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Seufferlein T, Mayerle J, Boeck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie Exokrines Pankreaskarzinom – Version 3.1. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1724-1785. [PMID: 39389105 DOI: 10.1055/a-2338-3716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
Affiliation(s)
| | | | | | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Gastroenterologie und Endokrinologie Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik und Poliklinik für Allgemein-, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Medizinische Klinik und Poliklinik II Onkologie und Hämatologie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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Seufferlein T, Mayerle J, Boeck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie Exokrines Pankreaskarzinom – Version 3.1. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:874-995. [PMID: 39389103 DOI: 10.1055/a-2338-3533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
Affiliation(s)
| | | | | | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Gastroenterologie und Endokrinologie Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik und Poliklinik für Allgemein-, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Medizinische Klinik und Poliklinik II Onkologie und Hämatologie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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Rykina-Tameeva N, Samra JS, Sahni S, Mittal A. Non-Surgical Interventions for the Prevention of Clinically Relevant Postoperative Pancreatic Fistula-A Narrative Review. Cancers (Basel) 2023; 15:5865. [PMID: 38136409 PMCID: PMC10741911 DOI: 10.3390/cancers15245865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/06/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Clinically relevant postoperative pancreatic fistula (CR-POPF) is the leading cause of morbidity and mortality after pancreatic surgery. Post-pancreatectomy acute pancreatitis (PPAP) has been increasingly understood as a precursor and exacerbator of CR-POPF. No longer believed to be the consequence of surgical technique, the solution to preventing CR-POPF may lie instead in non-surgical, mainly pharmacological interventions. Five databases were searched, identifying eight pharmacological preventative strategies, including neoadjuvant therapy, somatostatin and its analogues, antibiotics, analgesia, corticosteroids, protease inhibitors, miscellaneous interventions with few reports, and combination strategies. Two further non-surgical interventions studied were nutrition and fluids. New potential interventions were also identified from related surgical and experimental contexts. Given the varied efficacy reported for these interventions, numerous opportunities for clarifying this heterogeneity remain. By reducing CR-POPF, patients may avoid morbid sequelae, experience shorter hospital stays, and ensure timely delivery of adjuvant therapy, overall aiding survival where prognosis, particularly in pancreatic cancer patients, is poor.
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Affiliation(s)
- Nadya Rykina-Tameeva
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW 2065, Australia
| | - Jaswinder S. Samra
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Upper GI Surgical Unit, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
- Upper GI Surgical Unit, North Shore Private Hospital, St Leonards, NSW 2065, Australia
- Australian Pancreatic Centre, St Leonards, NSW 2065, Australia
| | - Sumit Sahni
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW 2065, Australia
- Australian Pancreatic Centre, St Leonards, NSW 2065, Australia
| | - Anubhav Mittal
- Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Upper GI Surgical Unit, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
- Upper GI Surgical Unit, North Shore Private Hospital, St Leonards, NSW 2065, Australia
- Australian Pancreatic Centre, St Leonards, NSW 2065, Australia
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Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Langversion 2.0 – Dezember 2021 – AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:e812-e909. [PMID: 36368658 DOI: 10.1055/a-1856-7346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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Li T, Zhang J, Zeng J, Sun M, Li D, Yuan T, Zhang R, Jiang H. Early drain removal and late drain removal in patients after pancreatoduodenectomy: A systematic review and meta-analysis. Asian J Surg 2022; 46:1909-1916. [PMID: 36207205 DOI: 10.1016/j.asjsur.2022.09.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 09/06/2022] [Accepted: 09/14/2022] [Indexed: 11/26/2022] Open
Abstract
Whether early or late drain removal (EDR/LDR) is better for patients after pancreatic resection remains controversial. We aim to systematically evaluate the safety and efficacy of early or late drain removal in patients who undergo pancreatic resection. We searched seven databases from January 1, 2000, through September 2021, and included randomized controlled trials (RCTs) or observational studies comparing EDR vs. LDR in patients after pancreatic resection. We separately pooled effect estimates across RCTs and observational studies. Finally, we included 4 RCTs with 711 patients and 8 nonRCTs with 7207 patients. Based on the pooled RCT data, compared to LDR, EDR reduced hospital length of stay (LOS) (RR: -2.59, 95% CI: -4.13 to -1.06) and hospital cost (RR: -1022.27, 95% CI: -1990.39 to -54.19). Based on the pooled nonRCT data, EDR may reduce the incidence of all complications (OR: 0.45, 95% CI: 0.32 to 0.63), pancreatic fistula (OR: 0.26, 95% CI: 0.15 to 0.45), wound infection (RR: 0.59, 95% CI: 0.06 to 5.45)), reoperation (OR: 0.62, 95% CI: 0.40 to 0.96) and hospital readmission (OR: 0.57, 95% CI: 0.47 to 0.69). There was an uncertain effect on mortality (OR from pooled nonRCTs: 1.02, 95% CI: 0.41 to 2.53) and delayed gastric emptying (RR from pooled RCTs: 0.76, 95% CI: 0.41 to 1.41). The findings of this meta-analysis suggest that early drain removal is associated with lower hospital cost, is safe and may reduce the incidence of complications compared to late drain removal in patients after pancreaticoduodenectomy.
