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Langenbeck's Archives of Surgery May 2023Pancreatic fistula following distal pancreatectomies still remains a relevant problem. The present study describes our first series with a new method of pancreatic...
PURPOSE
Pancreatic fistula following distal pancreatectomies still remains a relevant problem. The present study describes our first series with a new method of pancreatic remnant closure.
METHODS
A free fascia-peritoneum graft - harvested from the internal rectus sheet - was fixed onto the pancreatic stump by one circular stitch. The method was applied in 18 cases.
RESULTS
The postoperative hospital stay was 8 days in average. No clinically relevant postoperative pancreatic fistula (CR-POPF) developed. The morbidity rate was 39%, mostly Clavien-Dindo Grade II types. There was no reoperation or mortality.
CONCLUSION
The first series showed advantageous results with our method. Certainly, further studies are needed for the evaluation of this new and promising technique.
Topics: Humans; Pancreatectomy; Pancreatic Fistula; Pancreas; Suture Techniques; Postoperative Complications; Retrospective Studies
PubMed: 37140674
DOI: 10.1007/s00423-023-02916-2 -
Surgery Sep 2023Machine learning is increasingly advocated to develop prediction models for postoperative complications. It is, however, unclear if machine learning is superior to... (Observational Study)
Observational Study
BACKGROUND
Machine learning is increasingly advocated to develop prediction models for postoperative complications. It is, however, unclear if machine learning is superior to logistic regression when using structured clinical data. Postoperative pancreatic fistula and delayed gastric emptying are the two most common complications with the biggest impact on patient condition and length of hospital stay after pancreatoduodenectomy. This study aimed to compare the performance of machine learning and logistic regression in predicting pancreatic fistula and delayed gastric emptying after pancreatoduodenectomy.
METHODS
This retrospective observational study used nationwide data from 16 centers in the Dutch Pancreatic Cancer Audit between January 2014 and January 2021. The area under the curve of a machine learning and logistic regression model for clinically relevant postoperative pancreatic fistula and delayed gastric emptying were compared.
RESULTS
Overall, 799 (16.3%) patients developed a postoperative pancreatic fistula, and 943 developed (19.2%) delayed gastric emptying. For postoperative pancreatic fistula, the area under the curve of the machine learning model was 0.74, and the area under the curve of the logistic regression model was 0.73. For delayed gastric emptying, the area under the curve of the machine learning model and logistic regression was 0.59.
CONCLUSION
Machine learning did not outperform logistic regression modeling in predicting postoperative complications after pancreatoduodenectomy.
Topics: Humans; Pancreaticoduodenectomy; Pancreatic Fistula; Logistic Models; Gastroparesis; Postoperative Complications; Retrospective Studies; Machine Learning
PubMed: 37150712
DOI: 10.1016/j.surg.2023.03.012 -
Asian Journal of Surgery Jan 2021Postoperative pancreatic fistula (POPF) after pancreatoduodenectomy greatly influences patients' postoperative course. Several evaluation methods have been used to...
BACKGROUND
Postoperative pancreatic fistula (POPF) after pancreatoduodenectomy greatly influences patients' postoperative course. Several evaluation methods have been used to assess the risk of clinically relevant POPF (CR-POPF) after pancreatoduodenectomy namely, the original, alternative, and updated alternative fistula risk scores (o-FRS, a-FRS, and ua-FRS, respectively).
METHODS
We enrolled 106/179 patients who underwent pancreatoduodenectomy in our institution between April 2013 and Mar 2018. CR-POPF was defined as grade B and C POPF according to the 2016 definitions of the International Study Group on Pancreatic Surgery.
RESULTS
Pancreatic gland texture was the only significant risk factor for CR-POPF (p = 0.007). The CR-POPF incidence increased significantly according to the risk groups defined by both o-FRS (p = 0.004) and a-FRS (p = 0.004). The area under the curve for o-FRS, a-FRS, and ua-FRS was 0.693, 0.693, and 0.671, respectively.
CONCLUSION
o-FRS, a-FRS, and ua-FRS were almost equally useful for risk evaluation for CR-POPF after pancreatoduodenectomy. Further studies, especially for preoperative objective evaluation of pancreatic gland texture, are needed for more useful and accurate risk evaluation.
