-
Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery.The Cochrane Database of Systematic... Jun 2018Postoperative pancreatic fistula is one of the most frequent and potentially life-threatening complications following pancreatic resections. Fibrin sealants are... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Postoperative pancreatic fistula is one of the most frequent and potentially life-threatening complications following pancreatic resections. Fibrin sealants are introduced to reduce postoperative pancreatic fistula by some surgeons. However, the use of fibrin sealants during pancreatic surgery is controversial. This is an update of a Cochrane Review last published in 2016.
OBJECTIVES
To assess the safety, effectiveness, and potential adverse effects of fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery.
SEARCH METHODS
We searched trial registers and the following biomedical databases: the Cochrane Library (2018, Issue 4), MEDLINE (1946 to 12 April 2018), Embase (1980 to 12 April 2018), Science Citation Index Expanded (1900 to 12 April 2018), and Chinese Biomedical Literature Database (CBM) (1978 to 12 April 2018).
SELECTION CRITERIA
We included all randomized controlled trials that compared fibrin sealant (fibrin glue or fibrin sealant patch) versus control (no fibrin sealant or placebo) in people undergoing pancreatic surgery.
DATA COLLECTION AND ANALYSIS
Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes (or a Peto odds ratio (OR) for very rare outcomes), and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs).
MAIN RESULTS
We included 11 studies involving 1462 participants in the review.Application of fibrin sealants to pancreatic stump closure reinforcement after distal pancreatectomyWe included seven studies involving 860 participants: 428 were randomized to the fibrin sealant group and 432 to the control group after distal pancreatectomy. Fibrin sealants may lead to little or no difference in postoperative pancreatic fistula (fibrin sealant 19.3%; control 20.1%; RR 0.96, 95% CI 0.68 to 1.35; 755 participants; four studies; low-quality evidence). Fibrin sealants may also lead to little or no difference in postoperative mortality (0.3% versus 0.5%; Peto OR 0.52, 95% CI 0.05 to 5.03; 804 participants; six studies; low-quality evidence), or overall postoperative morbidity (28.5% versus 23.2%; RR 1.23, 95% CI 0.97 to 1.58; 646 participants; three studies; low-quality evidence). We are uncertain whether fibrin sealants reduce reoperation rate (2.0% versus 3.8%; RR 0.51, 95% CI 0.15 to 1.71; 376 participants; two studies; very low-quality evidence). There is probably little or no difference in length of hospital stay between the groups (12.1 days versus 11.4 days; MD 0.32 days, 95% CI -1.06 to 1.70; 755 participants; four studies; moderate-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness.Application of fibrin sealants to pancreatic anastomosis reinforcement after pancreaticoduodenectomyWe included three studies involving 251 participants: 115 were randomized to the fibrin sealant group and 136 to the control group after pancreaticoduodenectomy. We are uncertain whether fibrin sealants reduce postoperative pancreatic fistula (1.6% versus 6.2%; RR 0.25, 95% CI 0.01 to 5.06; 57 participants; one study; very low-quality evidence). Fibrin sealants may lead to little or no difference in postoperative mortality (0.1% versus 0.7%; Peto OR 0.15, 95% CI 0.00 to 7.76; 251 participants; three studies; low-quality evidence) or length of hospital stay (12.8 days versus 14.8 days; MD -1.58 days, 95% CI -3.96 to 0.81; 181 participants; two studies; low-quality evidence). We are uncertain whether fibrin sealants reduce overall postoperative morbidity (33.7% versus 34.7%; RR 0.97, 95% CI 0.65 to 1.45; 181 participants; two studies; very low-quality evidence), or reoperation rate (7.6% versus 9.2%; RR 0.83, 95% CI 0.33 to 2.11; 181 participants; two studies, very low-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness.Application of fibrin sealants to pancreatic duct occlusion after pancreaticoduodenectomyWe included two studies involving 351 participants: 188 were randomized to the fibrin sealant group and 163 to the control group after pancreaticoduodenectomy. Fibrin sealants may lead to little or no difference in postoperative mortality (8.4% versus 6.1%; Peto OR 1.41, 95% CI 0.63 to 3.13; 351 participants; two studies; low-quality evidence) or length of hospital stay (17.0 days versus 16.5 days; MD 0.58 days, 95% CI -5.74 to 6.89; 351 participants; two studies; low-quality evidence). We are uncertain whether fibrin sealants reduce overall postoperative morbidity (32.0% versus 27.6%; RR 1.16, 95% CI 0.67 to 2.02; 351 participants; two studies; very low-quality evidence), or reoperation rate (13.6% versus 16.0%; RR 0.85, 95% CI 0.52 to 1.41; 351 participants; two studies; very low-quality evidence). Serious adverse events were reported in one study: more participants developed diabetes mellitus when fibrin sealants were applied to pancreatic duct occlusion, both at three months' follow-up (33.7% fibrin sealant group versus 10.8% control group; 29 participants versus 9 participants) and 12 months' follow-up (33.7% fibrin sealant group versus 14.5% control group; 29 participants versus 12 participants). The studies did not report postoperative pancreatic fistula, quality of life, or cost effectiveness.