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Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Kurzversion 2.0 – Dezember 2021, AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:991-1037. [PMID: 35671996 DOI: 10.1055/a-1771-6811] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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Hai H, Li Z, Zhang Z, Cheng Y, Liu Z, Gong J, Deng Y. Duct-to-mucosa versus other types of pancreaticojejunostomy for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy. Cochrane Database Syst Rev 2022; 3:CD013462. [PMID: 35289922 PMCID: PMC8923262 DOI: 10.1002/14651858.cd013462.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula is a common and serious complication following pancreaticoduodenectomy. Duct-to-mucosa pancreaticojejunostomy has been used in many centers to reconstruct pancreatic digestive continuity following pancreatoduodenectomy, however, its efficacy and safety are uncertain. OBJECTIVES To assess the benefits and harms of duct-to-mucosa pancreaticojejunostomy versus other types of pancreaticojejunostomy for the reconstruction of pancreatic digestive continuity in participants undergoing pancreaticoduodenectomy, and to compare the effects of different duct-to-mucosa pancreaticojejunostomy techniques. SEARCH METHODS We searched the Cochrane Library (2021, Issue 1), MEDLINE (1966 to 9 January 2021), Embase (1988 to 9 January 2021), and Science Citation Index Expanded (1982 to 9 January 2021). SELECTION CRITERIA We included all randomized controlled trials (RCTs) that compared duct-to-mucosa pancreaticojejunostomy with other types of pancreaticojejunostomy (e.g. invagination pancreaticojejunostomy, binding pancreaticojejunostomy) in participants undergoing pancreaticoduodenectomy. We also included RCTs that compared different types of duct-to-mucosa pancreaticojejunostomy in participants undergoing pancreaticoduodenectomy. DATA COLLECTION AND ANALYSIS Two review authors independently identified the studies for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CIs). For all analyses, we used the random-effects model. We used the Cochrane RoB 1 tool to assess the risk of bias. We used GRADE to assess the certainty of the evidence for all outcomes. MAIN RESULTS We included 11 RCTs involving a total of 1696 participants in the review. One RCT was a dual-center study; the other 10 RCTs were single-center studies conducted in: China (4 studies); Japan (2 studies); USA (1 study); Egypt (1 study); Germany (1 study); India (1 study); and Italy (1 study). The mean age of participants ranged from 54 to 68 years. All RCTs were at high risk of bias. Duct-to-mucosa versus any other type of pancreaticojejunostomy We included 10 RCTs involving 1472 participants comparing duct-to-mucosa pancreaticojejunostomy with invagination pancreaticojejunostomy: 732 participants were randomized to the duct-to-mucosa group, and 740 participants were randomized to the invagination group after pancreaticoduodenectomy. Comparing the two techniques, the evidence is very uncertain for the rate of postoperative pancreatic fistula (grade B or C; RR 1.45, 95% CI 0.64 to 3.26; 7 studies, 1122 participants; very low-certainty evidence), postoperative mortality (RR 0.77, 95% CI 0.39 to 1.49; 10 studies, 1472 participants; very low-certainty evidence), rate of surgical reintervention (RR 1.12, 95% CI 0.65 to 1.95; 10 studies, 1472 participants; very low-certainty evidence), rate of postoperative bleeding (RR 0.85, 95% CI 0.51 to 1.42; 9 studies, 1275 participants; very low-certainty evidence), overall rate of surgical complications (RR 1.12, 95% CI 0.92 to 1.36; 5 studies, 750 participants; very low-certainty evidence), and length of hospital stay (MD -0.41 days, 95% CI -1.87 to 1.04; 4 studies, 658 participants; very low-certainty evidence). The studies did not report adverse events or quality of life outcomes. One type of duct-to-mucosa pancreaticojejunostomy versus a different type of duct-to-mucosa pancreaticojejunostomy We included one RCT involving 224 participants comparing duct-to-mucosa pancreaticojejunostomy using the modified Blumgart technique with duct-to-mucosa pancreaticojejunostomy using the traditional interrupted technique: 112 participants were randomized to the modified Blumgart group, and 112 participants were randomized to the traditional interrupted group after pancreaticoduodenectomy. Comparing the two techniques, the evidence is very uncertain for the rate of postoperative pancreatic fistula (grade B or C; RR 1.51, 95% CI 0.61 to 3.75; 1 study, 210 participants; very low-certainty evidence), postoperative mortality (there were no deaths in either group; 1 study, 210 participants; very low-certainty evidence), rate of surgical reintervention (RR 1.93, 95% CI 0.18 to 20.91; 1 study, 210 participants; very low-certainty evidence), rate of postoperative bleeding (RR 2.89, 95% CI 0.12 to 70.11; 1 study, 210 participants; very low-certainty evidence), overall rate of surgical complications (RR 1.10, 95% CI 0.80 to 1.51; 1 study, 210 participants; very low-certainty evidence), and length of hospital stay (15 days versus 15 days; 1 study, 210 participants; very low-certainty evidence). The study did not report adverse events or quality of life outcomes. AUTHORS' CONCLUSIONS The evidence is very uncertain about the effects of duct-to-mucosa pancreaticojejunostomy compared to invagination pancreaticojejunostomy on any of the outcomes, including rate of postoperative pancreatic fistula (grade B or C), postoperative mortality, rate of surgical reintervention, rate of postoperative bleeding, overall rate of surgical complications, and length of hospital stay. The evidence is also very uncertain whether duct-to-mucosa pancreaticojejunostomy using the modified Blumgart technique is superior, equivalent or inferior to duct-to-mucosa pancreaticojejunostomy using the traditional interrupted technique. None of the studies reported adverse events or quality of life outcomes.
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Affiliation(s)
- Hua Hai
- Department of Operating Room, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhuyin Li
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ziwei Zhang
- Chongqing Medical University, Chongqing, China
| | - Yao Cheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Zuojin Liu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Jianping Gong
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yilei Deng
- Department of Hepatopancreatobiliary Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Kamarajah SK, Bundred JR, Lin A, Halle-Smith J, Pande R, Sutcliffe R, Harrison EM, Roberts KJ. Systematic review and meta-analysis of factors associated with post-operative pancreatic fistula following pancreatoduodenectomy. ANZ J Surg 2021; 91:810-821. [PMID: 33135873 DOI: 10.1111/ans.16408] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/05/2020] [Accepted: 10/11/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Many studies have explored factors relating to post-operative pancreatic fistula (POPF); however, the original definition (All-POPF) was revised to include only 'clinically relevant' (CR) POPF. This study identified variables associated with the two International Study Group on Pancreatic Surgery definitions to identify which variables are more strongly associated with CR-POPF. METHODS A systematic review identified all studies reporting risk factors for POPF (using both International Study Group on Pancreatic Fistula definitions) following pancreatoduodenectomy. The primary outcome was factors associated with CR-POPF. Meta-analyses (random effects models) of pre-, intra- and post-operative factors associated with POPF in more than two studies were included. RESULTS Among 52 774 patients All-POPF (n = 69 studies) and CR-POPF (n = 53 studies) affected 27% (95% confidence interval (CI95% ) 23-30) and 19% (CI95% 17-22), respectively. Of the 176 factors, 24 and 17 were associated with All- and CR-POPF, respectively. Absence of pre-operative pancreatitis, presence of renal disease, no pre-operative neoadjuvant therapy, use of post-operative somatostatin analogues, absence of associated venous or arterial resection were associated with CR-POPF but not All-POPF. CONCLUSION In conclusion this study demonstrates wide variation in reported rates of POPF and that several risk factors associated with CR-POPF are not used within risk prediction models. Data from this study can be used to shape future studies, research and audit across ethnic and geographic boundaries in POPF following pancreatoduodenectomy.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle University NHS Trust Hospitals, Newcastle-Upon-Tyne, UK
- Institute of Cellular Medicine, University of Newcastle, Newcastle-Upon-Tyne, UK
| | - James R Bundred
- Department of Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Aaron Lin
- Department of Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - James Halle-Smith
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Rupaly Pande
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Robert Sutcliffe
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | - Keith J Roberts
- Department of Hepatobiliary and Pancreatic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Clinical Surgery, Edinburgh Royal Infirmary, Edinburgh, UK
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Kawai M, Yamaue H, Jang JY, Uesaka K, Unno M, Nakamura M, Fujii T, Satoi S, Choi SH, Sho M, Fukumoto T, Kim SC, Hong TH, Izumo W, Yoon DS, Amano R, Park SJ, Choi SB, Yu HC, Kim JS, Ahn YJ, Kim H, Ashida R, Hirono S, Heo JS, Song KB, Park JS, Yamamoto M, Shimokawa T, Kim SW. Propensity score-matched analysis of internal stent vs external stent for pancreatojejunostomy during pancreaticoduodenectomy: Japanese-Korean cooperative project. Pancreatology 2020; 20:984-991. [PMID: 32680728 DOI: 10.1016/j.pan.2020.06.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/08/2020] [Accepted: 06/18/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Several studies comparing internal and external stents have been conducted with the aim of reducing pancreatic fistula after PD. There is still no consensus, however, on the appropriate use of pancreatic stents for prevention of pancreatic fistula. This multicenter large cohort study aims to evaluate whether internal or external pancreatic stents are more effective in reduction of clinically relevant pancreatic fistula after pancreaticoduodenectomy (PD). METHODS We reviewed 3149 patients (internal stent n = 1,311, external stent n = 1838) who underwent PD at 20 institutions in Japan and Korea between 2007 and 2013. Propensity score matched analysis was used to minimize bias from nonrandomized treatment assignment. The primary endpoint was the incidence of clinically relevant pancreatic fistula. This study was registered on the UMIN Clinical Trials Registry (UMIN000032402). RESULTS After propensity score matched analysis, clinically relevant pancreatic fistula occurred in more patients in the external stents group (280 patients, 28.7%) than in patients in the internal stents group (126 patients, 12.9%) (OR 2.713 [95% CI, 2.139-3.455]; P < 0.001). In subset analysis of a high-risk group with soft pancreas and no dilatation of the pancreatic duct, clinically relevant pancreatic fistula occurred in 90 patients (18.8%) in internal stents group and 183 patients (35.4%) in external stents group. External stents were significantly associated with increased risk for clinically relevant pancreatic fistula (OR 2.366 [95% CI, 1.753-3.209]; P < 0.001). CONCLUSION Propensity score matched analysis showed that, regarding clinically relevant pancreatic fistula after PD, internal stents are safer than external stents for pancreaticojejunostomy.
