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World Journal of Gastrointestinal... Aug 2023Post-operative pancreatic fistula (POPF) is the primary cause of morbidity following pancreaticoduodenectomy. Rates of POPF have remained high despite well known risk...
BACKGROUND
Post-operative pancreatic fistula (POPF) is the primary cause of morbidity following pancreaticoduodenectomy. Rates of POPF have remained high despite well known risk factors. The theory that hypoperfusion of the pancreatic stump leads to anastomotic failure has recently gained interest.
AIM
To define the published literature with regards to intraoperative pancreas perfusion assessment and its correlation with POPF.
METHODS
A systematic search of available literature was performed in November 2022. Data extracted included study characteristics, method of assessment of pancreas stump perfusion, POPF and other post-pancreatic surgery specific complications.
RESULTS
Five eligible studies comprised two prospective non-randomised studies and three case reports, total 156 patients. Four studies used indocyanine green fluorescence angiography to assess the pancreatic stump, with the remaining study assessing pancreas perfusion by visual inspection of arterial bleeding of the pancreatic stump. There was significant heterogeneity in the definition of POPF. Studies had a combined POPF rate of 12%; intraoperative perfusion assessment revealed hypoperfusion was present in 39% of patients who developed POPF. The rate of POPF was 11% in patients with no evidence of hypoperfusion and 13% in those with evidence of hypoperfusion, suggesting that not all hypoperfusion gives rise to POPF and further analysis is required to analyse if there is a clinically relevant cut off. Significant variance in practice was seen in the pancreatic stump management once hypoperfusion was identified.
CONCLUSION
The current published evidence around pancreas perfusion during pancreaticoduodenectomy is of poor quality. It does not support a causative link between hypoperfusion and POPF. Further well-designed prospective studies are required to investigate this.
PubMed: 37701689
DOI: 10.4240/wjgs.v15.i8.1799 -
Cancers Sep 2023Parenchymal-sparing approaches to pancreatectomy are technically challenging procedures but allow for preserving a normal pancreas and decreasing the rate of... (Review)
Review
BACKGROUND
Parenchymal-sparing approaches to pancreatectomy are technically challenging procedures but allow for preserving a normal pancreas and decreasing the rate of postoperative pancreatic insufficiency. The robotic platform is increasingly being used for these procedures. We sought to evaluate robotic parenchymal-sparing pancreatectomy and assess its complication profile and efficacy.
METHODS
This systematic review consisted of all studies on robotic parenchymal-sparing pancreatectomy (central pancreatectomy, duodenum-preserving partial pancreatic head resection, enucleation, and uncinate resection) published between January 2001 and December 2022 in PubMed and Embase.
RESULTS
A total of 23 studies were included in this review ( = 788). Robotic parenchymal-sparing pancreatectomy is being performed worldwide for benign or indolent pancreatic lesions. When compared to the open approach, robotic parenchymal-sparing pancreatectomies led to a longer average operative time, shorter length of stay, and higher estimated intraoperative blood loss. Postoperative pancreatic fistula is common, but severe complications requiring intervention are exceedingly rare. Long-term complications such as endocrine and exocrine insufficiency are nearly nonexistent.
CONCLUSIONS
Robotic parenchymal-sparing pancreatectomy appears to have a higher risk of postoperative pancreatic fistula but is rarely associated with severe or long-term complications. Careful patient selection is required to maximize benefits and minimize morbidity.
PubMed: 37686648
DOI: 10.3390/cancers15174369 -
Journal of Gastrointestinal Surgery :... Nov 2023Pancreatic benign, cystic, and neuroendocrine neoplasms are increasingly detected and recommended for surgical treatment. In multiorgan resection pancreatoduodenectomy... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Pancreatic benign, cystic, and neuroendocrine neoplasms are increasingly detected and recommended for surgical treatment. In multiorgan resection pancreatoduodenectomy or parenchyma-sparing, local extirpation is a challenge for decision-making regarding surgery-related early and late postoperative morbidity.
