-
Annals of Surgery Mar 2023The aim of this study was to develop a classification system for pancreas-associated risk factors in pancreatoduodenectomy (PD). (Meta-Analysis)
Meta-Analysis
A Simple Classification of Pancreatic Duct Size and Texture Predicts Postoperative Pancreatic Fistula: A classification of the International Study Group of Pancreatic Surgery.
OBJECTIVE
The aim of this study was to develop a classification system for pancreas-associated risk factors in pancreatoduodenectomy (PD).
SUMMARY BACKGROUND DATA
Postoperative pancreatic fistula (POPF) is the most relevant PD-associated complication. A simple standardized surgical reporting system based on pancreas-associated risk factors is lacking.
METHODS
A systematic literature search was conducted to identify studies investigating clinically relevant (CR) POPF (CR-POPF) and pancreas-associated risk factors after PD. A meta-analysis of CR-POPF rate for texture of the pancreas (soft vs not-soft) and main pancreatic duct (MPD) diameter was performed using the Mantel-Haenszel method. Based on the results, the International Study Group of Pancreatic Surgery (ISGPS) proposes the following classification: A, not-soft (hard) texture and MPD >3 mm; B, not-soft (hard) texture and MPD ≤3 mm; C, soft texture and MPD >3 mm; D, soft texture and MPD ≤3 mm. The classification was evaluated in a multi-institutional, international cohort.
RESULTS
Of the 2917 articles identified, 108 studies were included in the analyses. Soft pancreatic texture was significantly associated with the development of CR-POPF [odds ratio (OR) 4.24, 95% confidence interval (CI) 3.67-4.89, P < 0.01) following PD. Similarly, MPD diameter ≤3 mm significantly increased CR-POPF risk compared with >3 mm diameter MPDs (OR 3.66, 95% CI 2.62-5.12, P < 0.01). The proposed 4-stage system was confirmed in an independent cohort of 5533 patients with CR-POPF rates of 3.5%, 6.2%, 16.6%, and 23.2% for type A-D, respectively ( P < 0.001).
CONCLUSION
For future pancreatic surgical outcomes studies, the ISGPS recommends reporting these risk factors according to the proposed classification system for better comparability of results.
Topics: Humans; Pancreatic Fistula; Pancreas; Pancreatic Ducts; Pancreaticoduodenectomy; Risk Factors; Postoperative Complications
PubMed: 33914473
DOI: 10.1097/SLA.0000000000004855 -
Langenbeck's Archives of Surgery Sep 2022Postoperative pancreatic fistula (POPF) is a complication discussed in the context of pancreatic surgery, but may also result from splenectomy; a relationship that has...
PURPOSE
Postoperative pancreatic fistula (POPF) is a complication discussed in the context of pancreatic surgery, but may also result from splenectomy; a relationship that has not been investigated extensively yet.
METHODS
This retrospective single-center study aimed to analyze incidence of and risk factors for POPF after splenectomy. Patient characteristics included demographic data, surgical procedure, and intra- and postoperative complications. POPF was defined according to the International Study Group on Pancreatic Surgery as POPF of grade B and C or biochemical leak (BL).
RESULTS
Over ten years, 247 patients were identified, of whom 163 underwent primary (spleen-associated pathologies) and 84 secondary (extrasplenic oncological or technical reasons) splenectomy. Thirty-six patients (14.6%) developed POPF of grade B/C or BL, of which 13 occurred after primary (7.9%) and 23 after secondary splenectomy (27.3%). Of these, 25 (69.4%) were BL, 7 (19.4%) POPF of grade B and 4 (11.1%) POPF of grade C. BL were treated conservatively while three patients with POPF of grade B required interventional procedures and 4 with POPF of grade C required surgery. POPF and BL was noted significantly more often after secondary splenectomy and longer procedures. Multivariate analysis confirmed secondary splenectomy and use of energy-based devices as independent risk factors for development of POPF/BL after splenectomy.
CONCLUSION
With an incidence of 4.5%, POPF is a relevant complication after splenectomy. The main risk factor identified was secondary splenectomy. Although POPF and BL can usually be treated conservatively, it should be emphasized when obtaining patients' informed consent and treated at centers with experience in pancreatic surgery.
