moreover, neutrophil-dominated inflammatory cells are concentrated in the ductal system. Notably, neutrophils migrated through the ductal wall in acinar duct metaplasia-formed ducts. Additionally, evidence indicates that gut microbes migrate from the digestive tract. Gradient inflammation occurs in pancreatic stumps after PD.
CONCLUSION
The mechanisms underlying POPF include high biochemical activity in the pancreas, mechanical injury, and digestive reflux. To prevent POPF and address pancreatic inflammation and reflux, breaking the link with anastomotic dehiscence is practical.
PubMed: 38576729
DOI: 10.12998/wjcc.v12.i9.1649 -
Journal of Gastric Cancer Apr 2024Prevention of pancreas-related complications after gastric cancer surgery is critical. Polyglycolic acid (PGA) mesh reduces postoperative pancreatic fistula formation...
Clinical Impact of Polyglycolic Acid Mesh to Reduce Pancreas-Related Complications After Minimally Invasive Surgery for Gastric Cancer: A Propensity Score Matching Analysis.
PURPOSE
Prevention of pancreas-related complications after gastric cancer surgery is critical. Polyglycolic acid (PGA) mesh reduces postoperative pancreatic fistula formation following pancreatic resection. However, the clinical efficacy of PGA mesh in gastric cancer surgery has not been adequately investigated.
MATERIALS AND METHODS
This retrospective study compared the short-term outcomes between two groups: patients who underwent minimally invasive R0 gastrectomy for gastric cancer with the use of a PGA mesh (PGA group) and those without the use of a PGA mesh (non-PGA group) at the Cancer Institute Hospital, Tokyo, between January 2019 and May 2023. Propensity score matching (PSM) was performed to adjust for the possible confounding factors.
RESULTS
A total of 834 patients were initially included, of whom 614 (307 in each group) remained after PSM. The amylase levels in the drained abdominal fluid on postoperative days 1 and 3 were similar between the PGA and non-PGA groups. The PGA group had a significantly lower incidence of pancreas-related complications of Clavien-Dindo grade ≥2 than that in the non-PGA group (6.8% vs. 2.9%, P=0.025). In subgroup analyses, the odds ratio for pancreas-related complications appeared to be better in the PGA group than in the non-PGA group in patients with American Society of Anesthesiologists Physical Status Classification score of 2 or 3, those operated via a laparoscopic approach, and those undergoing procedures other than proximal gastrectomy.
CONCLUSIONS
The use of PGA mesh significantly reduced pancreas-related complications after minimally invasive surgery for gastric cancer and might thus benefit patients at risk of such complications.
PubMed: 38575514
DOI: 10.5230/jgc.2024.24.e17 -
Przeglad Gastroenterologiczny 2024Pancreaticoduodenectomy is a major procedure. Delayed gastric emptying (DGE) is a frequent postoperative complication that is attributed to several factors.
Association between perineural infiltrations and delayed gastric emptying after Whipple procedure for periampullary tumours, and the relationship with other clinicopathological factors and overall survival.
INTRODUCTION
Pancreaticoduodenectomy is a major procedure. Delayed gastric emptying (DGE) is a frequent postoperative complication that is attributed to several factors.
AIM
To investigate the probable association between perineural infiltrations and DGE, and the effects on overall survival.
MATERIAL AND METHODS
A total of 123 patients who underwent pancreaticoduodenectomy were enrolled in the study. Factors like the presence of perineural infiltrations and post-operative DGE along with age, gender, presence of postoperative fistula, and grade of fistula and postoperative haemorrhage were analysed, and survival analyses were conducted.
RESULTS
The presence of perineural infiltrations is statistically associated with DGE occurrence ( = 0.01). Moreover, the occurrence of DGE is statistically associated with male gender ( = 0.001), worse grade of postoperative fistula ( < 0.01), and the presence of postoperative haemorrhage ( = 0.03). There was no statistical association between the presence of perineural infiltrations and the other factors. Cox regression and Kaplan-Meier survival analyses showed that increased overall survival is associated with low age ( = 0.018 and = 0.028, respectively), absence of perineural infiltrations ( = 0.005 and = 0.003, respectively), better grade of postoperative fistula ( < 0.001), and absence of postoperative haemorrhage ( < 0.001). Multivariate analysis showed that independent prognostic factors for survival prognosis are perineural infiltrations, age, the presence of postoperative pancreatic fistula, and the presence of postoperative haemorrhage.
