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Scandinavian Journal of Gastroenterology Oct 2016Pancreas surgery has developed into a fairly safe procedure in terms of mortality, but is still hampered by considerable morbidity. Among the most frequent and dreaded... (Review)
Review
BACKGROUND
Pancreas surgery has developed into a fairly safe procedure in terms of mortality, but is still hampered by considerable morbidity. Among the most frequent and dreaded complications are the development of a post-operative pancreatic fistula (POPF). The prediction and prevention of POPF remains an area of debate with several questions yet to be firmly addressed with solid answers.
METHODS
A systematic review of systematic reviews/meta-analyses and randomized trials in the English literature (PubMed/MEDLINE, Cochrane library, EMBASE) covering January 2005 to December 2015 on risk factors and preventive strategies for POPF.
RESULTS
A total of 49 systematic reviews and meta-analyses over the past decade discussed patient, surgeon, pancreatic disease and intraoperative related factors of POPF. Non-modifiable factors (age, BMI, comorbidity) and pathology (histotype, gland texture, duct size) that indicates surgery are associated with POPF risk. Consideration of anastomotic technique and use of somatostatin-analogs may slightly modify the risk of fistula. Sealant products appear to have no effect. Perioperative bleeding and transfusion enhance risk, but is modifiable by focus on technique and training. Drains may not prevent fistulae, but may help in early detection. Early drain-amylase may aid in detection. Predictive scores lack uniform validation, but may have a role in patient information if reliable pre-operative risk factors can be obtained.
CONCLUSIONS
Development of POPF occurs through several demonstrated risk factors. Anastomotic technique and use of somatostatin-analogs may slightly decrease risk. Drains may aid in early detection of leaks, but do not prevent POPF.
Topics: Digestive System Surgical Procedures; Drainage; Humans; Morbidity; Pancreas; Pancreatic Fistula; Postoperative Complications; Predictive Value of Tests; Randomized Controlled Trials as Topic; Risk Factors
PubMed: 27216233
DOI: 10.3109/00365521.2016.1169317 -
International Journal of Surgery... May 2018Laparoscopic pancreatic surgery (LPS) has been widely used in the treatment of benign and low-grade pancreatic diseases. It is necessary to expand the current knowledge... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Laparoscopic pancreatic surgery (LPS) has been widely used in the treatment of benign and low-grade pancreatic diseases. It is necessary to expand the current knowledge on the feasibility and safety of LPS for pancreatic ductal adenocarcinoma (PDAC) by systematic reviewing the published studies and analyzing them by meta-analysis.
METHODS
Original articles compared LPS with open pancreatic surgery (OPS) for PDAC, published from January 1994 to August 2017 were searched in medical databases. Postoperative pancreatic fistula (POPF), morbidity, mortality, operation time, blood loss, transfusion, hospital stay, retrieved lymph nodes (RLNs), and survival outcomes were compared.
RESULTS
Fourteen studies with a total of 13174 patients (1705 in LPS and 11469 in OPS) were included for the meta-analysis. LPS showed less morbidity (RR = 0.78, 95%CI: 0.66-0.92, P < .01), blood loss (WMD = -298.05 ml, 95% CI, -482.98∼-113.12 ml; P < .01), shorter hospital stay (WMD = -2.86, 95%CI, -3.85∼-1.87; P < .01), more RLNs (WMD = 1.47, 95%CI: 0.15-2.78; P = .03) and comparable POPF (RR = 1.12, 95%CI: 0.82-1.53, P = .50), operation time (WMD = 22.23 min; 95%CI: -19.56-64.01, P = .30), and 5-year overall survival (HR = 0.92, 95%CI: 0.80-1.06; P = .23) compared to OPS.
CONCLUSION
LPS can be performed safely in carefully selected patients with PADC and would improve the surgical outcomes. Considering the limitation of study design, the conclusions should be interpret cautiously and warrant to be confirmed by randomized controlled studies.