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Affiliation(s)
- Manabu Kawai
- Second Department of Surgery, Wakayama Medical University, Jap
| | - Hiroki Yamaue
- Second Department of Surgery, Wakayama Medical University, Jap
| | - Jin-Young Jang
- Department of Surgery, Seoul National University, Republic of Korea
| | - Katsuhiko Uesaka
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Tsutomu Fujii
- Department of Gastroenterological Surgery (Surgery II), Nagoya University Graduate School of Medicine, Japan
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Japan
| | - Seong Ho Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University, Republic of Korea
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Japan
| | - Takumi Fukumoto
- Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Japan
| | - Song Cheol Kim
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, Ulsan University College of Medicine, Republic of Korea
| | - Tae Ho Hong
- Department of Hepato-biliary and Pancreas Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Republic of Korea
| | - Wataru Izumo
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Japan
| | - Dong Sup Yoon
- Pancreatobiliary Cancer Clinic, Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Ryosuke Amano
- Department of Surgical Oncology, Osaka City University, Japan
| | - Sang-Jae Park
- Department of Surgery, National Cancer Center, Republic of Korea
| | - Sae Byeol Choi
- Department of Surgery, Korea University Guro Hospital, Republic of Korea
| | - Hee Chul Yu
- Department of Surgery, Jeonbuk National University, Republic of Korea
| | - Joo Seop Kim
- Department of Surgery, Hallym University, Republic of Korea
| | - Young Joon Ahn
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Hospital, Republic of Korea
| | - Hongbeom Kim
- Department of Surgery, Seoul National University, Republic of Korea
| | - Ryo Ashida
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Japan
| | - Seiko Hirono
- Second Department of Surgery, Wakayama Medical University, Jap
| | - Jin Seok Heo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University, Republic of Korea
| | - Ki Byung Song
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Asan Medical Center, Ulsan University College of Medicine, Republic of Korea
| | - Joon Seong Park
- Pancreatobiliary Cancer Clinic, Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Republic of Korea
| | - Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Japan
| | - Toshio Shimokawa
- Clinical Study Support Center, Wakayama Medical University Hospital, Japan
| | - Sun-Whe Kim
- Department of Surgery, Seoul National University, Republic of Korea.
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Deng Y, He S, Cheng Y, Cheng N, Gong J, Gong J, Zeng Z, Zhao L, Cochrane Upper GI and Pancreatic Diseases Group. Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery. Cochrane Database Syst Rev 2020; 3:CD009621. [PMID: 32157697 PMCID: PMC7064369 DOI: 10.1002/14651858.cd009621.pub4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Postoperative pancreatic fistula is one of the most frequent and potentially life-threatening complications following pancreatic resections. Fibrin sealants have been used in some centers to reduce postoperative pancreatic fistula. However, the use of fibrin sealants during pancreatic surgery is controversial. This is an update of a Cochrane Review last published in 2018. OBJECTIVES To assess the safety, effectiveness, and potential adverse effects of fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery. SEARCH METHODS We searched trial registers and the following biomedical databases: the Cochrane Library (2019, Issue 2), MEDLINE (1946 to 13 March2019), Embase (1980 to 11 March 2019), Science Citation Index Expanded (1900 to 13 March 2019), and Chinese Biomedical Literature Database (CBM) (1978 to 13 March 2019). SELECTION CRITERIA We included all randomised controlled trials that compared fibrin sealant (fibrin glue or fibrin sealant patch) versus control (no fibrin sealant or placebo) in people undergoing pancreatic surgery. DATA COLLECTION AND ANALYSIS Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes (or a Peto odds ratio (OR) for very rare outcomes), and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs). MAIN RESULTS We included 12 studies involving 1604 participants in the review. Application of fibrin sealants to pancreatic stump closure reinforcement after distal pancreatectomy We included seven studies involving 860 participants: 428 were randomised to the fibrin sealant group and 432 to the control group after distal pancreatectomy. Fibrin sealants may lead to little or no difference in postoperative pancreatic fistula (fibrin sealant 19.3%; control 20.1%; RR 0.96, 95% CI 0.68 to 1.35; 755 participants; four studies; low-quality evidence). Fibrin sealants may also lead to little or no difference in postoperative mortality (0.3% versus 0.5%; Peto OR 0.52, 95% CI 0.05 to 5.03; 804 participants; six studies; low-quality evidence), or overall postoperative morbidity (28.5% versus 23.2%; RR 1.23, 95% CI 0.97 to 1.58; 646 participants; three studies; low-quality evidence). We are uncertain whether fibrin sealants reduce reoperation rate (2.0% versus 3.8%; RR 0.51, 95% CI 0.15 to 1.71; 376 participants; two studies; very low-quality evidence) or length of hospital stay (MD 0.99 days, 95% CI -1.83 to 3.82; 371 participants; two studies; very low-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness. Application of fibrin sealants to pancreatic anastomosis reinforcement after pancreaticoduodenectomy We included four studies involving 393 participants: 186 were randomised to the fibrin sealant group and 207 to the control group after pancreaticoduodenectomy. We are uncertain whether fibrin sealants reduce postoperative pancreatic fistula (16.7% versus 11.7%; RR 1.14, 95% CI 0.28 to 4.69; 199 participants; two studies; very low-quality evidence). We are uncertain whether fibrin sealants reduce postoperative mortality (0.5% versus 2.4%; Peto OR 0.26, 95% CI 0.05 to 1.32; 393 participants; four studies; low-quality evidence) or length of hospital stay (MD 0.01 days, 95% CI -3.91 to 3.94; 323 participants; three studies; very low-quality evidence). There is probably little or no difference in overall postoperative morbidity (52.6% versus 50.3%; RR 1.04, 95% CI 0.87 to 1.24; 323 participants; three studies; moderate-quality evidence) between the groups. We are uncertain whether fibrin sealants reduce reoperation rate (5.2% versus 7.7%; RR 0.74, 95% CI 0.33 to 1.66; 323 participants; three studies, very low-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness. Application of fibrin sealants to pancreatic duct occlusion after pancreaticoduodenectomy We included two studies involving 351 participants: 188 were randomised to the fibrin sealant group and 163 to the control group after pancreaticoduodenectomy. Fibrin sealants may lead to little or no difference in postoperative mortality (8.4% versus 6.1%; Peto OR 1.41, 95% CI 0.63 to 3.13; 351 participants; two studies; low-quality evidence) or length of hospital stay (median 16 to 17 days versus 17 days; 351 participants; two studies; low-quality evidence). We are uncertain whether fibrin sealants reduce overall postoperative morbidity (32.0% versus 27.6%; RR 1.16, 95% CI 0.67 to 2.02; 351 participants; two studies; very low-quality evidence), or reoperation rate (13.6% versus 16.0%; RR 0.85, 95% CI 0.52 to 1.41; 351 participants; two studies; very low-quality evidence). Serious adverse events were reported in one study (169 participants; low-quality evidence): more participants developed diabetes mellitus when fibrin sealants were applied to pancreatic duct occlusion, both at three months' follow-up (33.7% fibrin sealant group versus 10.8% control group; 29 participants versus 9 participants) and 12 months' follow-up (33.7% fibrin sealant group versus 14.5% control group; 29 participants versus 12 participants). The studies did not report postoperative pancreatic fistula, quality of life, or cost effectiveness. AUTHORS' CONCLUSIONS Based on the current available evidence, fibrin sealants may have little or no effect on postoperative pancreatic fistula in people undergoing distal pancreatectomy. The effects of fibrin sealants on the prevention of postoperative pancreatic fistula are uncertain in people undergoing pancreaticoduodenectomy.