Topics: Adult; Aged; Aged, 80 and over; Female; Humans; Incidence; Male; Middle Aged; Multivariate Analysis; Pancreas; Pancreatic Fistula; Pancreaticoduodenectomy; Postoperative Complications; ROC Curve; Retrospective Studies; Risk Assessment; Risk Factors
PubMed: 32409242
DOI: 10.1016/j.asjsur.2020.04.004 -
HPB : the Official Journal of the... Sep 2020The role of wrapping in the setting of pancreaticoduodenectomy (PD) is controversial. This study aimed to assess whether the use of omental or falciform ligament... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The role of wrapping in the setting of pancreaticoduodenectomy (PD) is controversial. This study aimed to assess whether the use of omental or falciform ligament wrapping of pancreatic anastomosis and/or vessels could reduce the rate of POPF and postpancreatectomy hemorrhage (PPH) after PD.
METHODS
Studies comparing PD with (PD-W) and without wrapping (PD-nW) were included. Primary outcomes were POPF and extraluminal PPH. Dichotomous variables were analyzed for risk ratios (RR) with 95% Confidence Intervals.
RESULTS
Nine studies involving 4384 patients were considered. The risk of POPF and clinically relevant POPF (CR-POPF) was similar between patients with and without omental wrapping of pancreatic anastomosis when considered as overall. A significant benefit from wrapping in terms of CR-POPF (RR 0.14, P = 0.002) was reported for patients who underwent PD with pancreaticojejunostomy (PJ). The risk of extraluminal PPH was slightly lower in patients who underwent vessels wrapping compared to those who did not (RR 0.58, P = 0.020). Similar extraluminal PPH rates were reported for patients with and without wrapping of pancreatic anastomosis (P = 0.620).
DISCUSSION
Data from low-evidence studies suggest that omental wrapping of PJ may reduce the incidence of CR-POPF, whereas vessels wrapping may have a slight effect for preventing extraluminal PPH.
Topics: Anastomosis, Surgical; Humans; Ligaments; Pancreatic Fistula; Pancreaticoduodenectomy; Pancreaticojejunostomy; Postoperative Complications
PubMed: 32631806
DOI: 10.1016/j.hpb.2020.05.003 -
BMC Surgery Jun 2020Our aim is to elucidate the true preoperative risk factors for postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD), making it possible to select...
BACKGROUND
Our aim is to elucidate the true preoperative risk factors for postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD), making it possible to select POPF high-risk patients preoperatively regardless of intraoperative pancreatic consistency judged by the surgeon's hand.
METHODS
Among the 298 patients who underwent PD with pancreaticojejunostomy from 2007 to 2016, 262 patients had preoperative CT configurations that could be precisely evaluated. Risk factor analyses were conducted using various perioperative factors, including preoperative CT findings, such as CT values of the pancreas, pancreas-visceral fat CT value ratio and pancreatic outer contour. Pancreatic outer contour was further divided into smooth- (smooth interlobular) and serrated-type contours (feathery, irregular interlobular) by preoperative CT.
RESULTS
In terms of the incidence of POPF, among the 262 patients, POPF grade B/C was found in 27 (10.3%): grade B in 23 (8.8%) and grade C in 4 (1.5%). According to multivariate analysis, a high pancreas-visceral fat CT value ratio (p = 0.002), serrated-type contour (p = 0.02) and no history of chemoradiotherapy (p = 0.019) were identified as independent risk factors for POPF grade B/C. Even in patients with soft pancreas, the incidence of POPF grade B/C was 0% (0/57) in patients with a pancreas-visceral fat CT value ratio of less than - 0.4 and smooth-type contour, whereas the incidence was markedly high (45.0%, 9/20) in patients with a pancreas-visceral fat CT value ratio of - 0.4 or greater and serrated-type contour, indicating that patients with soft pancreas should be categorized into POPF high-risk and low-risk groups according to preoperative CT scan results.
CONCLUSIONS
The pancreas-visceral fat CT value ratio and serrated-type pancreas are useful markers to preoperatively identify true POPF high-risk groups in patients undergoing PD, regardless of the pancreatic texture judged intraoperatively.
