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Langenbeck's Archives of Surgery May 2021Postoperative pancreatic fistula (POPF), a difficult complication after surgery, can cause peripancreatic fluid collection and infections in the operative area. In...
PURPOSE
Postoperative pancreatic fistula (POPF), a difficult complication after surgery, can cause peripancreatic fluid collection and infections in the operative area. In addition, pancreatic fluid is corrosive and can lead to postoperative bleeding. Clinically significant grade B and C fistulas (CR-POPF) increase postoperative morbidity, resulting in a prolonged hospital stay. Delaying adjuvant therapy due to fistula formation in cancer patients can affect their prognosis. In this study, we aimed to determine if pasireotide affects fistula formation, and the severity of other complications in patients following pancreatic distal resections.
DATA AND METHODS
Between 2000 and 2016, 258 distal pancreatectomies were performed at Helsinki University Hospital and were included in our analysis. Pasireotide was administered to patients undergoing distal resections between July 2014 and December 2016. Patients received 900-μg pasireotide administered twice daily perioperatively. Other patients who received octreotide treatment were analyzed separately. Complications such as fistulas (POPF), delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), reoperations, and mortality were recorded and analyzed 90 days postoperatively.
RESULTS
Overall, 47 (18%) patients received pasireotide and 31 (12%) octreotide, while 180 patients (70%) who received neither constituted the control group. There were 40 (16%) clinically relevant grade B and C POPFs: seven (15%) in the pasireotide group, three (10%) in the octreotide group, and 30 (17%) in the control group (p = 0.739). Severe complications categorized as Clavien-Dindo grade III or IV were recorded in 64 (25%) patients: 17 (27%) in the pasireotide group, 4 (6%) in the octreotide group, and 43 (67%) in the control group (p = 0.059). We found no 90-day mortality.
CONCLUSIONS
In this study, pasireotide did not reduce clinically relevant POPFs or severe complications following pancreatic distal resection.
Topics: Humans; Octreotide; Pancreatectomy; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; Somatostatin
PubMed: 33474568
DOI: 10.1007/s00423-021-02083-2 -
Journal of Radiology Case Reports Mar 2014Pseudocysts containing activated enzymes are a common complication of pancreatitis. Pseudocysts can rupture into adjacent structures including the peritoneal cavity,... (Review)
Review
Pseudocysts containing activated enzymes are a common complication of pancreatitis. Pseudocysts can rupture into adjacent structures including the peritoneal cavity, adjacent organs, and rarely vascular structures. While arterial pseudoaneurysms and venous thrombosis or occlusion are well known complications of acute and chronic pancreatitis, only 17 cases of pancreas-portal venous fistula have been encountered in review of the literature. A patient with chronic pancreatitis presented with a history of weight loss, fatigue and was found to have a pancreatic duct-portal vein fistula. The patient was treated surgically with good outcome.
Topics: Cholangiopancreatography, Endoscopic Retrograde; Diagnosis, Differential; Female; Humans; Imaging, Three-Dimensional; Magnetic Resonance Imaging; Middle Aged; Pancreatic Ducts; Pancreatic Fistula; Pancreatic Pseudocyst; Pancreatitis, Alcoholic; Portal Vein; Portography; Tomography, X-Ray Computed; Vascular Fistula
PubMed: 24967026
DOI: 10.3941/jrcr.v8i3.1552 -
International Journal of Surgery... Dec 2014Reconstruction of digestive tract after pancreaticodudenectomy now has been proved associated with pancreatic fistula and complication incidence. The meta-analysis was... (Meta-Analysis)
Meta-Analysis Review
Pancreaticogastrostomy or pancreaticojejunostomy? Methods of digestive continuity reconstruction after pancreaticodudenectomy: a meta-analysis of randomized controlled trials.
BACKGROUND AND AIMS
Reconstruction of digestive tract after pancreaticodudenectomy now has been proved associated with pancreatic fistula and complication incidence. The meta-analysis was conducted at the appropriate time enough randomized controlled trials were reported.
METHODS
Systematically literature search was performed through PubMed, EMBASE and Cochrane Library database without restriction to regions, or languages, only randomized controlled trials was included. 7 studies compared pancreatogastrostomy with pancreaticojejunostomy were included for meta-analysis. Fixed and random-effects models were used to measure the pooled estimates.
RESULTS
Patient underwent pancreatogastrostomy after pancreatoduodenectomy suffered less pancreatic fistula(p = 0.001) and bile leakage (p = 0.02), while the operative time, hospital stay, delayed gastric emptying and overall morbidity were comparable.
CONCLUSION
Pancreatogastrostomy is a recommended anastomosis technique according to the meta-analysis due to minimize incidence of pancreatic fistula and bile leakage.