AUTHORS' CONCLUSIONS
Based on the current available evidence, fibrin sealants may have little or no effect on postoperative pancreatic fistula in people undergoing distal pancreatectomy. The effects of fibrin sealants on the prevention of postoperative pancreatic fistula are uncertain in people undergoing pancreaticoduodenectomy.
Topics: Fibrin Tissue Adhesive; Humans; Length of Stay; Pancreas; Pancreatectomy; Pancreatic Fistula; Postoperative Complications; Randomized Controlled Trials as Topic; Reoperation; Tissue Adhesives
PubMed: 29934987
DOI: 10.1002/14651858.CD009621.pub3 -
Frontiers in Oncology 2022To evaluate the consistencies and inconsistencies between distal cholangiocarcinoma (DCCA) and pancreatic ductal adenocarcinoma (PDCA) regarding their biological...
OBJECTIVE
To evaluate the consistencies and inconsistencies between distal cholangiocarcinoma (DCCA) and pancreatic ductal adenocarcinoma (PDCA) regarding their biological features and long-term prognosis.
METHODS
PubMed, the Cochrane Library, and EMBASE were searched to find comparative studies between DCCA and PDCA. RevMan5.3 and Stata 13.0 software were used for the statistical analyses.
RESULTS
Eleven studies with 4,698 patients with DCCA and 100,629 patients with PDCA were identified. Pooled results indicated that patients with DCCA had a significantly higher rate of preoperative jaundice (p = 0.0003). Lymphatic metastasis (p < 0.00001), vascular invasion (p < 0.0001), and peri-neural invasion (p = 0.005) were more frequently detected in patients with PDCA. After curative pancreaticoduodenectomy (PD), a significantly higher R0 rate (p < 0.0001) and significantly smaller tumor size (p < 0.00001) were detected in patients with DCCA. Patients with DCCA had a more favorable overall survival (OS) (p < 0.00001) and disease-free survival (DFS) (p = 0.005) than patients with PDCA. However, postoperative morbidities (p = 0.02), especially postoperative pancreatic fistula (POPF) (p < 0.00001), more frequently occurred in DCCA.
CONCLUSION
Patients with DCCA had more favorable tumor pathological features and long-term prognosis than patients with PDCA. An early diagnosis more frequently occurred in patients with DCCA. However, postoperative complications, especially POPF, were more frequently observed in patients with DCCA.
PubMed: 36578941
DOI: 10.3389/fonc.2022.1042493 -
World Journal of Emergency Surgery :... Jan 2023A series of randomized controlled trials have investigated the efficacy and safety of different timings of interventions and methods of intervention. However, the... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
A series of randomized controlled trials have investigated the efficacy and safety of different timings of interventions and methods of intervention. However, the optimal treatment strategy is not yet clear.
METHODS
We searched PubMed, EMBASE, ClinicalTrials.gov and the Cochrane Library until November 30, 2022. A systematic review and Bayesian network meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Trials comparing different treatment strategies for necrotizing pancreatitis were included. This study was registered in the Prospective Register of Systematic Reviews (CRD42022364409) to ensure transparency.
RESULTS
We analyzed a total of 10 studies involving 570 patients and 8 treatment strategies. Although no statistically significant differences were identified comparing odds ratios, trends were confirmed by the surface under the cumulative ranking (SUCRA) scores. The interventions with a low rate of mortality were delayed surgery (DS), delayed surgical step-up approach (DSU) and delayed endoscopic step-up approach (DEU), while the interventions with a low rate of major complications were DSU, DEU and DS. According to the clustered ranking plot, DSU performed the best overall in reducing mortality and major complications, while DD performed the worst. Analysis of the secondary endpoints confirmed the superiority of DEU and DSU in terms of individual components of major complications (organ failure, pancreatic fistula, bleeding, and visceral organ or enterocutaneous fistula), exocrine insufficiency, endocrine insufficiency and length of stay. Overall, DSU was superior to other interventions.