Topics: Humans; Incidence; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; Retrospective Studies; Risk Factors; Splenectomy
PubMed: 35508768
DOI: 10.1007/s00423-022-02531-7 -
Updates in Surgery Aug 2021Postoperative pancreatic fistula (POPF) still represents the major driver of surgical morbidity after pancreaticoduodenectomy. The purpose of this narrative review was... (Review)
Review
Postoperative pancreatic fistula (POPF) still represents the major driver of surgical morbidity after pancreaticoduodenectomy. The purpose of this narrative review was to critically analyze current evidence supporting the use of total pancreatectomy (TP) to prevent the development of POPF in patients with high-risk pancreas, and to explore the role of completion total pancreatectomy (CP) in the management of severe POPF. Considering the encouraging perioperative outcomes, TP may represent a promising tool to avoid the morbidity related to an extremely high-risk pancreatic anastomosis in selected patients. Surgical management of severe POPF is only required in few critical scenarios. In this context, even if anecdotal, CP might play a role as last resort in expert hands.
Topics: Humans; Pancreas; Pancreatectomy; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; Retrospective Studies; Risk Factors
PubMed: 34363601
DOI: 10.1007/s13304-021-01130-3 -
Indian Journal of Cancer 2023Postoperative pancreatic fistula (POPF) is the most feared complication following pancreatic resection. Octreotide, a synthetic somatostatin analog, has been widely used... (Review)
Review
Postoperative pancreatic fistula (POPF) is the most feared complication following pancreatic resection. Octreotide, a synthetic somatostatin analog, has been widely used by pancreatic surgeons worldwide after pancreatic resections, often as per surgeon's discretion, to prevent POPF especially in cases at high risk of developing POPF. We herein analyze the data available till date of the subject. A PubMed search with keywords "somatostatin OR octreotide OR somatostatin analogues AND postoperative pancreatic fistula" was made. Further filters were applied in the search "Clinical Trial, Meta-Analysis, Randomized Controlled Trial, Systematic Review, from 1990 - 2021," and the 68 results thus obtained were analyzed and included in this narrative review. There is considerable heterogeneity among the studies assessing the role of octreotide in the prevention of POPF making data comparison difficult, and hence results remain inconclusive. Most of the earlier studies used different definitions of POPF and other complications; included patients with varied pancreatic pathologies such as cancer, chronic pancreatitis, and benign lesions; surgical techniques such as pancreaticoduodenectomy, distal pancreatectomy, and other procedures; use of somatostatin and its analogs such as octreotide, lanreotide, pasireotide, and vapreotide; varied surgeon and institutional volume; and so on. Besides, pancreatic surgery is per se a complex surgical procedure and has its own inherent biases related to patient and the pancreas itself affecting the overall outcome. Data indicate favorable role of newer somatostatin analogs, and further studies are urgently needed. The question about the efficacy of prophylactic octreotide to reduce POPF after pancreaticoduodenectomy remains open to debate.
Topics: Humans; Octreotide; Pancreas; Pancreatectomy; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; Randomized Controlled Trials as Topic; Risk Factors; Somatostatin; Treatment Outcome
PubMed: 37530235
DOI: 10.4103/ijc.IJC_280_21 -
International Journal of Surgery... Feb 2022To determine the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) following radical gastrectomy and to identify independent risk factors of...
OBJECTIVE
To determine the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) following radical gastrectomy and to identify independent risk factors of CR-POPF.
BACKGROUND
CR-POPF and its sequelae are potential complications following radical gastrectomy. The reported incidence of CR-POPF was quite different across various regions, and no consensus was reached.
METHODS
Between December 2017 to November 2018, patients who underwent radical gastrectomy from 22 centers across 13 regions in China were prospectively recruited. The primary endpoint was the occurrence of CR-POPF, defined by the International Study Group of Pancreatic Fistula (ISGPF) in 2016. Clinically relevant change and short-term outcomes were recorded to diagnose and grade the POPF. Multivariate regression analyses were performed to identify independent risk factors of clinically relevant postoperative pancreatic fistula (CR-POPF).
RESULTS
A total of 2089 cases were analyzed. The incidence of biochemical leakage (BL) and CR-POPF were 19.6% and 1.1% respectively. All CR-POPF patients recovered well after appropriate treatment and no Grade C POPF were recorded. Logistic regression analysis showed pTNM III (OR, 2.940; 95% CI 1.180-7.325; P = 0.021) and LigaSure usage (OR, 6.618; 95% CI 1.847-23.707; P = 0.004) were independent risk factors of CR-POPF. LigaSure usage (OR, 4.817; 95% CI 1.184-19.598; P = 0.028), the drain amylase content (D-AMY) on postoperative day 3 (POD3) ≥5 times the upper limit of normal amylase (OR, 3.476; 95% CI 1.240-9.744; P = 0.018) and open surgery (OR, 2.463; 95% CI 1.003-6.050; P = 0.049) were independent predictors for identifying CR-POPF from BL.