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Affiliation(s)
- Yilei Deng
- The First Affiliated Hospital of Zhengzhou UniversityDepartment of Hepatopancreatobiliary SurgeryNo. 1, Jianshe East RoadZhengzhouHenan ProvinceChina450000
| | - Sirong He
- Chongqing Medical UniversityDepartment of Immunology, College of Basic MedicineNo. 1 Yixue RoadChongqingChina450000
| | - Yao Cheng
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryNo. 74, Lin Jiang Road, ChongqingChongqingChina400010
| | - Nansheng Cheng
- West China Hospital, Sichuan UniversityDepartment of Bile Duct SurgeryNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Jianping Gong
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryNo. 74, Lin Jiang Road, ChongqingChongqingChina400010
| | - Junhua Gong
- First Affiliated Hospital of Kunming Medical UniversityOrgan Transplant CenterNo. 295, Xi Chang RoadKunmingYunnanChina650032
| | - Zhong Zeng
- First Affiliated Hospital of Kunming Medical UniversityOrgan Transplant CenterNo. 295, Xi Chang RoadKunmingYunnanChina650032
| | - Longshuan Zhao
- The First Affiliated Hospital of Zhengzhou UniversityDepartment of Hepatopancreatobiliary SurgeryNo. 1, Jianshe East RoadZhengzhouHenan ProvinceChina450000
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Howe JR, Merchant NB, Conrad C, Keutgen XM, Hallet J, Drebin JA, Minter RM, Lairmore TC, Tseng JF, Zeh HJ, Libutti SK, Singh G, Lee JE, Hope TA, Kim MK, Menda Y, Halfdanarson TR, Chan JA, Pommier RF. The North American Neuroendocrine Tumor Society Consensus Paper on the Surgical Management of Pancreatic Neuroendocrine Tumors. Pancreas 2020; 49:1-33. [PMID: 31856076 PMCID: PMC7029300 DOI: 10.1097/mpa.0000000000001454] [Citation(s) in RCA: 259] [Impact Index Per Article: 51.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This manuscript is the result of the North American Neuroendocrine Tumor Society consensus conference on the surgical management of pancreatic neuroendocrine tumors from July 19 to 20, 2018. The group reviewed a series of questions of specific interest to surgeons taking care of patients with pancreatic neuroendocrine tumors, and for each, the available literature was reviewed. What follows are these reviews for each question followed by recommendations of the panel.
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Affiliation(s)
- James R. Howe
- Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, IA
| | | | - Claudius Conrad
- Department of Surgery, St. Elizabeth Medical Center, Tufts University School of Medicine, Boston, MA
| | | | - Julie Hallet
- Department of Surgery, University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jeffrey A. Drebin
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Rebecca M. Minter
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | | | - Herbert J. Zeh
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Steven K. Libutti
- §§ Department of Surgery, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Gagandeep Singh
- Department of Surgery, City of Hope Comprehensive Cancer Center, Duarte, CA
| | - Jeffrey E. Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Thomas A. Hope
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA
| | - Michelle K. Kim
- Department of Medicine, Mt. Sinai Medical Center, New York, NY
| | - Yusuf Menda
- Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, IA
| | | | - Jennifer A. Chan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Rodney F. Pommier
- Department of Surgery, Oregon Health & Sciences University, Portland, OR
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Ke ZX, Xiong JX, Hu J, Chen HY, Li Q, Li YQ. Risk Factors and Management of Postoperative Pancreatic Fistula Following Pancreaticoduodenectomy: Single-center Experience. Curr Med Sci 2019; 39:1009-1018. [DOI: 10.1007/s11596-019-2136-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 09/03/2019] [Indexed: 12/19/2022]
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Di Donato V, Bardhi E, Tramontano L, Capomacchia FM, Palaia I, Perniola G, Plotti F, Angioli R, Giancotti A, Muzii L, Panici PB. Management of morbidity associated with pancreatic resection during cytoreductive surgery for epithelial ovarian cancer: A systematic review. Eur J Surg Oncol 2019; 46:694-702. [PMID: 31806515 DOI: 10.1016/j.ejso.2019.11.516] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 11/09/2019] [Accepted: 11/18/2019] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION In ovarian cancer (OC), survival benefit in case of complete cytoreduction with absence of residual tumor has been clearly demonstrated; however, it often requires extensive surgery. Particularly, pancreatic resection during cytoreduction, may severely impact perioperative morbidity and mortality. OBJECTIVES The aim of this systematic review is to evaluate complication rates and related optimal management of ovarian cancer patients undergoing pancreatic resection as part of cytoreductive surgery. METHODS Literature was searched for relevant records reporting distal pancreatectomy for advanced ovarian cancer. All cohorts were rated for quality. We focused our analysis on complications related to pancreatic surgical procedures evaluating the following outcomes: pancreatic fistula (PF), abdominal abscess, pancreatitis, iatrogenic diabetes, hemorrhage from splenic vessels and pancreatic-surgery-related mortality. RESULTS The most frequent complication reported was PF. Similar rates of PF were reported after hand-sewn (20%) or stapled closure (24%). Continued drainage is the standard treatment, and often, the leak can be managed conservatively and does not require re-intervention. Abdominal abscess is the second most frequent complication and generally follows a non-adequately drained PF and often required re-laparotomy. Pancreatitis is a rare event that could be treated conservatively; however, death can occur in case of necrotic evolution. Cases of post-operative hemorrhage due to splenic vessel bleeding have been described and represent an emergency. CONCLUSIONS Knowledge of pancreatic surgery and management of possible complications ought to be present in the oncologic-gynecologic armamentarium. All patients should be referred to specialized, dedicated, tertiary centers in order to reduce, promptly recognize and optimally manage complications.