CONCLUSION
DSU was the optimal treatment strategy for necrotizing pancreatitis. Drainage alone should be avoided in clinical practice. Any interventions should be postponed for at least 4 weeks if possible. The step-up approach was preferred.
Topics: Humans; Network Meta-Analysis; Bayes Theorem; Pancreatitis, Acute Necrotizing; Drainage
PubMed: 36707836
DOI: 10.1186/s13017-023-00479-7 -
HPB : the Official Journal of the... May 2014Over the last decade laparoscopic pancreatic surgery (LPS) has emerged as an alternative to open pancreatic surgery (OPS) in selected patients with neuroendocrine... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Over the last decade laparoscopic pancreatic surgery (LPS) has emerged as an alternative to open pancreatic surgery (OPS) in selected patients with neuroendocrine tumours (NET) of the pancreas (PNET). Evidence on the safety and efficacy of LPS is available from non-comparative studies.
OBJECTIVES
This study was designed as a meta-analysis of studies which allow a comparison of LPS and OPS for resection of PNET.
METHODS
Studies conducted from 1994 to 2012 and reporting on LPS and OPS were reviewed. Studies considered were required to report on outcomes in more than 10 patients on at least one of the following: operative time; hospital length of stay (LoS); intraoperative blood loss; postoperative morbidity; pancreatic fistula rates, and mortality. Outcomes were compared using weighted mean differences and odds ratios.
RESULTS
Eleven studies were included. These referred to 906 patients with PNET, of whom 22% underwent LPS and 78% underwent OPS. Laparoscopic pancreatic surgery was associated with a lower overall complication rate (38% in LPS versus 46% in OPS; P < 0.001). Blood loss and LoS were lower in LPS by 67 ml (P < 0.001) and 5 days (P < 0.001), respectively. There were no differences in rates of pancreatic fistula, operative time or mortality.
CONCLUSIONS
The nature of this meta-analysis is limited; nevertheless LPS for PNET appears to be safe and is associated with a reduced complication rate and shorter LoS than OPS.
Topics: Chi-Square Distribution; Humans; Laparoscopy; Length of Stay; Neuroendocrine Tumors; Odds Ratio; Pancreatectomy; Pancreatic Neoplasms; Postoperative Complications; Risk Factors; Time Factors; Treatment Outcome
PubMed: 24245906
DOI: 10.1111/hpb.12162 -
HPB : the Official Journal of the... Jan 2018Pancreatic fistula remains a major complication after pancreaticoduodenectomy (PD). Re-operation is generally considered only after exhaustion of non-surgical options. A...
BACKGROUND
Pancreatic fistula remains a major complication after pancreaticoduodenectomy (PD). Re-operation is generally considered only after exhaustion of non-surgical options. A variety of pancreas-preserving operations have been proposed, but completion pancreatectomy (CP) stands out in locally complicated cases as a universal approach. This study aims to provide a qualitative synthesis of the peer-reviewed literature regarding emergency CP for post-PD pancreatic fistula.
METHODS
A systematic search of PubMed and EMBASE for all studies reporting clinical outcomes for CP in the acute treatment of pancreatic fistula following PD from January 1975 until May 2016.
RESULTS
Eleven patient-series with a total of 5566 PD and 151 (3%) emergency CP were included. Median time from PD to CP ranged from 6 to 17 days (7 studies), and mean operative time and blood loss - reported in only two studies - were 197 min and 2173 mL respectively. Re-laparotomy following CP was required in 35% of patients. Median hospital length-of-stay varied from 21 to 64 days, and postoperative mortality was 42%.
CONCLUSIONS
Emergency surgery for postoperative pancreatic fistula should only be considered after expert consultation. CP carries a high risk of mortality, and it is most commonly recommended for a selected subgroup of patients with locally complicated fistula.
Topics: Humans; Pancreatectomy; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; Reoperation
PubMed: 28978403
DOI: 10.1016/j.hpb.2017.08.036 -
International Journal of Surgery... Jul 2023The best approach for treating benign or low-grade malignant lesions localized in the pancreatic neck or body remains debatable. Conventional pancreatoduodenectomy and... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The best approach for treating benign or low-grade malignant lesions localized in the pancreatic neck or body remains debatable. Conventional pancreatoduodenectomy and distal pancreatectomy (DP) are associated with a risk of impairment of pancreatic function at long-term follow-up. With advances in technology and surgical skills, the use of central pancreatectomy (CP) has gradually increased.
OBJECTIVES
The objective was to compare the safety, feasibility, and short-term and long-term clinical benefits of CP and DP in matched cases.