Topics: Anastomotic Leak; Bile; Gastrostomy; Humans; Incidence; Length of Stay; Operative Time; Pancreas; Pancreatic Fistula; Pancreaticoduodenectomy; Pancreaticojejunostomy; Randomized Controlled Trials as Topic; Plastic Surgery Procedures
PubMed: 25448669
DOI: 10.1016/j.ijsu.2014.10.024 -
International Journal of Surgery... Jun 2022Clinically relevant postoperative pancreatic fistula (CR-POPF) remains the major cause of morbidity following pancreaticoduodenectomy (PD). Several model score systems...
OBJECTIVE
Clinically relevant postoperative pancreatic fistula (CR-POPF) remains the major cause of morbidity following pancreaticoduodenectomy (PD). Several model score systems such as the Fistula Risk Score (FRS) have been developed to predict CR-POPF using preoperative and intraoperative data. Machine learning (ML) algorithms are increasingly applied in the medical field and they could be used to assess the risk of CR-POPF, identify clinically meaningful data and guide drain removal.
METHODS
Data from consecutive patients who underwent PD between January 1, 2010 and March 31, 2021 at a single high-volume center was collected retrospectively in this study. Demographics, clinical features, intraoperative parameters, and laboratory values were used to conduct the ML model. Four different ML algorithms (CatBoost, lightGBM, XGBoost and Random Forest) were used to train this model with cross-validation.
RESULTS
A total of 2421 patients with 62 clinical parameters were enrolled in this ML model. The majority of patients (76.3%) underwent open PD while others underwent robot-assisted PD. CR-POPF occurred in 424 (17.5%) patients. The CatBoost algorithm outperformed other algorithms with a mean area under the receiver operating characteristic curve (AUC) of 0.81 (95% confidence interval: 0.80-0.82) from the 5-fold cross-validation procedure. In the test dataset, the CatBoost algorithm also achieved the best mean-AUC of 0.83. The most important value was mean drain fluid amylase (DFA) in the first seven postoperative days (POD). The performance of models that used only preoperative data and intraoperative data was marginally lower than that of models that used combined data.
CONCLUSION
Our ML algorithms could be applied as early diagnostic tools for CR-POPF in patients who underwent PD. Such real-time clinical decision support tools can identify patients with a high risk of CR-POPF, help in developing the perioperative management plan and guide the optimal timing of drain removal.
Topics: Algorithms; Drainage; Humans; Machine Learning; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; Retrospective Studies; Risk Factors
PubMed: 35500881
DOI: 10.1016/j.ijsu.2022.106638 -
EBioMedicine Dec 2020To develop a modified Fistula Risk Score (FRS) for predicting clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD) based on...
Computed tomography-adjusted fistula risk score for predicting clinically relevant postoperative pancreatic fistula after pancreatoduodenectomy: Training and external validation of model upgrade.
BACKGROUND
To develop a modified Fistula Risk Score (FRS) for predicting clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD) based on both FRS and contrast-enhanced computed tomography (CE-CT).
METHODS
In this multicenter retrospective analysis, we focused on 990 consecutive patients with pancreatoduodenectomy performed at four institutions between 2009 and 2019. The enhanced CT-FRS model initially targeted 26 pre- and intraoperative factors, including CT descriptors, FRS elements and clinical factors, using LASSO-penalized multivariable logistic regression for predicting CR-POPF events in discovery (n = 718) and externally validated (n = 272) datasets. Probabilities generated were further correlated with histologic features of pancreatic stumps in 356 patients. C-indices were analyzed to compare the predictive potential between the original FRS and the CT-FRS.
FINDINGS
CR-POPF developed in 112 (15.6%) and 36 (13.2%) patients in discovery and validation datasets, respectively. The final CT-FRS construct, incorporating remnant pancreatic volume (RPV), stump area, fat and atrophy scores by CT, and main pancreatic duct size, offered significantly greater overall predictability than the original FRS in discovery (C-index: 0.825 vs 0.794; p = 0.04) and validation (0.807 vs 0.741; p = 0.05) cohorts. Importantly, it outperformed the FRS in patients at moderate risk levels (FRS: 3-6), showing remarkably improved C-indices (discovery: 0.729 vs 0.626 [p<0.001], validation: 0.722 vs 0.573 [p = 0.006]). CT-FRS probabilities increased in conjunction with less extensive pancreatic fibrosis (p<0.001), ample glandular acini (p<0.001), and advanced lipomatosis (p<0.001).
INTERPRETATION
The enhanced CT-FRS performed significantly better than the original FRS in predicting CR-POPF occurrences after PD, especially at moderate FRS levels.