CONCLUSIONS
This is the first study that proves a statistically significant association between the presence of perineural infiltrations and the occurrence of DGE. Moreover, perineural infiltrations are an important independent prognostic factor for overall survival, along with other clinical factors.
PubMed: 38571537
DOI: 10.5114/pg.2023.129464 -
Surgery Jun 2024The use of robot-assisted and laparoscopic pancreatoduodenectomy is increasing, yet large adjusted analyses that can be generalized internationally are lacking. This... (Comparative Study)
Comparative Study
BACKGROUND
The use of robot-assisted and laparoscopic pancreatoduodenectomy is increasing, yet large adjusted analyses that can be generalized internationally are lacking. This study aimed to compare outcomes after robot-assisted pancreatoduodenectomy and laparoscopic pancreatoduodenectomy in a pan-European cohort.
METHODS
An international multicenter retrospective study including patients after robot-assisted pancreatoduodenectomy and laparoscopic pancreatoduodenectomy from 50 centers in 12 European countries (2009-2020). Propensity score matching was performed in a 1:1 ratio. The primary outcome was major morbidity (Clavien-Dindo ≥III).
RESULTS
Among 2,082 patients undergoing minimally invasive pancreatoduodenectomy, 1,006 underwent robot-assisted pancreatoduodenectomy and 1,076 laparoscopic pancreatoduodenectomy. After matching 812 versus 812 patients, the rates of major morbidity (31.9% vs 29.6%; P = .347) and 30-day/in-hospital mortality (4.3% vs 4.6%; P = .904) did not differ significantly between robot-assisted pancreatoduodenectomy and laparoscopic pancreatoduodenectomy, respectively. Robot-assisted pancreatoduodenectomy was associated with a lower conversion rate (6.7% vs 18.0%; P < .001) and higher lymph node retrieval (16 vs 14; P = .003). Laparoscopic pancreatoduodenectomy was associated with shorter operation time (446 minutes versus 400 minutes; P < .001), and lower rates of postoperative pancreatic fistula grade B/C (19.0% vs 11.7%; P < .001), delayed gastric emptying grade B/C (21.4% vs 7.4%; P < .001), and a higher R0-resection rate (73.2% vs 84.4%; P < .001).
CONCLUSION
This European multicenter study found no differences in overall major morbidity and 30-day/in-hospital mortality after robot-assisted pancreatoduodenectomy compared with laparoscopic pancreatoduodenectomy. Further, laparoscopic pancreatoduodenectomy was associated with a lower rate of postoperative pancreatic fistula, delayed gastric emptying, wound infection, shorter length of stay, and a higher R0 resection rate than robot-assisted pancreatoduodenectomy. In contrast, robot-assisted pancreatoduodenectomy was associated with a lower conversion rate and a higher number of retrieved lymph nodes as compared with laparoscopic pancreatoduodenectomy.
Topics: Humans; Pancreaticoduodenectomy; Male; Female; Robotic Surgical Procedures; Laparoscopy; Retrospective Studies; Propensity Score; Middle Aged; Europe; Aged; Postoperative Complications; Hospital Mortality; Pancreatic Neoplasms; Treatment Outcome
PubMed: 38570225
DOI: 10.1016/j.surg.2024.02.015 -
BMJ Open Apr 2024The surgical intervention approach to insulinomas in proximity to the main pancreatic duct remains controversial. Standard pancreatic resection is recommended by several...
Preoperative pancreatic stent placement before the enucleation of insulinoma located in the head and neck of the pancreas in proximity to the main pancreatic duct: study protocol for a multicentre randomised clinical trial in Chinese tertiary medical centres.
INTRODUCTION
The surgical intervention approach to insulinomas in proximity to the main pancreatic duct remains controversial. Standard pancreatic resection is recommended by several guidelines; however, enucleation (EN) still attracts surgeons with less risk of late exocrine/endocrine insufficiency, despite a higher postoperative pancreatic fistula (POPF) rate. Recently, the efficacy and safety of preoperative pancreatic stent placement before the EN have been demonstrated. Thus, a multicentre open-label study is being conducted to evaluate the efficacy and safety of stent placement in improving the outcome of EN of insulinomas in proximity to the main pancreatic duct.