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Affiliation(s)
- Violante Di Donato
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Viale Del Policlinico 155, 00161, Rome, Italy
| | - Erlisa Bardhi
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Viale Del Policlinico 155, 00161, Rome, Italy.
| | - Luca Tramontano
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Viale Del Policlinico 155, 00161, Rome, Italy
| | - Filippo Maria Capomacchia
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Viale Del Policlinico 155, 00161, Rome, Italy
| | - Innocenza Palaia
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Viale Del Policlinico 155, 00161, Rome, Italy
| | - Giorgia Perniola
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Viale Del Policlinico 155, 00161, Rome, Italy
| | - Francesco Plotti
- Department of Gynecology, University of Rome "Campus Bio-Medico", Via Álvaro Del Portillo, 21, 00128, Rome, Italy
| | - Roberto Angioli
- Department of Gynecology, University of Rome "Campus Bio-Medico", Via Álvaro Del Portillo, 21, 00128, Rome, Italy
| | - Antonella Giancotti
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Viale Del Policlinico 155, 00161, Rome, Italy
| | - Ludovico Muzii
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Viale Del Policlinico 155, 00161, Rome, Italy
| | - Pierluigi Benedetti Panici
- Department of Maternal and Child Health and Urological Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Viale Del Policlinico 155, 00161, Rome, Italy
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Cheng Y, He S, Xia J, Ding X, Liu Z, Gong J. Duct-to-mucosa pancreaticojejunostomy for the prevention of postoperative pancreatic fistula following pancreaticoduodenectomy. Hippokratia 2019. [DOI: 10.1002/14651858.cd013462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Yao Cheng
- The Second Affiliated Hospital, Chongqing Medical University; Department of Hepatobiliary Surgery; No. 74, Lin Jiang Road, Chongqing Chongqing China 400010
| | - Sirong He
- Chongqing Medical University; Department of Immunology, College of Basic Medicine; No. 1 Yixue Road Chongqing China 450000
| | - Jie Xia
- Chongqing Medical University; The Key Laboratory of Molecular Biology on Infectious Diseases; Chongqing China 450000
| | - Xiong Ding
- The Second Affiliated Hospital, Chongqing Medical University; Department of Hepatobiliary Surgery; No. 74, Lin Jiang Road, Chongqing Chongqing China 400010
| | - Zuojin Liu
- The Second Affiliated Hospital, Chongqing Medical University; Department of Hepatobiliary Surgery; No. 74, Lin Jiang Road, Chongqing Chongqing China 400010
| | - Jianping Gong
- The Second Affiliated Hospital, Chongqing Medical University; Department of Hepatobiliary Surgery; No. 74, Lin Jiang Road, Chongqing Chongqing China 400010
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Tankel J, Sahnan K, Neumann M, Carmel O, Dagan A, Reissman P, Ben Haim M. Enhanced Recovery Deviation and Failure After Pancreaticoduodenectomy: Causative Factors and Impact. J Surg Res 2019; 245:569-576. [PMID: 31494390 DOI: 10.1016/j.jss.2019.07.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 06/26/2019] [Accepted: 07/17/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) following pancreaticoduodenectomy (PD) is popular and safe. This study aimed to describe the incidence, causative factors, and clinical impact of deviation from and failure of an ERAS protocol. MATERIALS AND METHODS A prospective cohort analysis of elective PD patients managed according to an ERAS protocol between October 2015 and June 2018 was performed. Univariate and multivariate analyses identified variables associated with protocol deviation and failure. The relationship between protocol deviation and failure was also explored. RESULTS A total of 97 patients were identified comprising of 46 females and 51 males. The median age was 68 y (range 17-85). Twenty-one patients (21.6%) suffered serious complications, whereas two (2.1%) died perioperatively. The median length of stay (LoS) was 14 d (6-36). In total, 73 (75.3%) patients deviated, whereas 39 (40.2%) failed the protocol. On univariate analysis, protocol deviation was associated with male gender, surgery time ≥270 min, and prolonged LoS. On multivariate analysis only prolonged LoS remained significant. Only serious complications were associated with protocol failure on multivariate analysis. Protocol deviation was not associated with significant complications nor ERAS protocol failure. CONCLUSIONS ERAS protocol deviation does not alter the course of those destined to protocol failure. Greater understanding into the causative factors of either protocol deviation or failure may be the only way to personalize care and realize the maximal benefit of ERAS in this specific group of patients.
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Affiliation(s)
- James Tankel
- Department of General Surgery, Shaare Zedek Medical Centre, The Hebrew University School of Medicine, Jerusalem, Israel; Department of Surgery and Cancer, Imperial College Healthcare Trust, London, St Mary's Hospital, London, UK.
| | - Kapil Sahnan
- Department of Surgery and Cancer, Imperial College Healthcare Trust, London, St Mary's Hospital, London, UK
| | - Michael Neumann
- Department of General Surgery, Shaare Zedek Medical Centre, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Ofra Carmel
- Department of General Surgery, Shaare Zedek Medical Centre, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Amir Dagan
- Department of General Surgery, Shaare Zedek Medical Centre, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Petachia Reissman
- Department of General Surgery, Shaare Zedek Medical Centre, The Hebrew University School of Medicine, Jerusalem, Israel
| | - Menahem Ben Haim
- Department of General Surgery, Shaare Zedek Medical Centre, The Hebrew University School of Medicine, Jerusalem, Israel
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Huang W, Lu J, Chen KM, Wu ZY, Wang QB, Liu JJ, Gong J, Chen ZJ, Ding XY, Wang ZM. Preliminary application of 3D-printed coplanar template for iodine-125 seed implantation therapy in patients with advanced pancreatic cancer. World J Gastroenterol 2018; 24:5280-5287. [PMID: 30581276 PMCID: PMC6295836 DOI: 10.3748/wjg.v24.i46.5280] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 11/27/2018] [Accepted: 11/27/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate a 3D-printed coplanar template for iodine-125 seed implantation therapy in patients with pancreatic cancer.
METHODS A retrospective analysis of our database was performed, and a total of 25 patients with pancreatic cancer who underwent iodine-125 seed implantation between January 2014 and November 2017 were analyzed. Of these, 12 implantations were assisted by a 3D-printed coplanar template (group A), and 13 implantations performed freehand were selected as a control group (group B). A 3D coplanar template was designed and printed according to a preoperative CT scan and treatment planning system. The iodine-125 seeds were then implanted using the template as a guide. Dosimetric verification was performed after implantation. Pre- and postoperative D90, V100, and V150 were calculated. The success rate of iodine-125 seed implantation, dosimetric parameters, and complications were analyzed and compared between the two groups.
RESULTS Iodine-125 seed implantation was successfully performed in both groups. In group A, the median pre- and postoperative D90 values were 155.32 ± 8.05 Gy and 154.82 ± 16.43 Gy, respectively; the difference between these values was minimal and not statistically significant (P > 0.05). Postoperative V100 and V150 were 91.05% ± 4.06% and 64.54% ± 13.40%, respectively, which met the treatment requirement. A better dosimetric parameter was observed in group A than in group B, and the difference was statistically significant (V100: 91.05% ± 4.06% vs 72.91% ± 13.78%, P < 0.05). No major procedure-related complications were observed in either group. For group A, mild hemorrhage was observed in 1 patient with a peritoneal local hematoma due to mesenteric vein damage from the iodine-125 seed implantation needle. The hematoma resolved spontaneously without treatment. Postoperative blood amylase levels remained within the normal range for all patients.
CONCLUSION A 3D-printed coplanar template appears to be a safe and effective iodine-125 seed implantation guidance tool to improve implantation accuracy and optimize dosimetric distribution.