Topics: Blood Loss, Surgical; Blood Transfusion; Carcinoma, Pancreatic Ductal; Humans; Laparoscopy; Length of Stay; Operative Time; Pancreatectomy; Pancreatic Fistula; Pancreatic Neoplasms; Postoperative Complications; Treatment Outcome
PubMed: 29337177
DOI: 10.1016/j.ijsu.2017.12.032 -
HPB : the Official Journal of the... Aug 2021Risk factors for the development of clinically relevant POPF (CR-POPF) following distal pancreatectomy (DP) need clarification particularly following the 2016... (Meta-Analysis)
Meta-Analysis Review
Systematic review and meta-analysis of risk factors of postoperative pancreatic fistula after distal pancreatectomy in the era of 2016 International Study Group pancreatic fistula definition.
BACKGROUND
Risk factors for the development of clinically relevant POPF (CR-POPF) following distal pancreatectomy (DP) need clarification particularly following the 2016 International Study Group of Pancreatic Fistula (ISGPF) definition.
METHODS
A systemic search of MEDLINE, Pubmed, Scopus, and EMBASE were conducted using the PRISMA framework. Studies were evaluated for risk factors for the development CR-POPF after DP using the 2016 ISGPF definition. Further subgroup analysis was undertaken on studies ≥10 patients in exposed and non-exposed subgroups.
RESULTS
Forty-three studies with 8864 patients were included in the meta-analysis. The weighted rate of CR-POPF was 20.4% (95%-CI: 17.7-23.4%). Smoking (OR 1.29, 95%-CI: 1.08-1.53, p = 0.02) and open DP (OR 1.43, 95%-CI: 1.02-2.01, p = 0.04) were found to be significant risk factors of CR-POPF. Diabetes (OR 0.81, 95%-CI: 0.68-0.95, p = 0.02) was a significant protective factor against CR-POPF. Substantial heterogeneity was observed in the comparisons of pancreatic texture and body mass index. Seventeen risk factors achieved significance in a univariate or multivariate comparison as reported by individual studies in the narrative synthesis, however, they remain difficult to interpret as statistically significant comparisons were not uniform.
CONCLUSION
This meta-analysis found smoking and open DP to be risk factors and diabetes to be protective factor of CR-POPF in the era of 2016 ISGPF definition.
Topics: Humans; Pancreas; Pancreatectomy; Pancreatic Fistula; Postoperative Complications; Retrospective Studies; Risk Factors
PubMed: 33820687
DOI: 10.1016/j.hpb.2021.02.015 -
Medicina (Kaunas, Lithuania) Jan 2023: Postoperative pancreatic fistula (POPF) is one of the most challenging complications after pancreatic resections, associated with prolonged hospital stay and high... (Review)
Review
: Postoperative pancreatic fistula (POPF) is one of the most challenging complications after pancreatic resections, associated with prolonged hospital stay and high mortality. Early identification of pancreatic fistula is necessary for the treatment to be effective. Several prognostic factors have been identified, although it is unclear which one is the most crucial. Some studies show that post-pancreatectomy hypophosphatemia may be associated with the development of POPF. The aim of this systematic review was to determine whether postoperative hypophosphatemia can be used as a prognostic factor for postoperative pancreatic fistula. : The systematic literature review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations (PRISMA) and was registered in the International Prospective Register of Systematic Reviews (PROSPERO). The PubMed, ScienceDirect, and Web of Science databases were systematically searched up to the 31st of January 2022 for studies analyzing postoperative hypophosphatemia as a prognostic factor for POPF. Data including study characteristics, patient characteristics, operation type, definitions of postoperative hypophosphatemia and postoperative pancreatic fistula were extracted. : Initially, 149 articles were retrieved. After screening and final assessment, 3 retrospective studies with 2893 patients were included in this review. An association between postoperative hypophosphatemia and POPF was found in all included studies. Patients undergoing distal pancreatectomy were more likely to develop severe hypophosphatemia compared to patients undergoing proximal pancreatectomy. Serum phosphate levels on postoperative day 4 (POD 4) and postoperative day 5 (POD 5) remained significantly lower in patients who developed leak-related complications showing a slower recovery of hypophosphatemia from postoperative day 3 (POD 3) through postoperative day 7 (POD 7). Moreover, body mass index (BMI) higher than 30 kg/m, soft pancreatic tissue, abnormal white blood cell count on postoperative day 3 (POD 3), and shorter surgery time were associated with leak-related complications (LRC) and lower phosphate levels. : Early postoperative hypophosphatemia might be used as a prognostic biomarker for early identification of postoperative pancreatic fistula. However, more studies are needed to better identify significant cut-off levels of postoperative hypophosphatemia and development of hypophosphatemia in the postoperative period.