METHODS
PubMed, Embase, and Cochrane Libraries were searched for studies reporting early surgery-related complications following pancreatoduodenectomy (PD) and duodenum-preserving total (DPPHRt) or partial (DPPHRp) pancreatic head resection for benign tumors. Thirty-four cohort studies comprising data from 1099 patients were analyzed. In total, 654 patients underwent DPPHR and 445 patients PD for benign tumors. This review and meta-analysis does not need ethical approval.
RESULTS
Comparing DPPHRt and PD, the need for blood transfusion (OR 0.20, 95% CI 0.10-0.41, p<0.01), re-intervention for serious surgery-related complications (OR 0.48, 95% CI 0.31-0.73, p<0.001), and re-operation for severe complications (OR 0.50, 95% CI 0.26-0.95, p=0.04) were significantly less frequent following DPPHRt. Pancreatic fistula B+C (19.0 to 15.3%, p=0.99) and biliary fistula (6.3 to 4.3%; p=0.33) were in the same range following PD and DPPHRt. In-hospital mortality after DPPHRt was one of 350 patients (0.28%) and after PD eight of 445 patients (1.79%) (OR 0.32, 95% CI 0.10-1.09, p=0.07). Following DPPHRp, there was no mortality among the 192 patients.
CONCLUSION
DPPHR for benign pancreatic tumors is associated with significantly fewer surgery-related, serious, and severe postoperative complications and lower in-hospital mortality compared to PD. Tailored use of DPPHRt or DPPHRp contributes to a reduction of surgery-related complications. DPPHR has the potential to replace PD for benign tumors and premalignant cystic and neuroendocrine neoplasms of the pancreatic head.
Topics: Humans; Pancreatectomy; Pancreas; Pancreaticoduodenectomy; Pancreatic Neoplasms; Duodenum; Neuroendocrine Tumors; Pancreatic Cyst
PubMed: 37670106
DOI: 10.1007/s11605-023-05789-4 -
Langenbeck's Archives of Surgery Sep 2023Prevention and management of postoperative pancreatic fistula (POPF) after pancreatic resections is still an unresolved issue. Continuous irrigation of the...
PURPOSE
Prevention and management of postoperative pancreatic fistula (POPF) after pancreatic resections is still an unresolved issue. Continuous irrigation of the peripancreatic area is frequently used to treat necrotizing pancreatitis, but its use after elective pancreatic surgery is not well-known. With this systematic review, we sought to evaluate the current knowledge and expertise regarding the use of continuous irrigation in the surgical area to prevent or treat POPF after elective pancreatic resections.
METHODS
A systematic search of the literature was conducted according to the PRISMA 2020 guidelines, screening the databases of Pubmed, Scopus, Web of Science, and Ovid MEDLINE. Because of the heterogeneity of the included articles, a statistical inference could not be performed and the literature was reviewed only descriptively. The study was pre-registered online (OSF Registry).
RESULTS
Nine studies were included. Three studies provided data regarding the prophylactic use of continuous irrigation after distal and limited pancreatectomies. Here, patients after irrigation showed a lower rate of clinically relevant POPF, related complications, lengths of stay, and mortality. Six other papers reported the use of local lavage to treat clinically relevant POPF and subsequent fluid collections, with successful outcomes.
CONCLUSION
In the current literature, only a few publications are focused on the use of continuous irrigation after pancreatic resection to prevent or manage POPF. The included studies showed promising results, and this technique may be useful in patients at high risk of POPF. Further investigations and randomized trials are needed.
Topics: Humans; Pancreatectomy; Elective Surgical Procedures; Therapeutic Irrigation; Pancreas; Postoperative Complications
PubMed: 37659027
DOI: 10.1007/s00423-023-03070-5 -
ANZ Journal of Surgery Dec 2023To compare the clinical outcomes and prognosis of total pancreatectomy (TP) and pancreaticoduodenectomy (PD) for the treatment of pancreatic ductal adenocarcinoma... (Meta-Analysis)
Meta-Analysis Review
Comparison of clinical outcomes and prognosis between total pancreatectomy and pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: a systematic review and meta-analysis.