METHODS AND ANALYSIS
This is a prospective, randomised, open-label, superiority clinical trial conducted at multiple tertiary centres in China. The major eligibility criterion is the presence of insulinoma located in the head and neck of the pancreas in proximity (≤2 mm) to the main pancreatic duct. Blocked randomisation will be performed to allocate patients into the stent EN group and the direct EN group. Patients in the stent EN group will go through stent placement by the endoscopist within 24 hours before the EN surgery, whereas other patients will receive EN surgery directly. The primary outcome is the assessment of the superiority of stent placement in reducing POPF rate measured by the International Study Group of Pancreatic Surgery standard. Both interventions will be performed in an inpatient setting and regular follow-up will be performed. The primary outcome (POPF rate) will be tested for superiority with the Χ test. The difference in secondary outcomes between the two groups will be analysed using appropriate tests.
ETHICS AND DISSEMINATION
The study has been approved by the Peking Union Medical College Hospital Institutional Review Board (K23C0195), Ruijin Hospital Ethics Committee (2023-314), Peking University First Hospital Ethics Committee (2024033-001), Institutional Review Board of Xuanwu Hospital of Capital Medical University (2023223-002), Ethics Committee of the First Affiliated Hospital of Xi'an Jiaotong University (XJTU1AF2023LSK-473), Institutional Review Board of Tongji Medical College Tongji Hospital (TJ-IRB202402059), Ethics Committee of Tongji Medical College Union Hospital (2023-0929) and Shanghai Cancer Center Institutional Review Board (2309282-16). The results of the study will be published in an international peer-reviewed journal.
TRIAL REGISTRATION NUMBER
NCT05523778.
Topics: Humans; Insulinoma; Prospective Studies; China; Pancreas; Pancreatic Ducts; Pancreatic Fistula; Postoperative Complications; Stents; Pancreatic Neoplasms; Hospitals; Randomized Controlled Trials as Topic; Multicenter Studies as Topic
PubMed: 38569703
DOI: 10.1136/bmjopen-2023-078516 -
Chirurgie (Heidelberg, Germany) Jun 2024Currently, the most frequently used surgical treatment for symptomatic, benign, premalignant cystic and neuroendocrine neoplasms of the pancreatic head is the Whipple... (Review)
Review
Currently, the most frequently used surgical treatment for symptomatic, benign, premalignant cystic and neuroendocrine neoplasms of the pancreatic head is the Whipple procedure or pylorus-preserving pancreatoduodenectomy (PD). However, when performed for treatment of benign tumors, PD is a multiorgan resection involving loss of pancreatic and extrapancreatic tissue and functions. PD for benign neoplasm is associated with the risk of considerable early postoperative complications and an in-hospital mortality of up to 5%. Following the Whipple procedure a new onset of diabetes mellitus is observed in 14-20% and new exocrine insufficiency in 25-45%, leading to metabolic dysfunction and impairment of quality of life persisting after resection of benign tumors. Symptomatic neoplasms are indication for surgery. Patients with asymptomatic pancreatic tumors are treated according to the criteria of surveillance protocols. The goal of surgical treatment for asymptomatic patients is, according to the guideline criteria, interruption of the surveillance program before the development of an advanced stage cancer associated with the neoplasm. Tumor enucleation and duodenum-preserving pancreatic head resection, either total or partial, are parenchyma-sparing resections for benign neoplasms of the pancreatic head. The first choice for small tumors is enucleation; however, enucleation is associated with an increased risk of pancreatic fistula B + C following pancreatic main duct injury. Duodenum-preserving total or partial pancreatic head resection has the advantage of low postoperative surgery-related complications, a mortality of < 0.5% and maintenance of the endocrine and exocrine pancreatic functions. Parenchyma-sparing pancreatic head resections should replace classical Whipple procedures for neoplasms of the pancreatic head.
Topics: Humans; Pancreatic Neoplasms; Pancreaticoduodenectomy; Neuroendocrine Tumors; Precancerous Conditions; Pancreatic Cyst; Postoperative Complications
PubMed: 38568302
DOI: 10.1007/s00104-024-02070-5 -
The Indian Journal of Radiology &... Apr 2024High fat content of pancreas can contribute to its soft texture, which is a strong predictor for postoperative pancreatic fistula (POPF). We propose to assess the...