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Affiliation(s)
- Wei Huang
- Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Jian Lu
- Department of Radiology, Ruijin Hospital Luwan Branch, Shanghai Jiao Tong University School of Medicine, Shanghai 200020, China
| | - Ke-Min Chen
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Zhi-Yuan Wu
- Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Qing-Bin Wang
- Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Jing-Jing Liu
- Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Ju Gong
- Department of Radiology, Ruijin Hospital Luwan Branch, Shanghai Jiao Tong University School of Medicine, Shanghai 200020, China
| | - Zhi-Jin Chen
- Department of Radiology, Ruijin Hospital Luwan Branch, Shanghai Jiao Tong University School of Medicine, Shanghai 200020, China
| | - Xiao-Yi Ding
- Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Zhong-Min Wang
- Department of Interventional Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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You DD, Paik KY, Park IY, Yoo YK. Randomized controlled study of the effect of octreotide on pancreatic exocrine secretion and pancreatic fistula after pancreatoduodenectomy. Asian J Surg 2018; 42:458-463. [PMID: 30262436 DOI: 10.1016/j.asjsur.2018.08.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 07/09/2018] [Accepted: 08/23/2018] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Octreotide is known to decrease the rate of postoperative complication after pancreatic resection by diminishing exocrine function of the pancreas. The aim of this study was to evaluate the effect of octreotide in decreasing exocrine excretion of pancreas and preventing pancreatic fistula. MATERIALS AND METHODS Prospective randomized trial was conducted involving 59 patients undergoing pancreaticoduodenectomy for either malignant or benign tumor, 29 patients were randomized to receive octreotide; 30 patients allotted to placebo. All pancreaticojejunal anastomosis was performed with external stent of negative-pressured drainage and the amount of pancreatic juice through the external stent was measured until postoperative 7th day. Pancreatic fistula was recorded. RESULTS There were no differences in demographics, pancreatic texture and pancreatic duct diameter between the octreotide and placebo group. The median output of pancreatic juice was not significantly different between both groups during 7 days after surgery. When the patients were stratified according to the diameter of pancreatic duct (duct ≤5 mm, > 5 mm), there were no significant differences in daily amount of pancreatic juice, however, when stratified according to pancreatic texture, median output of pancreatic juice was significantly lower in patients with hard pancreas compared with those with soft pancreas from 5 day to 7 day after surgery (p < 0.05). No significant differences in pancreatic fistula and postoperative complications were found between the octreotide and placebo groups. CONCLUSIONS Prophylactic octreotide is not effective to inhibit the exocrine secretion of the remnant pancreas and does not decrease the incidence of pancreatic fistula after pancreaticoduodenectomy.
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Affiliation(s)
- Dong Do You
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kwang Yeol Paik
- Department of Surgery, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Il Young Park
- Department of Surgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Kyung Yoo
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Young S, Sung ML, Lee JA, DiFronzo LA, O'Connor VV. Pasireotide is not effective in reducing the development of postoperative pancreatic fistula. HPB (Oxford) 2018; 20:834-840. [PMID: 30060910 DOI: 10.1016/j.hpb.2018.03.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 01/30/2018] [Accepted: 03/23/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND In a single trial, perioperative pasireotide demonstrated reduction in postoperative pancreatic fistula (POPF) following pancreatectomy, yet recent studies question the efficacy of this drug. METHODS All patients who underwent pancreatic resection between January 2014 and August 2017 at a single institution were prospectively followed. Starting in February 2016, pasireotide was administered to all pancreatectomies. Pancreaticoduodenectomy (PD) patients were additionally risk-stratified using a validated clinical risk score. The primary endpoint was the development of clinically relevant POPF (CR-POPF), and was compared between patients who received pasireotide and controls. RESULTS Of 116 patients, 87 patients (75%) underwent PD, and 43 patients (37.1%) received pasireotide. CR-POPF occurred in 28.4% patients. The use of pasireotide was not associated with reduced CR-POPF among the total cohort (25.6% vs. 30.1%, P = 0.599), distal pancreatectomy patients (P = 0.339), PD (P = 0.274), or PD patients with elevated risk scores (P = 0.073). Pasireotide did not decrease hospital length of stay, use of parenteral nutrition, delayed gastric emptying, surgical site wound infection, or readmission rate. CONCLUSION Use of pasireotide after pancreatic resection does not decrease CR-POPF, nor is it associated with reduced length of stay or postoperative complications. A multi-center randomized trial is warranted to study its true effect on outcomes after pancreatectomy.
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Affiliation(s)
- Stephanie Young
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA 90027, USA
| | - Michael L Sung
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA 90027, USA
| | - Jennifer A Lee
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA 90027, USA
| | - Louis A DiFronzo
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA 90027, USA
| | - Victoria V O'Connor
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA 90027, USA. victoria.v.o'
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Gong J, He S, Cheng Y, Cheng N, Gong J, Zeng Z. Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery. Cochrane Database Syst Rev 2018; 6:CD009621. [PMID: 29934987 PMCID: PMC6513198 DOI: 10.1002/14651858.cd009621.pub3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula is one of the most frequent and potentially life-threatening complications following pancreatic resections. Fibrin sealants are introduced to reduce postoperative pancreatic fistula by some surgeons. However, the use of fibrin sealants during pancreatic surgery is controversial. This is an update of a Cochrane Review last published in 2016. OBJECTIVES To assess the safety, effectiveness, and potential adverse effects of fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery. SEARCH METHODS We searched trial registers and the following biomedical databases: the Cochrane Library (2018, Issue 4), MEDLINE (1946 to 12 April 2018), Embase (1980 to 12 April 2018), Science Citation Index Expanded (1900 to 12 April 2018), and Chinese Biomedical Literature Database (CBM) (1978 to 12 April 2018). SELECTION CRITERIA We included all randomized controlled trials that compared fibrin sealant (fibrin glue or fibrin sealant patch) versus control (no fibrin sealant or placebo) in people undergoing pancreatic surgery. DATA COLLECTION AND ANALYSIS Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes (or a Peto odds ratio (OR) for very rare outcomes), and the mean difference (MD) for continuous outcomes, with 95% confidence intervals (CIs). MAIN RESULTS We included 11 studies involving 1462 participants in the review.Application of fibrin sealants to pancreatic stump closure reinforcement after distal pancreatectomyWe included seven studies involving 860 participants: 428 were randomized to the fibrin sealant group and 432 to the control group after distal pancreatectomy. Fibrin sealants may lead to little or no difference in postoperative pancreatic fistula (fibrin sealant 19.3%; control 20.1%; RR 0.96, 95% CI 0.68 to 1.35; 755 participants; four studies; low-quality evidence). Fibrin sealants may also lead to little or no difference in postoperative mortality (0.3% versus 0.5%; Peto OR 0.52, 95% CI 