BACKGROUND
To compare the clinical outcomes and prognosis of total pancreatectomy (TP) and pancreaticoduodenectomy (PD) for the treatment of pancreatic ductal adenocarcinoma (PDAC), and to explore the safety and indications of TP.
METHODS
A systematic search was conducted on PubMed, Web of Science, and Embase databases from January 1943 to March 2023 for literatures comparing TP and PD in the treatment of PDAC. The primary outcome was postoperative overall survival (OS), and secondary outcomes included surgery time, blood loss, readmission, hospital stay, perioperative mortality, and overall morbidity. Fixed-effect or random-effect models were selected based on heterogeneity, and odds ratio (OR), mean difference (MD), or hazard ratio (HR) with 95% confidence intervals (CI) were calculated.
RESULTS
A total of six studies involving 8396 patients were included in the meta-analysis. There was no statistically significant difference in OS after surgery between the two groups (HR = 1.08, 95% CI: 0.91-1.27; P = 0.38). The TP group had a longer surgery time (MD = 13.66, 95% CI: 4.57-22.75; P = 0.003) and more blood loss (MD = 133.17, 95% CI: 8.00-258.33; P = 0.04) than the PD group. There were no significant differences between the two groups in terms of hospital stay (MD = 0.09, 95% CI: -2.04 to 2.22; P = 0.93), readmission rate (OR = 1.39; 95% CI: 1.00-1.92; P = 0.05), perioperative mortality (OR = 1.29, 95% CI: 0.98-1.69; P = 0.07), and overall morbidity (OR = 0.80, 95% CI: 0.50-1.26; P = 0.33).
CONCLUSION
The surgical process of TP is relatively complex, but there is no difference in short-term clinical outcomes and OS compared to PD, making it a safe and reliable procedure. Indications and treatment outcomes for planned TP and salvage TP may differ, and more research is needed in the future for further classification and verification.
Topics: Humans; Pancreatectomy; Pancreaticoduodenectomy; Pancreatic Neoplasms; Carcinoma, Pancreatic Ductal; Prognosis
PubMed: 37614050
DOI: 10.1111/ans.18653 -
Pancreatology : Official Journal of the... Nov 2023Intraductal papillary mucinous neoplasms (IPMNs) are a cystic precursor to pancreatic cancer. IPMNs deemed clinically to be at high-risk for malignant progression are...
BACKGROUND
Intraductal papillary mucinous neoplasms (IPMNs) are a cystic precursor to pancreatic cancer. IPMNs deemed clinically to be at high-risk for malignant progression are frequently treated with surgical resection, and pathological examination of the pancreatectomy specimen is a key component of the clinical care of IPMN patients.
METHODS
Systematic literature reviews were conducted around eight topics of clinical relevance in the examination of pathological specimens in patients undergoing resection of IPMN.
RESULTS
This review provides updated perspectives on morphological subtyping of IPMNs, classification of intraductal oncocytic papillary neoplasms, nomenclature for high-grade dysplasia, assessment of T stage, distinction of carcinoma associated or concomitant with IPMN, role of molecular assessment of IPMN tissue, role of intraoperative assessment by frozen section, and preoperative evaluation of cyst fluid cytology.
CONCLUSIONS
This analysis provides the foundation for data-driven approaches to several challenging issues in the pathology of IPMNs.
Topics: Humans; Carcinoma, Pancreatic Ductal; Pancreatic Intraductal Neoplasms; Adenocarcinoma, Mucinous; Retrospective Studies; Pancreatic Neoplasms
PubMed: 37604731
DOI: 10.1016/j.pan.2023.08.002 -
Langenbeck's Archives of Surgery Aug 2023Reducing clinically relevant post-operative pancreatic fistula (CR-POPF) incidence after pancreatic resections has been a topic of great academic interest. Optimizing... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Reducing clinically relevant post-operative pancreatic fistula (CR-POPF) incidence after pancreatic resections has been a topic of great academic interest. Optimizing post-operative drain management is a potential strategy in reducing this major complication.