CONCLUSION
In rich-experienced gastric cancer centers, there is high prevalence of BL secondary to radical gastrectomy without clinical impact. Fewer patients suffered Grade B POPF, and Grade C POPF was less common. The patients with pTNM III or LigaSure usage were prone to suffer CR-POPF. Surgery procedure, LigaSure usage combined with D-AMY measurement on POD3 are promising for early identification of CR-POPF.
Topics: Gastrectomy; Humans; Incidence; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; Prospective Studies; Retrospective Studies; Risk Factors
PubMed: 34990829
DOI: 10.1016/j.ijsu.2021.106219 -
Scandinavian Journal of Surgery : SJS :... Jun 2023Postoperative pancreatic fistula (POPF) is the leading cause of morbidity and early mortality in patients undergoing pancreatic resection. In addition, recent studies... (Review)
Review
BACKGROUND AND OBJECTIVE
Postoperative pancreatic fistula (POPF) is the leading cause of morbidity and early mortality in patients undergoing pancreatic resection. In addition, recent studies have identified postoperative acute pancreatitis (POAP) as an independent contributor to morbidity. Most perioperative mitigation strategies experimented for POPF have been shown to be in vain with no consensus on the best perioperative management. Clinical prediction models have been developed with the hope of identifying high POPF risk patients with the leading idea of finding subpopulations possibly benefiting from pre-existing or novel mitigation strategies. The aim of this review was to map out the existing prediction modeling studies to better understand the current stage of POPF prediction modeling, and the methodology behind them.
METHODS
A narrative review of the existing POPF prediction model studies was performed. Studies published before September 2022 were included.
RESULTS
While the number of POPF prediction models for pancreatoduodenectomy has increased, none of the currently existing models stand out from the crowd. For distal pancreatectomy, two unique POPF prediction models exist, but due to their freshness, no further external validation or adoption in clinics or research has been reported. There seems to be a lack of adherence to correct methodology or reporting guidelines in most of the studies, which has rendered external validity-if assessed-low. Few of the most recent studies have demonstrated preoperative assessment of pancreatic aspects from computed tomography (CT) scans to provide relatively strong predictors of POPF.
CONCLUSIONS
Main goal for the future would be to reach a consensus on the most important POPF predictors and prediction model. At their current state, few models have demonstrated adequate transportability and generalizability to be up to the task. Better understanding of POPF pathophysiology and the possible driving force of acute inflammation and POAP might be required before such a prediction model can be accessed.
Topics: Humans; Pancreatic Fistula; Pancreatectomy; Pancreaticoduodenectomy; Pancreatitis; Acute Disease; Risk Factors; Risk Assessment; Postoperative Complications; Retrospective Studies
PubMed: 37083016
DOI: 10.1177/14574969231167781 -
Surgery Jun 2022Previous studies reported a higher rate of postoperative pancreatic fistula after minimally invasive distal pancreatectomy compared to open distal pancreatectomy. It is... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Previous studies reported a higher rate of postoperative pancreatic fistula after minimally invasive distal pancreatectomy compared to open distal pancreatectomy. It is unknown whether the clinical impact of postoperative pancreatic fistula after minimally invasive distal pancreatectomy is comparable with that after open distal pancreatectomy. We aimed to compare not only the incidence of postoperative pancreatic fistula, but more importantly, also its clinical impact.
METHODS
This is a post hoc analysis of a multicenter randomized trial investigating a possible beneficial impact of a fibrin patch on the rate of clinically relevant postoperative pancreatic fistula (International Study Group for Pancreatic Surgery grade B/C) after distal pancreatectomy. Primary outcomes of the current analysis are the incidence and clinical impact of postoperative pancreatic fistula after both minimally invasive distal pancreatectomy and open distal pancreatectomy.
RESULTS
From October 2010 to August 2017, 252 patients undergoing distal pancreatectomy were randomized, and data of 247 patients were available for analysis: 87 minimally invasive distal pancreatectomy and 160 open distal pancreatectomies. The postoperative pancreatic fistula rate after minimally invasive distal pancreatectomy was significantly higher than that after open distal pancreatectomy (28.7% vs 16.9%, P = .029). More patients were discharged with an abdominal surgical drain after minimally invasive distal pancreatectomy compared to open distal pancreatectomy (30/87, 34.5% vs 26/160, 16.5%, P = .001). In patients with postoperative pancreatic fistula, additional percutaneous catheter drainage procedures were performed less often (52% vs 84.6%, P = .012), with fewer drainage procedures (median [range], 2 [1-4] vs 2, [1-7], P = .014) after minimally invasive distal pancreatectomy.
CONCLUSION
In this post hoc analysis, the postoperative pancreatic fistula rate after minimally invasive distal pancreatectomy was higher than that after open distal pancreatectomy, whereas the clinical impact was less.