0.05 to 5.03; 804 participants; six studies; low-quality evidence), or overall postoperative morbidity (28.5% versus 23.2%; RR 1.23, 95% CI 0.97 to 1.58; 646 participants; three studies; low-quality evidence). We are uncertain whether fibrin sealants reduce reoperation rate (2.0% versus 3.8%; RR 0.51, 95% CI 0.15 to 1.71; 376 participants; two studies; very low-quality evidence). There is probably little or no difference in length of hospital stay between the groups (12.1 days versus 11.4 days; MD 0.32 days, 95% CI -1.06 to 1.70; 755 participants; four studies; moderate-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness.Application of fibrin sealants to pancreatic anastomosis reinforcement after pancreaticoduodenectomyWe included three studies involving 251 participants: 115 were randomized to the fibrin sealant group and 136 to the control group after pancreaticoduodenectomy. We are uncertain whether fibrin sealants reduce postoperative pancreatic fistula (1.6% versus 6.2%; RR 0.25, 95% CI 0.01 to 5.06; 57 participants; one study; very low-quality evidence). Fibrin sealants may lead to little or no difference in postoperative mortality (0.1% versus 0.7%; Peto OR 0.15, 95% CI 0.00 to 7.76; 251 participants; three studies; low-quality evidence) or length of hospital stay (12.8 days versus 14.8 days; MD -1.58 days, 95% CI -3.96 to 0.81; 181 participants; two studies; low-quality evidence). We are uncertain whether fibrin sealants reduce overall postoperative morbidity (33.7% versus 34.7%; RR 0.97, 95% CI 0.65 to 1.45; 181 participants; two studies; very low-quality evidence), or reoperation rate (7.6% versus 9.2%; RR 0.83, 95% CI 0.33 to 2.11; 181 participants; two studies, very low-quality evidence). The studies did not report serious adverse events, quality of life, or cost effectiveness.Application of fibrin sealants to pancreatic duct occlusion after pancreaticoduodenectomyWe included two studies involving 351 participants: 188 were randomized to the fibrin sealant group and 163 to the control group after pancreaticoduodenectomy. Fibrin sealants may lead to little or no difference in postoperative mortality (8.4% versus 6.1%; Peto OR 1.41, 95% CI 0.63 to 3.13; 351 participants; two studies; low-quality evidence) or length of hospital stay (17.0 days versus 16.5 days; MD 0.58 days, 95% CI -5.74 to 6.89; 351 participants; two studies; low-quality evidence). We are uncertain whether fibrin sealants reduce overall postoperative morbidity (32.0% versus 27.6%; RR 1.16, 95% CI 0.67 to 2.02; 351 participants; two studies; very low-quality evidence), or reoperation rate (13.6% versus 16.0%; RR 0.85, 95% CI 0.52 to 1.41; 351 participants; two studies; very low-quality evidence). Serious adverse events were reported in one study: more participants developed diabetes mellitus when fibrin sealants were applied to pancreatic duct occlusion, both at three months' follow-up (33.7% fibrin sealant group versus 10.8% control group; 29 participants versus 9 participants) and 12 months' follow-up (33.7% fibrin sealant group versus 14.5% control group; 29 participants versus 12 participants). The studies did not report postoperative pancreatic fistula, quality of life, or cost effectiveness. AUTHORS' CONCLUSIONS Based on the current available evidence, fibrin sealants may have little or no effect on postoperative pancreatic fistula in people undergoing distal pancreatectomy. The effects of fibrin sealants on the prevention of postoperative pancreatic fistula are uncertain in people undergoing pancreaticoduodenectomy.
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Affiliation(s)
- Junhua Gong
- First Affiliated Hospital of Kunming Medical UniversityOrgan Transplant CenterNo. 295, Xi Chang RoadKunmingChina650032
| | - Sirong He
- Chongqing Medical UniversityDepartment of Immunology, College of Basic MedicineNo. 1 Yixue RoadChongqingChina450000
| | - Yao Cheng
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Nansheng Cheng
- West China Hospital, Sichuan UniversityDepartment of Bile Duct SurgeryNo. 37, Guo Xue XiangChengduChina610041
| | - Jianping Gong
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Zhong Zeng
- First Affiliated Hospital of Kunming Medical UniversityOrgan Transplant CenterNo. 295, Xi Chang RoadKunmingChina650032
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Zhang W, He S, Cheng Y, Xia J, Lai M, Cheng N, Liu Z, Cochrane Upper GI and Pancreatic Diseases Group. Prophylactic abdominal drainage for pancreatic surgery. Cochrane Database Syst Rev 2018; 6:CD010583. [PMID: 29928755 PMCID: PMC6513487 DOI: 10.1002/14651858.cd010583.pub4] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The use of surgical drains has been considered mandatory after pancreatic surgery. The role of prophylactic abdominal drainage to reduce postoperative complications after pancreatic surgery is controversial. OBJECTIVES To assess the benefits and harms of routine abdominal drainage after pancreatic surgery, compare the effects of different types of surgical drains, and evaluate the optimal time for drain removal. SEARCH METHODS For the last version of this review, we searched CENTRAL (2016, Issue 8), and MEDLINE, Embase, Science Citation Index Expanded, and Chinese Biomedical Literature Database (CBM) to 28 August 2016). For this updated review, we searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, and CBM from 2016 to 15 November 2017. SELECTION CRITERIA We included all randomized controlled trials that compared abdominal drainage versus no drainage in people undergoing pancreatic surgery. We also included randomized controlled studies that compared different types of drains and different schedules for drain removal in people undergoing pancreatic surgery. DATA COLLECTION AND ANALYSIS We identified six studies (1384 participants). Two review authors independently identified the studies for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). For all analyses, we used the random-effects model. MAIN RESULTS Drain use versus no drain useWe included four studies with 1110 participants, who were randomized to the drainage group (N = 560) and the no drainage group (N = 550) after pancreatic surgery. There was little or no difference in mortality at 30 days between groups (1.5% with drains versus 2.3% with no drains; RR 0.78, 95% CI 0.31 to 1.99; four studies, 1055 participants; moderate-quality evidence). Drain use probably slightly reduced mortality at 90 days (0.8% versus 4.2%; RR 0.23, 95% CI 0.06 to 0.90; two studies, 478 participants; moderate-quality evidence). We were uncertain whether drain use reduced intra-abdominal infection (7.9% versus 8.2%; RR 0.97, 95% CI 0.52 to 1.80; four studies, 1055 participants; very low-quality evidence), or additional radiological interventions for postoperative complications (10.9% versus 12.1%; RR 0.87, 95% CI 0.79 to 2.23; three studies, 660 participants; very low-quality evidence). Drain use may lead to similar amount of wound infection (9.8% versus 9.9%; RR 0.98 , 95% CI 0.68 to 1.41; four studies, 1055 participants; low-quality evidence), and additional open procedures for postoperative complications (9.4% versus 7.1%; RR 1.33, 95% CI 0.79 to 2.23; four studies, 1055 participants; low-quality evidence) when compared with no drain use. There was little or no difference in morbidity (61.7% versus 59.7%; RR 1.03, 95% CI 0.94 to 1.13; four studies, 1055 participants; moderate-quality evidence), or length of hospital stay (MD -0.66 days, 95% CI -1.60 to 0.29; three studies, 711 participants; moderate-quality evidence) between groups. There was one drain-related complication in the drainage group (0.2%). Health-related quality of life was measured with the pancreas-specific quality-of-life questionnaire (FACT-PA; a scale of 0 to 144 with higher values indicating a better quality of life). Drain use may lead to similar quality of life scores, measured at 30 days after pancreatic surgery, when compared with no drain use (105 points versus 104 points; one study, 399 participants; low-quality evidence). Hospital costs and pain were not reported in any of the studies.Type of drainWe included one trial involving 160 