METHODS
Studies involving pancreatic resections, including both pancreaticoduodenectomy (PD) and distal pancreatic resections (DP), with intra-operative drain placement were screened. Early drain removal was defined as removal before or on the 3rd post-operative day (POD) while late drain removal was defined as after the 3rd POD. The primary outcome was CR-POPF, International Study Group of Pancreatic Surgery (ISGPS) Grade B and above. Secondary outcomes were all complications, severe complications, post-operative haemorrhage, intra-abdominal infections, delayed gastric emptying, reoperation, length of stay, readmission, and mortality.
RESULTS
Nine studies met the inclusion criteria and were included for analysis. The studies had a total of 8574 patients, comprising 1946 in the early removal group and 6628 in the late removal group. Early drain removal was associated with a significantly lower risk of CR-POPF (OR: 0.24, p < 0.01). Significant reduction in risk of post-operative haemorrhage (OR: 0.55, p < 0.01), intra-abdominal infection (OR: 0.35, p < 0.01), re-admission (OR: 0.63, p < 0.01), re-operation (OR: 0.70, p = 0.03), presence of any complications (OR: 0.46, p < 0.01), and reduced length of stay (SMD: -0.75, p < 0.01) in the early removal group was also observed.
CONCLUSION
Early drain removal is associated with significant reductions in incidence of CR-POPF and other post-operative complications. Further prospective randomised trials in this area are recommended to validate these findings.
Topics: Humans; Pancreatectomy; Device Removal; Pancreas; Postoperative Complications; Postoperative Hemorrhage; Intraabdominal Infections
PubMed: 37587225
DOI: 10.1007/s00423-023-03053-6 -
Langenbeck's Archives of Surgery Aug 2023The systematic review is aimed to evaluate the cost-effectiveness of minimally invasive surgery (MIS) and open distal pancreatectomy and pancreaticoduodenectomy. (Meta-Analysis)
Meta-Analysis
BACKGROUND
The systematic review is aimed to evaluate the cost-effectiveness of minimally invasive surgery (MIS) and open distal pancreatectomy and pancreaticoduodenectomy.
METHOD
The MEDLINE, CENTRAL, EMBASE, Centre for Reviews and Dissemination, and clinical trial registries were systematically searched using the PRISMA framework. Studies of adults aged ≥ 18 year comparing laparoscopic and/or robotic versus open DP and/or PD that reported cost of operation or index admission, and cost-effectiveness outcomes were included. The risk of bias of non-randomised studies was assessed using the Newcastle-Ottawa Scale, while the Cochrane Risk of Bias 2 (RoB2) tool was used for randomised studies. Standardised mean differences (SMDs) with 95% confidence intervals (CI) were calculated for continuous variables.
RESULTS
Twenty-two studies (152,651 patients) were included in the systematic review and 15 studies in the meta-analysis (3 RCTs; 3 case-controlled; 9 retrospective studies). Of these, 1845 patients underwent MIS (1686 laparoscopic and 159 robotic) and 150,806 patients open surgery. The cost of surgical procedure (SMD 0.89; 95% CI 0.35 to 1.43; I = 91%; P = 0.001), equipment (SMD 3.73; 95% CI 1.55 to 5.91; I = 98%; P = 0.0008), and operating room occupation (SMD 1.17, 95% CI 0.11 to 2.24; I = 95%; P = 0.03) was higher with MIS. However, overall index hospitalisation costs trended lower with MIS (SMD - 0.13; 95% CI - 0.35 to 0.06; I = 80%; P = 0.17). There was significant heterogeneity among the studies.
CONCLUSION
Minimally invasive major pancreatic surgery entailed higher intraoperative but similar overall index hospitalisation costs.
Topics: Adult; Humans; Pancreatectomy; Retrospective Studies; Cost-Benefit Analysis; Pancreas; Pancreaticoduodenectomy; Minimally Invasive Surgical Procedures; Laparoscopy
PubMed: 37572127
DOI: 10.1007/s00423-023-03017-w -
Annals of Surgery Feb 2024To provide procedure-specific estimates of symptomatic venous thromboembolism (VTE) and major bleeding after abdominal surgery. (Meta-Analysis)
Meta-Analysis
Systematic Reviews and Meta-analyses of the Procedure-specific Risks of Thrombosis and Bleeding in General Abdominal, Colorectal, Upper Gastrointestinal, and Hepatopancreatobiliary Surgery.
