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Langenbeck's Archives of Surgery Aug 2017The purpose of this systematic review was to compare minimally invasive pancreatoduodenectomy (MIPD) versus open pancreatoduodenectomy (OPD) by using meta-analytical... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
The purpose of this systematic review was to compare minimally invasive pancreatoduodenectomy (MIPD) versus open pancreatoduodenectomy (OPD) by using meta-analytical techniques.
METHODOLOGY
Medline, Embase, and Cochrane Library were searched for eligible studies. Data from included studies were extracted for the following outcomes: operative time, overall morbidity, pancreatic fistula, delayed gastric emptying, blood loss, postoperative hemorrhage, yield of harvested lymph nodes, R1 rate, length of hospital stay, and readmissions. Random and fix effect meta-analyses were undertaken.
RESULTS
Initial reference search yielded 747 articles. Thorough evaluation resulted in 12 papers, which were analyzed. The total number of patients was 2186 (705 in MIPD group and 1481 in OPD). Although there were no differences in overall morbidity between groups, we noticed reduced blood loss, delayed gastric emptying, and length of hospital stay in favor of MIPD. In contrary, meta-analysis of operative time revealed significant differences in favor of open procedures. Remaining parameters did not differ among groups.
CONCLUSION
Our review suggests that although MIPD takes longer, it may be associated with reduced blood loss, shortened LOS, and comparable rate of perioperative complications. Due to heterogeneity of included studies and differences in baseline characteristics between analyzed groups, the analysis of short-term oncological outcomes does not allow drawing unequivocal conclusions.
Topics: Humans; Laparoscopy; Minimally Invasive Surgical Procedures; Pancreaticoduodenectomy; Robotic Surgical Procedures
PubMed: 28488004
DOI: 10.1007/s00423-017-1583-8 -
The British Journal of Surgery May 2024Clinical auditing is a powerful tool to evaluate and improve healthcare. Deviations from the expected quality of care are identified by benchmarking the results of...
BACKGROUND
Clinical auditing is a powerful tool to evaluate and improve healthcare. Deviations from the expected quality of care are identified by benchmarking the results of individual hospitals using national averages. This study aimed to evaluate the use of quality indicators for benchmarking hepato-pancreato-biliary (HPB) surgery and when outlier hospitals could be identified.
METHODS
A population-based study used data from two nationwide Dutch HPB audits (DHBA and DPCA) from 2014 to 2021. Sample size calculations determined the threshold (in percentage points) to identify centres as statistical outliers, based on current volume requirements (annual minimum of 20 resections) on a two-year period (2020-2021), covering mortality rate, failure to rescue (FTR), major morbidity rate and textbook/ideal outcome (TO) for minor liver resection (LR), major LR, pancreaticoduodenectomy (PD) and distal pancreatectomy (DP).
RESULTS
In total, 10 963 and 7365 patients who underwent liver and pancreatic resection respectively were included. Benchmark and corresponding range of mortality rates were 0.6% (0 -3.2%) and 3.3% (0-16.7%) for minor and major LR, and 2.7% (0-7.0%) and 0.6% (0-4.2%) for PD and DP respectively. FTR rates were 5.4% (0-33.3%), 14.2% (0-100%), 7.5% (1.6%-28.5%) and 3.1% (0-14.9%). For major morbidity rate, corresponding rates were 9.8% (0-20.5%), 28.1% (0-47.1%), 36% (15.8%-58.3%) and 22.3% (5.2%-46.1%). For TO, corresponding rates were 73.6% (61.3%-94.4%), 54.1% (35.3-100), 46.8% (25.3%-59.4%) and 63.3% (30.7%-84.6%). Mortality rate thresholds indicating a significant outlier were 8.6% and 15.4% for minor and major LR and 14.2% and 8.6% for PD and DP. For FTR, these thresholds were 17.9%, 31.6%, 22.9% and 15.0%. For major morbidity rate, these thresholds were 26.1%, 49.7%, 57.9% and 52.9% respectively. For TO, lower thresholds were 52.5%, 32.5%, 25.8% and 41.4% respectively. Higher hospital volumes decrease thresholds to detect outliers.