Topics: Aged; Female; Humans; Logistic Models; Male; Middle Aged; Pancreatic Fistula; Pancreaticoduodenectomy; Perioperative Period; Postoperative Complications; Prognosis; ROC Curve; Retrospective Studies; Risk Assessment; Risk Factors; Tomography, X-Ray Computed
PubMed: 33161232
DOI: 10.1016/j.ebiom.2020.103096 -
Tomography (Ann Arbor, Mich.) Jul 2023Transdiaphragmatic fistulae are rare conditions characterized by pathological communication between two epithelium-lined surfaces. Hepato-thoracic fistula consists of...
Transdiaphragmatic fistulae are rare conditions characterized by pathological communication between two epithelium-lined surfaces. Hepato-thoracic fistula consists of abnormal communication between the liver and/or the biliary system and the thorax; while the pancreaticopleural fistula consists of abnormal communication between the pancreas and the thorax, the pleuro-biliary fistula represents the more common type. Clinical symptoms and laboratory findings are generally non-specific (e.g., thoracic and abdominal pain, dyspnea, cough, neutrophilia, elevated CPR, and bilirubin values) and initially, first-level investigations, such as chest RX and abdominal ultrasound, are generally inconclusive for the diagnosis. Contrast-enhanced CT represents the first two-level radiological imaging technique, usually performed to identify and evaluate the underlying pathology sustained by transdiaphragmatic fistulae, their complications, and the evaluation of the fistulous tract. When the CT remains inconclusive, other techniques such as MRI and MRCP can be performed. A prompt and accurate diagnosis is crucial because the recognition of fistulae and the precise definition of the fistulous tract have a major impact on the management acquisition process.
Topics: Humans; Pancreatic Fistula; Magnetic Resonance Imaging; Biliary Tract; Tomography, X-Ray Computed
PubMed: 37489476
DOI: 10.3390/tomography9040108 -
Nutrients Dec 2022Postoperative pancreatic fistula (POPF) are major postoperative complications (POCs) following distal pancreatectomy (DP). Notably, POPF may worsen the prognosis of...
Association between the Preoperative -Reactive Protein-to-Albumin Ratio and the Risk for Postoperative Pancreatic Fistula following Distal Pancreatectomy for Pancreatic Cancer.
Postoperative pancreatic fistula (POPF) are major postoperative complications (POCs) following distal pancreatectomy (DP). Notably, POPF may worsen the prognosis of patients with pancreatic cancer. Previously reported risks for POCs include body mass index, pancreatic texture, and albumin levels. Moreover, the C-reactive protein-to-albumin ratio (CAR) is a valuable parameter for prognostication. On the other hand, POCs sometimes lead to a worse prognosis in several cancer types. Thus, we assumed that CAR could be a risk factor for POPFs. This study investigated whether CAR can predict POPF risk in patients with pancreatic cancer following DP. This retrospective study included 72 patients who underwent DP for pancreatic cancer at Ehime University between January 2009 and August 2022. All patients underwent preoperative CAR screening. Risk factors for POPF were analyzed. POPF were observed in 17 of 72 (23.6%) patients. POPF were significantly associated with a higher CAR (p = 0.001). The receiver operating characteristic curve analysis determined the cutoff value for CAR to be 0.05 (sensitivity: 76.5%, specificity: 88.9%, likelihood ratio: 6.88), indicating an increased POPF risk. Univariate and multivariate analysis revealed that CAR ≥ 0.05 was a statistically independent factor for POPF (p < 0.001, p = 0.013). Therefore, CAR has the potential to predict POPF following DP.
Topics: Humans; Pancreatectomy; Pancreatic Fistula; C-Reactive Protein; Retrospective Studies; Pancreas; Pancreatic Neoplasms; Postoperative Complications; Risk Factors; Pancreatic Hormones; Albumins
PubMed: 36558435
DOI: 10.3390/nu14245277 -
Langenbeck's Archives of Surgery Nov 2020Pancreatic fistula following pancreatic resections is still a relevant complication. The present work shows the efforts of a single institute to decrease this problem.
PURPOSE
Pancreatic fistula following pancreatic resections is still a relevant complication. The present work shows the efforts of a single institute to decrease this problem.
METHODS
A total of 130 patients (63 men, 67 women) with a mean age of 60 (range: 23-81) years were operated on between January 2013 and March 2020. The most frequent type of pancreatic resection was a Whipple procedure with partial antrectomy. During all operations, an innovative method was used, namely a modification of the purse-string suture pancreatojejunostomy. Moreover, an early drain removal policy was applied, based on the drain amylase level on the first and subsequent postoperative days.
RESULTS
Mean postoperative hospital stay was 13 days (range: 7-75). The overall morbidity rate was 43.8%; the clinically relevant (grade B/C) pancreatic fistula (CR-POPF) rate was 6.9%. Delayed gastric emptying (DGE) was observed in 4% of the patients. The ratio of operative mortality was 0.7%; the reoperation rate was 5.3%. Based on the drain amylase level on the first postoperative day, two groups could be established. In the first one, the drain was removed early, on the fourth day in average (range: 2-6). In the other group, the drain was left in situ protractedly or reinserted later on.