Topics: Adult; Aged; Aged, 80 and over; Bile Duct Neoplasms; Female; Humans; Intra-Abdominal Fat; Male; Middle Aged; Pancreas; Pancreatic Fistula; Pancreatic Neoplasms; Pancreaticoduodenectomy; Pancreaticojejunostomy; Postoperative Complications; Retrospective Studies; Risk Factors; Tomography, X-Ray Computed
PubMed: 32527310
DOI: 10.1186/s12893-020-00785-w -
HPB : the Official Journal of the... Jan 2018The level of utilization and acceptance of the 2005 International Study Group for Pancreatic Fistula (ISGPF) definition for postoperative pancreatic fistula (POPF) has...
BACKGROUND
The level of utilization and acceptance of the 2005 International Study Group for Pancreatic Fistula (ISGPF) definition for postoperative pancreatic fistula (POPF) has not be quantified. The aim of this study was to determine the uptake of the ISGPF definition and evaluate its use in the surgical literature.
METHODS
A sample of primary studies, review articles, and textbooks were identified through screening of literature searches. Included citations were assessed for their definition of POPF and use of the ISGPF criteria.
RESULTS
From 2006 to 2009, 6%-63% of primary papers were compliant with the ISGPF definition compared to 84%-98% from 2010 onwards. Of the primary studies compliant with the ISGPF criteria, 36% focused on grade B and C fistula and 15% did not report grade A fistula. 88% of European papers used the criteria compared to 77% and 72% of Asian and North American papers, respectively (p = 0.033). 46% of review articles and textbooks did not define POPF. Among those that defined POPF, 74% cited the ISGPF definition exclusively while 26% mentioned other definitions.
CONCLUSION
The ISGPF criteria have been widely adopted and accepted as the standard for defining POPF, although the utility of grade A fistulas is questionable.
Topics: Guideline Adherence; Humans; Pancreatic Fistula; Postoperative Complications; Practice Guidelines as Topic; Practice Patterns, Physicians'
PubMed: 28927654
DOI: 10.1016/j.hpb.2017.08.022 -
Digestive Surgery 2016The prevalence of pancreatic diseases needing surgical intervention is continuously rising. Distal pancreatectomy is performed in the case of pathologies affecting the... (Review)
Review
The prevalence of pancreatic diseases needing surgical intervention is continuously rising. Distal pancreatectomy is performed in the case of pathologies affecting the left side of the pancreas. More and more sophisticated surgical techniques have appeared and an increasing number of published articles discuss the possibilities for closure of the pancreatic remnant. However, the optimum solution is still under debate, as none of the examined techniques have been proven superior in reducing the incidence of the most common surgical complication, the formation of a postoperative pancreatic fistula (PF). Fistula rates have been stationary at 20-30% in the past decades despite the apparent advancement of medicine. This review presents a survey of the relevant articles examining different closure strategies and risk factors to reduce fistula formation rate. International medical publication database search and assessment was carried out to include the findings of studies investigating the efficacy of pancreatic remnant closure techniques to gain a clearer view on the complexity of pancreas fistulas. Emphasis is on indications for surgery, risk factors for postoperative fistula formation and strategies to seal the pancreatic remnant to avoid leakage. Findings suggest that careful patient selection, meticulous surgical techniques are equally important to reduce fistula rates. Ideal closure of the pancreatic remnant is still to be developed, as none of the widespread techniques (hand-sewn suture or staple closure) proved to be statistically significantly superior. Additional closure and covering methods (seromuscular patch, falciform ligament patch, pancreatico-enteric anastomosis, reinforced staplers, fibrin glue etc.) can have profitable effect but strong evidences are yet to come due to small case numbers. The recent introduction of standardized classification of PFs and future prospective randomized trials are more likely to be susceptible to determine if any of the standard or experimental closure techniques is more beneficial than the others.