Topics: Humans; Incidence; Pancreas; Pancreatectomy; Pancreatic Fistula; Pancreatic Neoplasms; Postoperative Complications; Retrospective Studies
PubMed: 34906371
DOI: 10.1016/j.surg.2021.11.009 -
Langenbeck's Archives of Surgery Feb 2020Pancreaticojejunal anastomosis is one of the most demanding procedures in surgery. Up to now, no technique has been proven to reduce the incidence of POPF when compared... (Review)
Review
BACKGROUND
Pancreaticojejunal anastomosis is one of the most demanding procedures in surgery. Up to now, no technique has been proven to reduce the incidence of POPF when compared to the other methods.
PURPOSE
The aim of this review was to provide a concise and illustrated description of the most recent methods of pancreaticojejunostomy. Their development was directly related to the still ongoing search by surgeons for such a technique of anastomosis that would eliminate the problem of POPF.
CONCLUSIONS
Knowledge of various techniques of anastomosis may help the surgeon to find the most suitable and optimal method of pancreatic-intestinal anastomosis for the patient.
Topics: Humans; Pancreas; Pancreatic Fistula; Pancreaticojejunostomy
PubMed: 31975148
DOI: 10.1007/s00423-020-01855-6 -
Langenbeck's Archives of Surgery Feb 2022Postoperative pancreatic fistula (POPF) is a major complication of pancreatic surgery and can be fatal. Better stratification of patients into risk groups may help to...
PURPOSE
Postoperative pancreatic fistula (POPF) is a major complication of pancreatic surgery and can be fatal. Better stratification of patients into risk groups may help to select those who might benefit from strategies to prevent complications. The aim of this study was to validate ten prognostic scores in patients who underwent pancreatic head surgery.
METHODS
A total of 364 patients were included in this study between September 2012 and August 2017. Ten risk scores were applied to this cohort. Univariate and multivariate analyses were performed considering all risk factors in the scores. Furthermore, the stratification of patients into risk categories was statistically tested.
RESULTS
Nine of the scores (Ansorge et al., Braga et al., Callery et al., Graham et al., Kantor et al., Mungroop et al., Roberts et al., Yamamoto et al. and Wellner et al.) showed strong prognostic stratification for developing POPF (p < 0.001). There was no significant prognostic value for the Fujiwara et al. risk score. Histology, pancreatic duct diameter, intraabdominal fat thickness in computed tomography findings, body mass index, and C-reactive protein were independent prognostic factors on multivariate analysis.
CONCLUSION
Most risk scores tend to stratify patients correctly according to risk for POPF. Nevertheless, except for the fistula risk score (Callery et al.) and its alternative version (Mungroop et al.), many of the published risk scores are obscure even for the dedicated pancreatic surgeon in terms of their clinical practicability. There is a need for future studies to provide strategies for preventing POPF and managing patients with high-risk stigmata.
Topics: Humans; Pancreas; Pancreatectomy; Pancreatic Ducts; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; Retrospective Studies; Risk Factors
PubMed: 34370113
DOI: 10.1007/s00423-021-02290-x -
HPB Surgery : a World Journal of... 1992The aim of this study was to evaluate the place of pancreaticogastrostomy (PG) in reducing pancreatic fistula after pancreatoduodenectomy. From January 1988 to June... (Review)
Review
The aim of this study was to evaluate the place of pancreaticogastrostomy (PG) in reducing pancreatic fistula after pancreatoduodenectomy. From January 1988 to June 1991, 32 consecutive patients (mean age, 57 years) were operated on, 25 for malignant disease (78%). The pancreatic remnant was normal in 17 patients (53%) and sclerotic in the others. There was one operative death (3.1%) unrelated to PG. Post-operative complications occurred in five patients (16%). Only two complications were related to PG: 1 patient had anastomotic intra-gastric bleeding and was reoperated on, 1 patient with a normal pancreatic remnant developed a pancreatic fistula (3.1%) treated conservatively. Reported series of PG, as well as our results, demonstrates that PG is associated with a dramatic decrease of both pancreatic fistula and mortality rates. The risk of anastomotic haemorrhage can be reduced by preventative ligation of submucosal gastric vessels. In conclusion, PG appears as a simple and reliable method of management of the pancreatic remnant after pancreatoduodenectomy.
Topics: Adult; Aged; Anastomosis, Surgical; Female; Gastrostomy; Humans; Male; Middle Aged; Pancreas; Pancreatic Fistula; Pancreaticoduodenectomy; Reoperation; Treatment Outcome
PubMed: 1363371
DOI: 10.1155/1992/96487