Topics: Humans; Pancreatic Fistula; Prognosis; Retrospective Studies; Hypophosphatemia; Postoperative Complications; Phosphates; Postoperative Period; Risk Factors
PubMed: 36837475
DOI: 10.3390/medicina59020274 -
International Journal of Surgery... Dec 2016Duct-to-mucosa and invagination are two commonly used techniques of pancreaticojejunostomy (PJ) after pancreaticoduodenectomy. Previously, we conducted a systematic... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Duct-to-mucosa and invagination are two commonly used techniques of pancreaticojejunostomy (PJ) after pancreaticoduodenectomy. Previously, we conducted a systematic review comparing the safety and efficacy of the two PJ techniques. Here, we added new evidence and updated our previous conclusion.
METHODS
We systematically searched multiple databases and included randomized controlled trials (RCTs) comparing duct-to-mucosa and invagination techniques of PJ. The quality of evidence was assessed using Jadad score, and reporting bias was evaluated using funnel plots. Meta-analysis was performed using a random-effects model. Risk ratio (RR) and 95% confidence interval (CI) were calculated. The primary outcome was pancreatic fistula, and the secondary outcomes included mortality, reoperation, morbidity and postoperative hospital stay. Trial sequential analysis was performed to calculate the required information size.
RESULTS
Seven RCTs with 850 participants were included. No significant difference was detected in the rates of pancreatic fistula (RR 0.98, 95% CI 0.63 to 1.53), mortality (RR 0.94, 95% CI 0.40 to 2.18), reoperation (RR 1.23, 95% CI 0.69 to 2.20) and morbidity (RR 0.98, 95% CI 0.82 to 1.16) between the two groups. However, patients who underwent duct-to-mucosa PJ had a significantly shorter postoperative hospital stay (mean difference -2.80, 95% CI -5.08 to -0.52). Trial sequential analysis showed that another 279 participants were needed for conclusive results.
CONCLUSIONS
Given the current evidence, duct-to-mucosa PJ did not decrease the rates of pancreatic fistula and other adverse events as compared to invagination PJ; however, it did reduce postoperative hospital stay. Further RCTs are needed.
Topics: Anastomosis, Surgical; Humans; Intestinal Mucosa; Length of Stay; Mortality; Pancreatic Ducts; Pancreatic Fistula; Pancreaticoduodenectomy; Pancreaticojejunostomy; Postoperative Complications; Randomized Controlled Trials as Topic; Reoperation; Safety
PubMed: 27826046
DOI: 10.1016/j.ijsu.2016.11.008 -
Langenbeck's Archives of Surgery Dec 2020Drains' role after pancreaticoduodenectomy (PD) is debated by proponents of no drain, draining selected cases, and early drain removal. The aim of the study was to... (Meta-Analysis)
Meta-Analysis
Systematic review and meta-analysis of surgical drain management after the diagnosis of postoperative pancreatic fistula after pancreaticoduodenectomy: draining-tract-targeted works better than standard management.
PURPOSE
Drains' role after pancreaticoduodenectomy (PD) is debated by proponents of no drain, draining selected cases, and early drain removal. The aim of the study was to assess the effect of "standard" and "draining-tract-targeted" management of abdominal drains still in situ after diagnosing a postoperative pancreatic fistula (POPF).
METHODS
PubMed and Scopus were searched for "pancreaticoduodenectomy or pancreatoduodenectomy or duodenopancreatectomy," "Whipple," "proximal pancreatectomy," "pylorus-preserving pancreatectomy," and "postoperative pancreatic fistula or POPF.". Main outcomes included clinically relevant (CR) POPF, grade-C POPF, overall mortality, POPF-related mortality, and CR-POPF-related mortality. Secondary outcomes were incidence of radiological and/or endoscopic interventions, reoperations, and completion pancreatectomies.