OBJECTIVE
To provide procedure-specific estimates of symptomatic venous thromboembolism (VTE) and major bleeding after abdominal surgery.
BACKGROUND
The use of pharmacological thromboprophylaxis represents a trade-off that depends on VTE and bleeding risks that vary between procedures; their magnitude remains uncertain.
METHODS
We identified observational studies reporting procedure-specific risks of symptomatic VTE or major bleeding after abdominal surgery, adjusted the reported estimates for thromboprophylaxis and length of follow-up, and estimated cumulative incidence at 4 weeks postsurgery, stratified by VTE risk groups, and rated evidence certainty.
RESULTS
After eligibility screening, 285 studies (8,048,635 patients) reporting on 40 general abdominal, 36 colorectal, 15 upper gastrointestinal, and 24 hepatopancreatobiliary surgery procedures proved eligible. Evidence certainty proved generally moderate or low for VTE and low or very low for bleeding requiring reintervention. The risk of VTE varied substantially among procedures: in general abdominal surgery from a median of <0.1% in laparoscopic cholecystectomy to a median of 3.7% in open small bowel resection, in colorectal from 0.3% in minimally invasive sigmoid colectomy to 10.0% in emergency open total proctocolectomy, and in upper gastrointestinal/hepatopancreatobiliary from 0.2% in laparoscopic sleeve gastrectomy to 6.8% in open distal pancreatectomy for cancer.
CONCLUSIONS
VTE thromboprophylaxis provides net benefit through VTE reduction with a small increase in bleeding in some procedures (eg, open colectomy and open pancreaticoduodenectomy), whereas the opposite is true in others (eg, laparoscopic cholecystectomy and elective groin hernia repairs). In many procedures, thromboembolism and bleeding risks are similar, and decisions depend on individual risk prediction and values and preferences regarding VTE and bleeding.
Topics: Humans; Anticoagulants; Colorectal Neoplasms; Hemorrhage; Postoperative Complications; Thrombosis; Venous Thromboembolism
PubMed: 37551583
DOI: 10.1097/SLA.0000000000006059 -
International Journal of Surgery... Jul 2023The aim of this study was to perform a systematic review and meta-analysis on the safety and effectiveness regarding outcomes of minimally invasive total pancreatectomy... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
The aim of this study was to perform a systematic review and meta-analysis on the safety and effectiveness regarding outcomes of minimally invasive total pancreatectomy (MITP) versus open total pancreatectomy (OTP).
BACKGROUND
Total pancreatectomy is a complicated operation in abdominal surgery. The flexibility of minimally invasive surgery offers a new surgical approach to this technology. At present, there is little research on MITP, and its advantages over OTP remain uncertain.
METHODS
A systematic literature review and meta-analysis was conducted basing on comparative studies between MITP and OTP from January 1943 to November 2022. Intraoperative outcomes and postoperative outcomes were assessed. Pooled odds ratios (ORs) and mean differences with a 95% CI were calculated using fixed-effect or random-effect models under heterogeneity.
RESULTS
Seven studies with a total of 4275 patients were included. The major morbidity in the MITP group was significant lower (OR 0.50, 95% CI: 0.30-0.84, P=0.008, I²= 0%) than OTP group. At the same time, comparing with OTP, the MITP group had lower estimated blood loss (MD -362.50, 95% CI -641.34 to -83.66, P=0.01, I²=96%) and lower intraoperative transfusion rate (OR 0.36, 95% CI 0.16-0.84, P=0.02, I²=0%). There were no significant differences between the MITP and OTP groups for other outcomes.
CONCLUSIONS
The results suggested that MITP was associated with lower major morbidity, estimated blood loss, and intraoperative transfusion rate comparing with OTP. However, the further evidence with a better design is required.
Topics: Humans; Pancreatectomy; Blood Loss, Surgical; Minimally Invasive Surgical Procedures; Length of Stay; Blood Transfusion; Postoperative Complications
PubMed: 37485920
DOI: 10.1097/JS9.0000000000000392