CONCLUSION
Current event rates and minimum volume requirements per hospital are too low to detect any meaningful between hospital differences in mortality rate and FTR. Major morbidity rate and TO are better candidates to use for benchmarking.
Topics: Humans; Benchmarking; Quality Indicators, Health Care; Netherlands; Pancreatectomy; Male; Pancreaticoduodenectomy; Hepatectomy; Female; Middle Aged; Aged; Hospital Mortality
PubMed: 38747683
DOI: 10.1093/bjs/znae119 -
Journal of Visceral Surgery Jun 2016Pancreato-duodenectomy (PD) is the treatment of choice for periampullary tumors, and currently, indications have been extended to benign disease, including symptomatic... (Review)
Review
Pancreato-duodenectomy (PD) is the treatment of choice for periampullary tumors, and currently, indications have been extended to benign disease, including symptomatic chronic pancreatitis, paraduodenal pancreatitis, and benign periampullary tumors that are not amenable to conservative surgery. In spite of a significant decrease in mortality in high volume centers over the last three decades (from>20% in the 1980s to<5% today), morbidity remains high, ranging from 30% to 50%. The most common complications are related to the pancreatic remnant, such as postoperative pancreatic fistula, anastomotic dehiscence, abscess, and hemorrhage, and are among the highest of all surgical complications following intra-abdominal gastro-intestinal anastomoses. Moreover, pancreatico-enteric anastomotic breakdown remains a life-threatening complication. For these reasons, the management of the pancreatic stump following resection is still one of the most hotly debated issues in digestive surgery; more than 80 different methods of pancreatico-enteric reconstructions having been described, and no gold standard has yet been defined. In this review, we analyzed the current trends in the surgical management of the pancreatic remnant after PD.
Topics: Humans; Pancreas; Pancreatic Diseases; Pancreaticoduodenectomy; Pancreaticojejunostomy; Postoperative Complications; Risk Factors
PubMed: 27130693
DOI: 10.1016/j.jviscsurg.2016.04.003 -
Scientific Reports May 2017The feasible of minimally invasive pancreaticoduodenectomy (MIPD) remains controversial when compared with open pancreaticoduodenectomy (OPD). We conducted a systemic... (Meta-Analysis)
Meta-Analysis Review
The feasible of minimally invasive pancreaticoduodenectomy (MIPD) remains controversial when compared with open pancreaticoduodenectomy (OPD). We conducted a systemic review and meta-analysis to summarise the available evidence to compare MIPD vs OPD. We systemically searched PubMed, EMBASE and Web of Science for studies published through February 2016. The primary endpoint was postoperative pancreatic fistula (POPF, grade B/C). A total of 27 studies involving 14,231 patients (2,377 MIPD and 11,854 OPD) were included. MIPD was associated with longer operative times (P < 0.01) and increased mortality (P < 0.01), but decreased estimated blood loss (P < 0.01), decreased delayed gastric emptying (P < 0.01), increased R0 resection rate (P < 0.01), decreased wound infection (P = 0.03) and shorter hospital stays (P < 0.01). There were no significant differences in BMI (P = 0.43), tumor size (P = 0.17), lymph nodes harvest (P = 0.57), POPF (P = 0.84), reoperation (P = 0.25) and 5-year survival rates (P = 0.82) for MIPD compared with OPD. Although there was an increased operative cost (P < 0.01) for MIPD compared with OPD, the postoperative cost was less (P < 0.01) with the similar total costs (P = 0.28). MIPD can be a reasonable alternative to OPD with the potential advantage of being minimally invasive. However, MIPD should be performed in high-volume centers and more randomized-controlled trials are needed to evaluate the appropriate indications of MIPD.
Topics: Humans; Neoplasms; Odds Ratio; Pancreaticoduodenectomy; Treatment Outcome
PubMed: 28533536
DOI: 10.1038/s41598-017-02488-4 -
Hepatobiliary & Pancreatic Diseases... Dec 2022In the past decades, the perioperative management of patients undergoing pancreaticoduodenectomy (PD) has undergone major changes worldwide. This review aimed to... (Meta-Analysis)
Meta-Analysis
BACKGROUND
In the past decades, the perioperative management of patients undergoing pancreaticoduodenectomy (PD) has undergone major changes worldwide. This review aimed to systematically determine the burden of complications of PD performed in the last 10 years.