RESULTS
Overall, 12,089 studies were retrieved by the search of the English literature (01/01/1990-31/12/2018). Three hundred and twenty-six studies (90,321 patients) reporting ≥ 100 PDs and ≥ 10 PD/year were finally included into the study. Average incidences were obtained by averaging the incidence rates reported in the single articles. Pooled incidences were calculated by combining the number of events and the total number of patients considered in the various studies. These were then meta-analyzed using DerSimonian and Laird's (1986) method. Pearson's chi-squared test was used to compare pooled incidences between groups. Post hoc testing was used to see which groups differed. The meta-analyzed incidences were compared using a fixed effect for moderators. "Draining-tract-targeted" management showed a significant advantage over "standard" management in four clinically relevant outcomes out of eight according to pool analysis and in one of them according to meta-analysis.
CONCLUSION
Clinically, "draining-targeted" management of POPF should be preferred to "standard" management.
Topics: Drainage; Humans; Pancreas; Pancreatectomy; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications
PubMed: 33104886
DOI: 10.1007/s00423-020-02005-8 -
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 -
Updates in Surgery Jun 2021The treatment of periampullary and pancreatic head neoplasms is evolving. While minimally invasive Pancreaticoduodenectomy (PD) has gained worldwide interest, there has... (Meta-Analysis)
Meta-Analysis
The treatment of periampullary and pancreatic head neoplasms is evolving. While minimally invasive Pancreaticoduodenectomy (PD) has gained worldwide interest, there has been a debate on its related outcomes. The purpose of this paper was to provide an updated evidence comparing short-term surgical and oncologic outcomes within Open Pancreaticoduodenectomy (OpenPD), Laparoscopic Pancreaticoduodenectomy (LapPD), and Robotic Pancreaticoduodenectomy (RobPD). MEDLINE, Web of Science, PubMed, Cochrane Central Library, and ClinicalTrials.gov were referred for systematic search. A Bayesian network meta-analysis was executed. Forty-one articles (56,440 patients) were included; 48,382 (85.7%) underwent OpenPD, 5570 (9.8%) LapPD, and 2488 (4.5%) RobPD. Compared to OpenPD, LapPD and RobPD had similar postoperative mortality [Risk Ratio (RR) = 1.26; 95%CrI 0.91-1.61 and RR = 0.78; 95%CrI 0.54-1.12)], clinically relevant (grade B/C) postoperative pancreatic fistula (POPF) (RR = 1.12; 95%CrI 0.82-1.43 and RR = 0.87; 95%CrI 0.64-1.14, respectively), and severe (Clavien-Dindo ≥ 3) postoperative complications (RR = 1.03; 95%CrI 0.80-1.46 and RR = 0.93; 95%CrI 0.65-1.14, respectively). Compared to OpenPD, both LapPD and RobPD had significantly reduced hospital length-of-stay, estimated blood loss, infectious, pulmonary, overall complications, postoperative bleeding, and hospital readmission. No differences were found in the number of retrieved lymph nodes and R0. OpenPD, LapPD, and RobPD seem to be comparable across clinically relevant POPF, severe complications, postoperative mortality, retrieved lymphnodes, and R0. LapPD and RobPD appears to be safer in terms of infectious, pulmonary, and overall complications with reduced hospital readmission We advocate surgeons to choose their preferred surgical approach according to their expertise, however, the adoption of minimally invasive techniques may possibly improve patients' outcomes.
Topics: Bayes Theorem; Humans; Laparoscopy; Network Meta-Analysis; Pancreatic Neoplasms; Pancreaticoduodenectomy; Postoperative Complications; Robotic Surgical Procedures
PubMed: 33315230
DOI: 10.1007/s13304-020-00916-1 -
The Cochrane Database of Systematic... Apr 2013Pancreatic resections are associated with high morbidity (30% to 60%) and mortality (5%). Synthetic analogues of somatostatin are advocated by some surgeons to reduce... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Pancreatic resections are associated with high morbidity (30% to 60%) and mortality (5%). Synthetic analogues of somatostatin are advocated by some surgeons to reduce complications following pancreatic surgery; however, their use is controversial.
OBJECTIVES
To determine whether prophylactic somatostatin analogues should be used routinely in pancreatic surgery.
SEARCH METHODS
We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 1), MEDLINE, EMBASE and Science Citation Index Expanded to February 2013.
SELECTION CRITERIA
We included randomised controlled trials comparing prophylactic somatostatin or one of its analogues versus no drug or placebo during pancreatic surgery (irrespective of language or publication status).