CONCLUSION
A single center's experience proves that the refinement of the technique can improve the results of pancreatic surgery.
Topics: Adult; Aged; Aged, 80 and over; Drainage; Female; Humans; Male; Middle Aged; Pancreas; Pancreatectomy; Pancreatic Fistula; Pancreaticoduodenectomy; Pancreaticojejunostomy; Postoperative Complications; Young Adult
PubMed: 32737588
DOI: 10.1007/s00423-020-01942-8 -
BMC Surgery Jun 2020The mortality following pancreaticoduodenectomy has markedly decreased but remains an important challenge for the complexity of operation and technical skills involved....
BACKGROUND
The mortality following pancreaticoduodenectomy has markedly decreased but remains an important challenge for the complexity of operation and technical skills involved. The present study aimed to clarify the impact of individualized pancreaticoenteric anastomosis and management to postoperative pancreatic fistula.
METHODS
Data from 529 consecutive pancreaticoduodenectomies were retrospectively analysed from the Hepatobiliary and Pancreatic Surgery Unit I, Peking Cancer Hospital. The pancreaticoenteric anastomosis was determined based on the pancreatic texture and diameter of the main pancreatic duct. The amylase value of the drainage fluid was dynamically monitored postoperatively on days 3, 5 and 7. A low speed intermittent irrigation was performed in selected patients. Intraoperative and postoperative results were collected and compared between the pancreaticogastrostomy (PG) group and pancreaticojejunostomy (PJ) group.
RESULTS
From 2010 to 2019, 529 consecutive patients underwent pancreaticoduodenectomy. Pancreaticogastrostomy was performed in 364 patients; pancreaticojejunostomy was performed in 150 patients respectively. The clinically relevant pancreatic fistula (CR-POPF) was 9.8% and mortality was zero. The soft pancreas, diameter of main pancreatic duct≤3 mm, BMI ≥ 25, operation time > 330 min and pancreaticogastrostomy was correlated with postoperative pancreatic fistula significantly. The CR-POPF of PJ was significantly higher than that of PG in soft pancreas patients; the operation time of PJ was shorter than that of PG significantly in hard pancreas patients. Intraoperative blood loss and operation time of PG was less than that of PJ significantly in normal pancreatic duct patients (p < 0.05).
CONCLUSIONS
Individualized pancreaticoenteric anastomosis should be determined based on the pancreatic texture and pancreatic duct diameter. The appropriate anastomosis and postoperative management could prevent mortality.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Amylases; Anastomosis, Surgical; Drainage; Female; Humans; Male; Middle Aged; Pancreas; Pancreatic Diseases; Pancreatic Ducts; Pancreatic Fistula; Pancreaticoduodenectomy; Pancreaticojejunostomy; Retrospective Studies; Stomach; Therapeutic Irrigation; Young Adult
PubMed: 32571289
DOI: 10.1186/s12893-020-00791-y -
HPB : the Official Journal of the... Dec 2022No studies to date have determined the impact of pancreatic fat infiltration on postoperative pancreatic fistula (POPF) occurrence in patients undergoing invagination...
BACKGROUND
No studies to date have determined the impact of pancreatic fat infiltration on postoperative pancreatic fistula (POPF) occurrence in patients undergoing invagination pancreaticojejunostomy (IV-PJ).
METHODS
The medical records of patients with a soft pancreas who underwent pancreatoduodenectomy followed by IV-PJ were reviewed . The pancreatic fat ratio on computed tomography (CT) images (I-PFR) was determined using preoperative CT and verified by histologic examination. The relationship between the I-PFR and POPF occurrence was determined. Patients were classified into 2 groups based on I-PFR value (fatty and non-fatty pancreas). Postoperative outcomes were compared between the two groups, and specifically among patients who developed POPF.
RESULTS
Of 221 patients, POPF occurred in 67 (30.3%). I-PFR was positively correlated with histologic-calculated fat ratio (ρ = 0.517, p < 0.001). This index was shown to be an independent predictor of POPF. Based on an I-PFR cut-off value of 3.2%, 92 patients were classified in the fatty pancreas group. Subgroup analysis of the patients who developed POPF showed that incidence of abscess formation and hemorrhage tended to be higher in patients with fatty pancreas than in those with non-fatty pancreas.
CONCLUSIONS
Pancreatic fat infiltration is highly associated with POPF and possibly causes subsequent serious complications in patients undergoing IV-PJ.
Topics: Humans; Pancreatic Fistula; Pancreaticojejunostomy; Pancreaticoduodenectomy; Pancreas; Postoperative Complications; Retrospective Studies
PubMed: 36163226
DOI: 10.1016/j.hpb.2022.08.013