DATA SOURCES
A systematic review was conducted in PubMed for randomized controlled trials and observational studies reporting postoperative complications in at least 100 PDs from January 2010 to April 2020. Risk of bias was assessed using the Cochrane RoB2 tool for randomized studies and the methodological index for non-randomized studies (MINORS). Pooled complication rates were estimated using random-effects meta-analysis. Heterogeneity was investigated by subgroup analysis and meta-regression.
RESULTS
A total of 20 randomized and 49 observational studies reporting 63 229 PDs were reviewed. Mean MINORS score showed a high risk of bias in non-randomized studies, while one quarter of the randomized studies were assessed to have high risk of bias. Pooled incidences of 30-day mortality, overall complications and serious complications were 1.7% (95% CI: 0.9%-2.9%; I = 95.4%), 54.7% (95% CI: 46.4%-62.8%; I = 99.4%) and 25.5% (95% CI: 21.8%-29.4%; I= 92.9%), respectively. Clinically-relevant postoperative pancreatic fistula risk was 14.3% (95% CI: 12.4%-16.3%; I = 92.0%) and mean length of stay was 14.8 days (95% CI: 13.6-16.1; I = 99.3%). Meta-regression partially attributed the observed heterogeneity to the country of origin of the study, the study design and the American Society of Anesthesiologists class.
CONCLUSIONS
Pooled complication rates estimated in this study may be used to counsel patients scheduled to undergo a PD and to set benchmarks against which centers can audit their practice. However, cautious interpretation is necessary due to substantial heterogeneity.
Topics: Humans; Pancreaticoduodenectomy; Pancreatectomy; Pancreatic Fistula; Pancreas; Postoperative Complications
PubMed: 35513962
DOI: 10.1016/j.hbpd.2022.04.006 -
Arquivos Brasileiros de Cirurgia... 2017Pancreatoduodenectomy is a technically challenging surgical procedure with an incidence of postoperative complications ranging from 30% to 61%. The procedure requires a...
BACKGROUND
Pancreatoduodenectomy is a technically challenging surgical procedure with an incidence of postoperative complications ranging from 30% to 61%. The procedure requires a high level of experience, and to minimize surgery-related complications and mortality, a high-quality standard surgery is imperative.
AIM
To understand the Brazilian practice patterns for pancreatoduodenectomy.
METHOD
A questionnaire was designed to obtain an overview of the surgical practice in pancreatic cancer, specific training, and experience in pancreatoduodenectomy. The survey was sent to members who declared an interest in pancreatic surgery.
RESULTS
A total of 60 questionnaires were sent, and 52 have returned (86.7%). The Southeast had the most survey respondents, with 25 surgeons (48.0%). Only two surgeons (3.9%) performed more than 50% of their pancreatoduodenectomies by laparoscopy. A classic Whipple procedure was performed by 24 surgeons (46.2%) and a standard International Study Group on Pancreatic Surgery lymphadenectomy by 43 surgeons (82.7%). For reconstruction, pancreaticojejunostomy was performed by 49 surgeons (94.2%), single limb technique by 41(78.9%), duct-to-mucosa anastomosis by 38 (73.1%), internal trans-anastomotic stenting by 26 (50.0%), antecolic route of gastric reconstruction by 39 (75.0%), and Braun enteroenterostomy was performed by only six surgeons (11.5%). Prophylactic abdominal drainage was performed by all surgeons, and somatostatin analogues were utilized by six surgeons (11.5%). Early postoperative enteral nutrition was routine for 22 surgeons (42.3%), and 34 surgeons (65.4%) reported routine use of a nasogastric suction tube.
CONCLUSION
Heterogeneity was observed in the pancreatoduodenectomy practice patterns of surgeons in Brazil, some of them in contrast with established evidence in the literature.
