Robertson FP, Spiers HVM, Lim WB, Loveday B, Roberts K, Pandanaboyana S. Intraoperative pancreas stump perfusion assessment during pancreaticoduodenectomy: A systematic scoping review. World J Gastrointest Surg 2023; 15(8): 1799-1807 [PMID: 37701689 DOI: 10.4240/wjgs.v15.i8.1799]
Corresponding Author of This Article
Francis P Robertson, BSc, FRCS (Ed), MBChB, PhD, Surgeon, Department of HPB and Transplant Surgery, Freeman Hospital, Freeman Road, Newcastle Upon Tyne NE7 7DN, United Kingdom. francis.robertson.13@ucl.ac.uk
Research Domain of This Article
Surgery
Article-Type of This Article
Systematic Reviews
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Gastrointest Surg. Aug 27, 2023; 15(8): 1799-1807 Published online Aug 27, 2023. doi: 10.4240/wjgs.v15.i8.1799
Intraoperative pancreas stump perfusion assessment during pancreaticoduodenectomy: A systematic scoping review
Francis P Robertson, Harry V M Spiers, Wei Boon Lim, Benjamin Loveday, Keith Roberts, Sanjay Pandanaboyana
Francis P Robertson, Wei Boon Lim, Sanjay Pandanaboyana, Department of HPB and Transplant Surgery, Freeman Hospital, Newcastle Upon Tyne NE7 7DN, United Kingdom
Harry V M Spiers, Department of HPB Surgery, Addenbrookes Hospital, Cambridge CB2 0QQ, United Kingdom
Benjamin Loveday, Department of General Surgery, Royal Melbourne Hospital, Melbourne VIC 3050, Australia
Keith Roberts, Department of HPB Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham BG15 2GW, United Kingdom
Author contributions: Robertson FP, Spiers HVM, and Pandanaboyana S contributed to the manuscript preparation, study concept, and critical review; Loveday B and Roberts K were involved in the study concept and critical review.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Francis P Robertson, BSc, FRCS (Ed), MBChB, PhD, Surgeon, Department of HPB and Transplant Surgery, Freeman Hospital, Freeman Road, Newcastle Upon Tyne NE7 7DN, United Kingdom. francis.robertson.13@ucl.ac.uk
Received: April 13, 2023 Peer-review started: April 13, 2023 First decision: May 19, 2023 Revised: May 23, 2023 Accepted: June 11, 2023 Article in press: June 11, 2023 Published online: August 27, 2023
Abstract
BACKGROUND
Post-operative pancreatic fistula (POPF) is the primary cause of morbidity following pancreaticoduodenectomy. Rates of POPF have remained high despite well known risk factors. The theory that hypoperfusion of the pancreatic stump leads to anastomotic failure has recently gained interest.
AIM
To define the published literature with regards to intraoperative pancreas perfusion assessment and its correlation with POPF.
METHODS
A systematic search of available literature was performed in November 2022. Data extracted included study characteristics, method of assessment of pancreas stump perfusion, POPF and other post-pancreatic surgery specific complications.
RESULTS
Five eligible studies comprised two prospective non-randomised studies and three case reports, total 156 patients. Four studies used indocyanine green fluorescence angiography to assess the pancreatic stump, with the remaining study assessing pancreas perfusion by visual inspection of arterial bleeding of the pancreatic stump. There was significant heterogeneity in the definition of POPF. Studies had a combined POPF rate of 12%; intraoperative perfusion assessment revealed hypoperfusion was present in 39% of patients who developed POPF. The rate of POPF was 11% in patients with no evidence of hypoperfusion and 13% in those with evidence of hypoperfusion, suggesting that not all hypoperfusion gives rise to POPF and further analysis is required to analyse if there is a clinically relevant cut off. Significant variance in practice was seen in the pancreatic stump management once hypoperfusion was identified.
CONCLUSION
The current published evidence around pancreas perfusion during pancreaticoduodenectomy is of poor quality. It does not support a causative link between hypoperfusion and POPF. Further well-designed prospective studies are required to investigate this.
Core Tip: The pathology of post-op pancreatic fistula remains to be elucidated, however, hypoperfusion of the pancreatic remanent is a suggested mechanism leading to post-operative pancreatitis and failure of the pancreatic jejunal anastomosis. Indocyanine green assessment of the pancreatic remanent is a safe way to visualise perfusion of the stump prior to anastomosis. Whether it can predict post-operative pancreatic fistula requires further studies.