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed trials for inclusion and independently extracted data. We analysed data with both the fixed-effect and random-effects models using Review Manager (RevMan). We calculated the risk ratio (RR), mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI) based on an intention-to-treat or available case analysis. When it was not possible to perform either of the above, we performed a per protocol analysis.
MAIN RESULTS
We identified 21 trials (19 trials of high risk of bias) involving 2348 people. There was no significant difference in the perioperative mortality (RR 0.80; 95% CI 0.56 to 1.16; n = 2210) or the number of people with drug-related adverse effects between the two groups (RR 2.09; 95% CI 0.83 to 5.24; n = 1199). Quality of life was not reported in any of the trials. The overall number of participants with postoperative complications was significantly lower in the somatostatin analogue group (RR 0.70; 95% CI 0.61 to 0.80; n = 1903) but there was no significant difference in the re-operation rate (RR 1.26; 95% CI 0.58 to 2.70; n = 687) or hospital stay (MD -1.29 days; 95% CI -2.60 to 0.03; n = 1314) between the groups. The incidence of pancreatic fistula was lower in the somatostatin analogue group (RR 0.66; 95% CI 0.55 to 0.79; n = 2206). The proportion of these fistulas that were clinically significant was not mentioned in most trials. On inclusion of trials that clearly distinguished clinically significant fistulas, there was no significant difference between the two groups (RR 0.69; 95% CI 0.38 to 1.28; n = 292).
AUTHORS' CONCLUSIONS
Somatostatin analogues may reduce perioperative complications but do not reduce perioperative mortality. Further adequately powered trials with low risk of bias are necessary. Based on the current available evidence, somatostatin and its analogues are recommended for routine use in people undergoing pancreatic resection.
Topics: Gastrointestinal Agents; Humans; Length of Stay; Octreotide; Pancreas; Pancreatectomy; Pancreatic Diseases; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; Publication Bias; Randomized Controlled Trials as Topic; Reoperation; Sepsis; Somatostatin
PubMed: 23633353
DOI: 10.1002/14651858.CD008370.pub3 -
Translational Gastroenterology and... 2017The prevalence of pancreatic cystic echinococcosis (PCE) in the world is low ranging between 0.2% and 0.6%. The diagnosis of PCE is easy when it is associated to other... (Review)
Review
The prevalence of pancreatic cystic echinococcosis (PCE) in the world is low ranging between 0.2% and 0.6%. The diagnosis of PCE is easy when it is associated to other location such as liver, it became difficult when PCE was isolated simulating other diagnosis such as pseudocyst, a choledochal cyst, serous or mucinous cystadenoma and cystadenocarcinoma. This systematic review aimed to provide evidence-based answer to the following questions: (I) what are the efficient tools to affirm the diagnosis of isolated PCE and (II) what are the best therapeutic strategy for the PCE? An electronic search was performed by two authors (W Dougaz, I Bouasker). Medline, Scopus, Embase, Web of Science, Google Scholar and Cochrane collaboration were consulted. The keywords used were "cyst", "echinococcosis", "hydatid cyst" and "pancreas". All abstracts were analyzed followed by extraction of the full text by the same two authors (W Dougaz, I Bouasker), all divergences were resolved by discussion with C Dziri. Recommendations were based on Oxford's classification: (I) what are the efficient tools to affirm the diagnosis of PCE? -ultrasound remains the cornerstone of diagnosis. Magnetic resonance imaging (MRI) reproduces the ultrasound defined features of CE better than computed tomography (CT). MRI with heavily T2-weighted series is preferable to CT. Pancreatic duct MRI should be promising to identify a fistula between PCE and pancreatic duct (level of evidence 3-recommendation B); (II) what are the best therapeutic strategy for the PCE? -surgery is the main treatment of PCE. Open approach is validated. The decision depends of the location of PCE: head body and/or tail of the pancreas (level of evidence 5-recommendation D): for the head of the pancreas, the tendency is toward conservative surgery. For body and/or tail of the pancreas, the tendency is toward radical surgery. Medical treatment (albendazole) should be prescribed 1 week before surgery and 2 months during postoperative period (level II evidence and grade C recommendation).
PubMed: 29354762
DOI: 10.21037/tgh.2017.11.13