Topics: Dissection; Humans; Incidence; Pancreas; Pancreatectomy; Pancreatic Fistula; Risk Factors; Wound Closure Techniques
PubMed: 27215609
DOI: 10.1159/000445017 -
Asian Journal of Surgery May 2022
Topics: Hemorrhage; Humans; Pancreatectomy; Pancreatic Fistula; Pancreaticoduodenectomy; Pancreaticojejunostomy; Postoperative Complications; Postoperative Hemorrhage; Risk Factors
PubMed: 35246345
DOI: 10.1016/j.asjsur.2022.02.045 -
PloS One 2018Pancreatic fistula/PF is the most frequent and feared complication after distal pancreatectomy/DP. However, the safest technique of pancreatic stump closure remains an... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Pancreatic fistula/PF is the most frequent and feared complication after distal pancreatectomy/DP. However, the safest technique of pancreatic stump closure remains an ongoing debate. Here, we aimed to compare the safety of different pancreatic stump closure techniques for preventing PF during DP.
METHODS
We performed a PRISMA-based meta-analysis of all relevant studies that compared at least two techniques of stump closure during DP with regard to PF rates/PFR. We further performed a retrospective analysis of our institutional PFR in correlation with stump closure techniques.
RESULTS
8301 studies were initially identified. From these, ten randomized controlled trials/RCTs, eleven prospective and 59 retrospective studies were eligible. Stapler closure (26%vs.31%, OR:0.73, p = 0.02), combination of stapler and suture (30%vs.33%, OR:0.70, p = 0.05), or stump anastomosis (14%vs.28%, OR:0.51, p = 0.02) were associated with lower PFR than suture closure alone. Spleen preservation/splenectomy, or laparoscopic/open DP, TachoSil®, fibrin-like glue-application, or bioabsorbable-stapler-reinforcements (Seamguard®) did not influence PFR after DP. In contrast, autologous patches (falciform ligament/seromuscular patches) resulted in lower PFR than no patch application (21.9%vs.25,8%, OR:0.60, p = 0.006). In our institution, the major three techniques of stump closure resulted in comparable PFR (suture:27%, stapler:29%, or combination:24%). However, selective suturing/clipping of the main pancreatic duct during pancreatic stump closure prevented severe PF (p = 0.02).
CONCLUSION
After DP, stapler closure, pancreatic anastomosis, or falciform/seromuscular patches lead to lower PFR than suture closure alone. However, the differences are rather small, and further RCTs are needed to test these effects. Selective closure of the main pancreatic duct during stump closure may prevent severe PF.
Topics: Aged; Female; Humans; Male; Middle Aged; Pancreas; Pancreatectomy; Pancreatic Fistula; Prospective Studies; Retrospective Studies; Risk Factors; Surgical Stapling; Suture Techniques; Wound Closure Techniques
PubMed: 29897920
DOI: 10.1371/journal.pone.0197553 -
Medicine Aug 2023Laparoscopic pancreaticoduodenectomy (LPD) is a classic surgical method for diseases, such as tumors at the lower end of the common bile duct, pancreatic head, and...
Laparoscopic pancreaticoduodenectomy (LPD) is a classic surgical method for diseases, such as tumors at the lower end of the common bile duct, pancreatic head, and benign and malignant tumors of the duodenum. Postoperative pancreatic fistula (POPF) is one of the most serious complications of LPD. To reduce the incidence of grade B or C POPF and other complications after LPD, we applied a split pancreatic duct stent combined with the characteristics of internal and external stent drainage. Between September 2020 and September 2022,12 patients underwent placement of the Split pancreatic duct stent during LPD. Data on basic characteristics of patients, surgical related indicators and postoperative POPF incidence were collected and analyzed. The results showed that the average operation time was 294.2 ± 36 minutes, average time for pancreaticojejunostomy was 35.9 ± 4.1 minutes, and average estimated blood loss was 204.2 ± 58.2 mL. Biochemical leakage occurred in 2 patients (16.7%), whereas no grade B or C POPF, 1 case (8.3%) had postoperative bleeding, and no death occurred within 30 days after the operation. Preliminary experience shows that the split pancreatic duct stent can effectively reduce the incidence of complications after LPD, especially grade B or C POPF.
Topics: Humans; Pancreaticoduodenectomy; Pancreatic Ducts; Pancreas; Pancreaticojejunostomy; Pancreatic Fistula; Postoperative Complications; Laparoscopy; Stents; Retrospective Studies
PubMed: 37543786
DOI: 10.1097/MD.0000000000034049