Topics: Brazil; Health Care Surveys; Humans; Pancreatic Neoplasms; Pancreaticoduodenectomy; Practice Patterns, Physicians'
PubMed: 29019560
DOI: 10.1590/0102-6720201700030007 -
World Journal of Gastroenterology Feb 2015To conduct a meta-analysis comparing outcomes after pancreaticoduodenectomy (PD) with or without prophylactic drainage. (Meta-Analysis)
Meta-Analysis Review
AIM
To conduct a meta-analysis comparing outcomes after pancreaticoduodenectomy (PD) with or without prophylactic drainage.
METHODS
Relevant comparative randomized and non-randomized studies were systemically searched based on specific inclusion and exclusion criteria. Postoperative outcomes were compared between patients with and those without routine drainage. Pooled odds ratios (OR) with 95%CI were calculated using either fixed effects or random effects models.
RESULTS
One randomized controlled trial and four non-randomized comparative studies recruiting 1728 patients were analyzed. Patients without prophylactic drainage after PD had significantly higher mortality (OR=2.32, 95%CI: 1.11-4.85; P=0.02), despite the fact that they were associated with fewer overall complications (OR=0.62, 95%CI: 0.48-0.82; P=0.00), major complications (OR=0.75, 95%CI: 0.60-0.93; P=0.01) and readmissions (OR=0.77, 95%CI: 0.60-0.98; P=0.04). There were no significant differences in the rates of pancreatic fistula, intra-abdominal abscesses, postpancreatectomy hemorrhage, biliary fistula, delayed gastric emptying, reoperation or radiologic-guided drains between the two groups.
CONCLUSION
Indiscriminate abandonment of intra-abdominal drainage following PD is associated with greater mortality, but lower complication rates. Future randomized trials should compare routine vs selective drainage.
Topics: Adult; Aged; Chi-Square Distribution; Drainage; Female; Humans; Male; Middle Aged; Odds Ratio; Pancreaticoduodenectomy; Patient Readmission; Postoperative Complications; Risk Factors; Time Factors; Treatment Outcome
PubMed: 25741162
DOI: 10.3748/wjg.v21.i8.2510 -
Journal of Gastrointestinal Surgery :... Sep 2022Pancreaticojejunostomy, an independent risk factor for pancreatic fistula, is the cause of several postoperative complications of pancreaticoduodenectomy. As suturing in... (Review)
Review
BACKGROUND
Pancreaticojejunostomy, an independent risk factor for pancreatic fistula, is the cause of several postoperative complications of pancreaticoduodenectomy. As suturing in minimally invasive surgery is difficult to perform, more simplified methods are needed to guarantee a safe pancreatic anastomosis. The concept of "biological healing" proposed in recent years has changed the conventional understanding of the anastomosis, which recommends rich blood supply, low tension, and loose sutures in the reconstruction of the pancreatic outflow tract.
METHODS
A literature search was conducted in PubMed for articles on pancreaticojejunostomy published between January 2014 and December 2021. After following a due selection process, several techniques developed in accordance with the concept of biological healing that were found suitable for minimally invasive surgery and their related clinical outcomes were described in this review.
RESULTS
The incidence of clinically relevant pancreatic fistula associated with the presented techniques did not exceed 15.9%, indicating superior results compared to Cattell-Warren double-layer duct-to-mucosa anastomosis (incidence: approximately 20%). The features and drawbacks of these approaches have been enumerated from the viewpoint of biological healing.
CONCLUSIONS
This review described several modified pancreaticojejunostomy techniques with the advantages of a simplified procedure and a lower incidence of pancreatic fistula. Surgeons can choose to apply them in clinical practice to improve patient prognosis.
Topics: Anastomosis, Surgical; Humans; Pancreas; Pancreatic Fistula; Pancreaticoduodenectomy; Pancreaticojejunostomy
PubMed: 35546220
DOI: 10.1007/s11605-022-05339-4 -
Annals of Surgery Dec 2000To perform a two-part study of pancreaticoduodenectomy in the Netherlands, focusing on the effects of risk factors on outcomes in a single high-volume hospital and the...
OBJECTIVE
To perform a two-part study of pancreaticoduodenectomy in the Netherlands, focusing on the effects of risk factors on outcomes in a single high-volume hospital and the effect of hospital volume on outcomes.
SUMMARY BACKGROUND DATA
Hospital volume and surgeon caseload can be related to the rates of complications and death, and the influence of risk factors can be volume-dependent. Provision of regionalized care should take this into account.