METHODS
The PubMed, MEDLINE, Web of Science, Cochrane, and EMBASE databases were systematically searched to identify studies published from database inception to February 2022 that compared CP and DP. This meta-analysis was performed using R software.
RESULTS
Twenty-six studies matched the selection criteria, including 774 CP and 1713 DP cases. CP was significantly associated with longer operative time ( P <0.0001), less blood loss ( P <0.01), overall and clinically relevant pancreatic fistula ( P <0.0001), postoperative hemorrhage ( P <0.0001), reoperation ( P =0.0196), delayed gastric emptying ( P =0.0096), increased hospital stay ( P =0.0002), intra-abdominal abscess or effusion ( P =0.0161), higher morbidity ( P <0.0001) and severe morbidity ( P <0.0001) but with a significantly lower incidence of overall endocrine and exocrine insufficiency ( P <0.01), and new-onset and worsening diabetes mellitus ( P <0.0001) than DP.
CONCLUSIONS
CP should be considered as an alternative to DP in selected cases such as without pancreatic disease, length of the residual distal pancreas is more than 5 cm, branch-duct intraductal papillary mucinous neoplasms, and a low risk of postoperative pancreatic fistula after adequate evaluation.
Topics: Humans; Pancreatectomy; Pancreatic Fistula; Retrospective Studies; Pancreas; Pancreatic Neoplasms; Postoperative Complications
PubMed: 37300889
DOI: 10.1097/JS9.0000000000000326 -
BioMed Research International 2020To compare the intraoperative and postoperative outcomes of central pancreatectomy (CP) with distal pancreatectomy (DP). (Meta-Analysis)
Meta-Analysis
Overall Postoperative Morbidity and Pancreatic Fistula Are Relatively Higher after Central Pancreatectomy than Distal Pancreatic Resection: A Systematic Review and Meta-Analysis.
OBJECTIVE
To compare the intraoperative and postoperative outcomes of central pancreatectomy (CP) with distal pancreatectomy (DP).
METHODS
A systematic literature search was performed on electronic databases from MEDLINE, Embase, and PubMed from 1998 to 2018. Statistical analysis and meta-analysis were performed using statistics/data analysis (Stata®) software, version 12.0 (StataCorp LP, College Station, Texas 77845, USA). Dichotomous variables were analyzed by estimation of relative risk (RR) with a 95 percent (%) confidence interval (CI) and continuous variables were analyzed by standardized mean differences (SMD) with 95% CI.
RESULTS
Twenty-four studies with 593 CP and 1226 DP were included in the meta-analysis. CP had significantly longer operation time (SMD: 1.03; 95% CI 0.62 to 1.44; < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; < 0.001) and lengthier postoperative hospital stay (SMD: 0.63; 95% CI 0.20 to 1.05; < 0.01). Estimated blood loss was significantly lower in CP (SMD: -0.34; 95% CI -0.58 to -0.09; = 0.007). Overall postoperative morbidity (RR: 1.30; 95% CI: 1.13 to 1.50; < 0.001), overall pancreatic fistula (RR: 1.41; 95% CI: 1.20 to 1.66; < 0.001), clinically relevant fistula (RR: 1.64; 95% CI: 1.25 to 2.16; < 0.001), and postoperative hemorrhage (RR: 1.90; 95% CI: 1.18 to 3.06; < 0.05) were all significantly higher after CP. On long-term follow-up, DP patients were more likely to have postoperative exocrine (RR: 0.56; 95% CI: 0.37 to 0.84; < 0.05) and endocrine (RR: 0.27; 95% CI: 0.18 to 0.40; < 0.001) insufficiency. There was no statistically significant difference in transfusion requirement, postoperative mortality, reoperation, and tumor recurrence.
CONCLUSION
CP is associated with significantly higher morbidity and clinically relevant pancreatic fistula. CP should only be reserved for selected patients who require postoperative pancreatic function preservation.
Topics: Blood Transfusion; Databases, Factual; Humans; Length of Stay; Morbidity; Operative Time; Pancreas; Pancreatectomy; Pancreatic Fistula; Postoperative Complications; Reoperation
PubMed: 32219139
DOI: 10.1155/2020/7038907 -
HPB : the Official Journal of the... Jan 2020Early recognition of postoperative pancreatic fistula might decrease the risk of subsequent life threatening complications. The aim of this review was to systematically...
BACKGROUND
Early recognition of postoperative pancreatic fistula might decrease the risk of subsequent life threatening complications. The aim of this review was to systematically evaluate the accuracy of postoperative clinical, biochemical and radiologic variables for early recognition of clinically relevant postoperative pancreatic fistula.