High fat content of pancreas can contribute to its soft texture, which is a strong predictor for postoperative pancreatic fistula (POPF). We propose to assess the relationship of pancreatic computed tomography (CT) attenuation index (PAI) with histopathological fat content of pancreas and postpancreatectomy outcomes. Data was collected prospectively from patients who underwent pancreatic resections from February 2021 to January 2023. CT attenuation was measured in pancreas and spleen in three regions of interest each. The mean of the three values was taken as the mean pancreatic attenuation (P) and splenic attenuation(S). PAI was calculated (P-S and P/S) preoperatively. The fat content was calculated histologically in resected specimens. The pancreatic texture was also assessed intraoperatively by the operating surgeon to classify it as soft or firm. The relationship of PAI with fat content and postpancreatectomy outcomes such as delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH) and POPF was assessed. Seventy patients underwent pancreatic resections of which 59 were taken for analysis after satisfying the exclusion criteria. The PAI ranged from P-S (-23 to +19) and P/S (0.54-1.5). The histologic fat content of pancreas ranged from 0.4 to 42% (mean= 9.5076/standard deviation: 9.19520). Significant correlation was found between P-S and P/S (Spearman's rank correlation coefficient ρ = -0.775[95% confidence interval [CI]: -0.919 to -0.583], -0.743[95% CI: -0.896 to -0.467]) with pancreatic fat content. Postpancreatectomy outcomes noted were POPF(B/C):13, DGE:33, and PPH:3. Statistical significance was not seen between PAI and postpancreatectomy outcomes (POPF, = 0.067 DGE; = 0.456; PPH, = 0.891). PAI may be used as a reliable tool in predicting pancreatic fat content. However, it did not show a statistically significant association in predicting postpancreatectomy outcomes.
PubMed: 38549910
DOI: 10.1055/s-0043-1776340 -
Journal of Medical Case Reports Mar 2024Pancreaticopleural fistula is a rare complication of pancreatitis and poses diagnostic and therapeutic challenges. This case report sheds light on the unique challenges... (Review)
Review
BACKGROUND
Pancreaticopleural fistula is a rare complication of pancreatitis and poses diagnostic and therapeutic challenges. This case report sheds light on the unique challenges posed by pancreaticopleural fistula as a rare complication of pancreatitis. The aim is to contribute valuable insights to the scientific literature by presenting a case involving a middle-aged man with acute necrotizing pancreatitis and associated pleural effusion.
CASE PRESENTATION
A 41-year-old Asian male with a history of pancreatitis and chronic alcohol use presented with severe dyspnea, chest pain, and left-sided pleural effusion. Elevated serum amylase lipase levels and imaging confirmed acute necrotizing pancreatitis with a computed tomography severity index of 8/10. Magnetic resonance cholangiopancreatography revealed pancreatic necrosis and pseudocyst formation and findings suggestive of pancreaticopleural fistula. The patient was then treated with octreotide therapy.
CONCLUSION
The management of pancreaticopleural fistula demands a comprehensive and individualized approach. Recognition guided by high clinical suspicion coupled with appropriate investigations and a careful balance between medical, endoscopic, and surgical interventions is crucial for achieving favorable outcomes. This case report adds to the scientific literature by providing insights into the complexities of pancreaticopleural fistula and emphasizing the importance of personalized strategies in its management.
Topics: Adult; Humans; Male; Cholangiopancreatography, Endoscopic Retrograde; Pancreatic Fistula; Pancreatitis, Acute Necrotizing; Pleural Diseases; Pleural Effusion; Respiratory Tract Fistula
PubMed: 38549170
DOI: 10.1186/s13256-024-04457-8 -
Annals of Surgical Oncology Jun 2024
Letter to the Editor Regarding the Article, "Development of a Nomogram to Predict Clinically Relevant Postoperative Pancreatic Fistula After Pancreaticoduodenectomy on the Basis of Visceral Fat Area and Magnetic Resonance Imaging: A Nomogram Incorporating the Inflammatory Burden Index and Drainage...
Topics: Humans; Pancreatic Fistula; Pancreaticoduodenectomy; Intra-Abdominal Fat; Postoperative Complications; Magnetic Resonance Imaging; Nomograms; Drainage; Amylases; Prognosis; Inflammation
PubMed: 38546798
DOI: 10.1245/s10434-024-15159-2