METHODS
In part A, a single-institution database on 300 consecutive patients undergoing pancreaticoduodenectomy was divided into two periods with similar numbers of patients. Overall complications, deaths, hospital stay, and risk factors were analyzed in the two periods and compared with an historical reference group. In part B, Netherlands medical registry data on age and postoperative death of patients who underwent partial pancreaticoduodenectomy from 1994 to 1998 were analyzed for the influence of hospital volume on death.
RESULTS
Between the time periods, the institutional death rate decreased from 4.9% to 0.7%, the complication rate from 60% to 41%. Median hospital stay decreased from 24 to 15 days. The death rate was not related to patient age and did not differ between surgeons. Serum creatinine levels, need for blood transfusion, and period of resection were independent risk factors for complications. The death rate after pancreaticoduodenectomy in the Netherlands was 12.6% in 1994 and 10.1% in 1998; it was greater in patients older than age 65. During the 5-year period, 40% of the procedures were performed in hospitals performing fewer than five resections per year, and the death rate was greater than in hospitals performing more than 25 resections per year.
CONCLUSIONS
The overall death rate after pancreaticoduodenectomy did not decrease significantly during the period, and it was greater in low-volume hospitals and older patients. The lower death and complication rates in high-volume hospitals, including the single-center outcomes, were similar to those reported in other countries and may be due to better prevention and management of complications. Pancreaticoduodenectomy should be performed in centers with sufficient experience and resources for support.
Topics: Data Interpretation, Statistical; Hospital Mortality; Hospitals; Humans; Length of Stay; Netherlands; Pancreaticoduodenectomy; Postoperative Complications; Risk Factors; Treatment Outcome
PubMed: 11088073
DOI: 10.1097/00000658-200012000-00007 -
Trials May 2023Pancreatic ductal carcinoma (PDAC) is the fourth most frequent cause of cancer-related death in the Western world, and its incidence is rising. In patients that undergo...
Conventional partial pancreatoduodenectomy versus an extended pancreatoduodenectomy (triangle operation) for pancreatic head cancers-study protocol for the randomised controlled TRIANGLE trial.
BACKGROUND
Pancreatic ductal carcinoma (PDAC) is the fourth most frequent cause of cancer-related death in the Western world, and its incidence is rising. In patients that undergo curative resection, local recurrence (LR) is frequent. A recently described surgical technique of extended pancreatoduodenectomy (PD) termed the TRIANGLE operation has been proposed as a promising approach to reduce LR and improve disease-free survival in PDAC patients.
METHODS
The TRIANGLE trial is a multicentre confirmatory randomised controlled superiority trial with two parallel study groups. A total of 270 patients with suspected or histologically confirmed pancreatic head cancer scheduled for PD will be included in the trial and randomly assigned to the intervention group (extended PD defined as Inoue level 3 dissection along the superior mesenteric and celiac artery as well as removal of all soft tissue in the so-called triangle between the celiac artery, the SMA and the mesenterico-portal axis) or the control group (conventional PD with lymphadenectomy and removal of soft tissue according to current guidelines). The primary endpoint of the trial will be the disease-free survival of patients. Other perioperative outcomes as well as oncological parameters and patient-reported outcomes will be analysed as secondary outcomes.
DISCUSSION
Despite multimodal treatment, LR remains high and disease-free survival is limited following PD for PDAC. The TRIANGLE operation could address these shortcomings of conventional PD as indicated in several retrospective studies. However, this technique could be associated with more adverse events for patients including intractable diarrhoea. The TRIANGLE trial will close the evidence gap as well as offer a risk-benefit assessment of this more radical approach to PD.
TRIAL REGISTRATION
German Clinical Trials Register DRKS00030576 (UTN U1111-1243-4412) 19th December 2022.
Topics: Humans; Pancreaticoduodenectomy; Retrospective Studies; Pancreas; Pancreatic Neoplasms; Carcinoma, Pancreatic Ductal; Head and Neck Neoplasms; Randomized Controlled Trials as Topic; Multicenter Studies as Topic
PubMed: 37254179
DOI: 10.1186/s13063-023-07337-6