METHODS
A systematic literature search was performed up to August 2018. Clinical studies reporting on the association between postoperative variables and clinically relevant postoperative pancreatic fistula were included. Variables were stratified: early prediction (postoperative day 1-2) versus early diagnosis (day 3) and had to be reported in 2 cohorts.
RESULTS
Overall, 37 included studies reported on 17 different diagnostic variables after 8701 pancreatic resections. Clinically relevant postoperative pancreatic fistula occurred in 1532/8701 patients (18%). Early prediction variables included elevated serum and drain amylase (day 1). Identified variables for early diagnosis were: non-serous drain efflux (day 3); positive drain culture (day 3); elevated temperature (any day); elevated C-Reactive Protein (CRP; day 4); elevated white blood cell count (day 4) and peripancreatic collections on computed tomography (CT; day 5-10).
CONCLUSION
This review provides a comprehensive overview of postoperative variables associated with clinically relevant pancreatic fistula. Incorporation of variables in future algorithms could potentially mitigate the clinical impact of postoperative pancreatic fistula.
Topics: Early Diagnosis; Humans; Pancreatectomy; Pancreatic Fistula; Postoperative Complications; Predictive Value of Tests; Risk Factors
PubMed: 31445782
DOI: 10.1016/j.hpb.2019.07.005 -
Digestive Surgery 2016Different scoring systems to predict the occurrence of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy have been described, but the considered risk... (Review)
Review
BACKGROUND/AIM
Different scoring systems to predict the occurrence of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy have been described, but the considered risk factors often suffer subjective scaling. The aim of this review is to evaluate and compare all published risk metrics predictive of POPF.
METHODS
All existing scores were retrieved by literature web search. Inclusion criteria were ISGPF classification of POPF and the development of a risk score metric.
RESULTS
From a total of 286 publications, 10 studies were selected. Most of them were retrospective and single center. The models considered a median number of 3 items (range from 2 to 5); in 5 of 10 trials only pre or intraoperative variables were included. The median number of patients/study was 186 (IQR 111.1-229.0). External validation was performed in 6 of 10 studies. The most recurrent items were abdominal fat (4/10), main pancreatic duct diameter (in 4/10), and pancreatic texture (3/10).
CONCLUSION
POPF risk estimation should be easy, accurate, and objective. It should consider preoperative patient-related and gland-related features, and intraoperative events. None of the published systems completely adhere to these principles. Large heterogeneous multicentric validations should be endorsed, to account for the case-mix and evaluate the reproducibility of each scoring system.
Topics: Abdominal Fat; Humans; Pancreatic Ducts; Pancreatic Fistula; Pancreaticoduodenectomy; Predictive Value of Tests; Risk Factors
PubMed: 27160158
DOI: 10.1159/000445068 -
HPB : the Official Journal of the... Nov 2015Pancreatic fistula is a potentially life-threatening complication after a pancreatic resection. The aim of this systematic review was to evaluate the role of... (Review)
Review
BACKGROUND
Pancreatic fistula is a potentially life-threatening complication after a pancreatic resection. The aim of this systematic review was to evaluate the role of matrix-bound sealants after a pancreatic resection in terms of preventing or ameliorating the course of a post-operative pancreatic fistula.
METHODS
A systematic search was performed in the literature from May 2005 to April 2015. Included were clinical studies using matrix-bound sealants after a pancreatic resection, reporting a post-operative pancreatic fistula (POPF) according to the International Study Group on Pancreatic Fistula classification, in which grade B and C fistulae were considered clinically relevant.
RESULTS
Two were studies on patients undergoing pancreatoduodenectomy (sealants n = 67, controls n = 27) and four studies on a distal pancreatectomy (sealants n = 258, controls n = 178). After a pancreatoduodenectomy, 13% of patients treated with sealants versus 11% of patients without sealants developed a POPF (P = 0.76), of which 4% versus 4% were clinically relevant (P = 0.87). After a distal pancreatectomy, 42% of patients treated with sealants versus 52% of patients without sealants developed a POPF (P = 0.03). Of these, 9% versus 12% were clinically relevant (P = 0.19).
CONCLUSIONS
The present data do not support the routine use of matrix-bound sealants after a pancreatic resection, as there was no effect on clinically relevant POPF. Larger, well-designed studies are needed to determine the efficacy of sealants in preventing POPF after a pancreatoduodenectomy.
Topics: Humans; Intraoperative Period; Pancreatectomy; Pancreatic Fistula; Pancreatic Neoplasms; Postoperative Complications; Tissue Adhesives
PubMed: 26292846
DOI: 10.1111/hpb.12472