participants, who were randomized to the active drain group (N = 82) and the passive drain group (N = 78) after pancreatic surgery. An active drain may lead to similar mortality at 30 days (1.2% with active drain versus 0% with passive drain; low-quality evidence), and morbidity (22.0% versus 32.1%; RR 0.68, 95% CI 0.41 to 1.15; low-quality evidence) when compared with a passive drain. We were uncertain whether an active drain decreased intra-abdominal infection (0% versus 2.6%; very low-quality evidence), wound infection (6.1% versus 9.0%; RR 0.68, 95% CI 0.23 to 2.05; very low-quality evidence), or the number of additional open procedures for postoperative complications (1.2% versus 7.7%; RR 0.16, 95% CI 0.02 to 1.29; very low-quality evidence). Active drain may reduce length of hospital stay slightly (MD -1.90 days, 95% CI -3.67 to -0.13; one study; low-quality evidence; 14.1% decrease of an 'average' length of hospital stay). Additional radiological interventions, pain, and quality of life were not reported in the study.Early versus late drain removalWe included one trial involving 114 participants with a low risk of postoperative pancreatic fistula, who were randomized to the early drain removal group (N = 57) and the late drain removal group (N = 57) after pancreatic surgery. There was no mortality in either group. Early drain removal may slightly reduce morbidity (38.6% with early drain removal versus 61.4% with late drain removal; RR 0.63, 95% CI 0.43 to 0.93; low-quality evidence), length of hospital stay (MD -2.10 days, 95% CI -4.17 to -0.03; low-quality evidence; 21.5% decrease of an 'average' length of hospital stay), and hospital costs (MD -EUR 2069.00, 95% CI -3872.26 to -265.74; low-quality evidence; 17.0% decrease of 'average' hospital costs). We were uncertain whether early drain removal reduced additional open procedures for postoperative complications (0% versus 1.8%; RR 0.33, 95% CI 0.01 to 8.01; one study; very low-quality evidence). Intra-abdominal infection, wound infection, additional radiological interventions, pain, and quality of life were not reported in the study. AUTHORS' CONCLUSIONS It was unclear whether routine abdominal drainage had any effect on the reduction of mortality at 30 days, or postoperative complications after pancreatic surgery. Moderate-quality evidence suggested that routine abdominal drainage probably slightly reduced mortality at 90 days. Low-quality evidence suggested that use of an active drain compared to the use of a passive drain may slightly reduce the length of hospital stay after pancreatic surgery, and early removal may be superior to late removal for people with low risk of postoperative pancreatic fistula.
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Affiliation(s)
- Wei Zhang
- The People's Hospital of Jianyang CityDepartment of Hepatopancreatobiliary SurgeryNo. 180, Hospital RoadJianyangSichuanChina641499
| | - Sirong He
- Chongqing Medical UniversityDepartment of Immunology, College of Basic MedicineNo. 1 Yixue RoadChongqingChina450000
| | - Yao Cheng
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
| | - Jie Xia
- Chongqing Medical UniversityThe Key Laboratory of Molecular Biology on Infectious DiseasesChongqingChina450000
| | - Mingliang Lai
- Jiangjin Central HospitalDepartment of Clinical LaboratoryNo. 65, Jiang Zhou RoadChongqingChina402260
| | - Nansheng Cheng
- West China Hospital, Sichuan UniversityDepartment of Bile Duct SurgeryNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Zuojin Liu
- The Second Affiliated Hospital, Chongqing Medical UniversityDepartment of Hepatobiliary SurgeryChongqingChina
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Edwards SJ, Crawford F, van Velthoven MH, Berardi A, Osei-Assibey G, Bacelar M, Salih F, Wakefield V. The use of fibrin sealant during non-emergency surgery: a systematic review of evidence of benefits and harms. Health Technol Assess 2018; 20:1-224. [PMID: 28051764 DOI: 10.3310/hta20940] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Fibrin sealants are used in different types of surgery to prevent the accumulation of post-operative fluid (seroma) or blood (haematoma) or to arrest haemorrhage (bleeding). However, there is uncertainty around the benefits and harms of fibrin sealant use. OBJECTIVES To systematically review the evidence on the benefits and harms of fibrin sealants in non-emergency surgery in adults. DATA SOURCES Electronic databases [MEDLINE, EMBASE and The Cochrane Library (including the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Health Technology Assessment database and the Cochrane Central Register of Controlled Trials)] were searched from inception to May 2015. The websites of regulatory bodies (the Medicines and Healthcare products Regulatory Agency, the European Medicines Agency and the Food and Drug Administration) were also searched to identify evidence of harms. REVIEW METHODS This review included randomised controlled trials (RCTs) and observational studies using any type of fibrin sealant compared with standard care in non-emergency surgery in adults. The primary outcome was risk of developing seroma and haematoma. Only RCTs were used to inform clinical effectiveness and both RCTs and observational studies were used for the assessment of harms related to the use of fibrin sealant. Two reviewers independently screened all titles and abstracts to identify potentially relevant studies. Data extraction was undertaken by one reviewer and validated by a second. The quality of included studies was assessed independently by two reviewers using the Cochrane Collaboration risk-of-bias tool for RCTs and the Centre for Reviews and Dissemination guidance for adverse events for observational studies. A fixed-effects model was used for meta-analysis. RESULTS We included 186 RCTs and eight observational studies across 14 surgical specialties and five reports from the regulatory bodies. Most RCTs were judged to be at an unclear risk of bias. Adverse events were inappropriately reported in observational studies. Meta-analysis across non-emergency surgical specialties did not show a statistically significant difference in the risk of seroma for fibrin sealants versus standard care in 32 RCTs analysed [n = 3472, odds ratio (OR) 0.84, 95% confidence interval (CI) 0.68 to 1.04; p = 0.13; I2 = 12.7%], but a statistically significant benefit was found on haematoma development in 24 RCTs (n = 2403, OR 0.62, 95% CI 0.44 to 0.86; p = 0.01; I2 = 0%). Adverse events related to fibrin sealant use were reported in 10 RCTs and eight observational studies across surgical specialties, and 22 RCTs explicitly stated that there were no adverse events. One RCT reported a single death but no other study reported mortality or any serious adverse events. Five regulatory body reports noted death from air emboli associated with fibrin sprays. LIMITATIONS It was not possible to provide a detailed evaluation of individual RCTs in their specific contexts because of the limited resources that were available for this research. In addition, the number of RCTs that were identified made it impractical to conduct independent data extraction by two reviewers in the time available. CONCLUSIONS The effectiveness of fibrin sealants does not appear to vary according to surgical procedures with regard to reducing the risk of seroma or haematoma. Surgeons should note the potential risk of gas embolism if spray application of fibrin sealants is used and not to exceed the recommended pressure and spraying distance. Future research should be carried out in surgery specialties for which only limited data were found, including neurological, gynaecological, oral and maxillofacial, urology, colorectal and orthopaedics surgery (for any outcome); breast surgery and upper gastrointestinal (development of haematoma); and cardiothoracic heart or lung surgery (reoperation rates). In addition, studies need to use adequate sample sizes, to blind participants and outcome assessors, and to follow reporting guidelines. STUDY REGISTRATION This study is registered as PROSPERO CRD42015020710. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Han X, Xu Z, Cao S, Zhao Y, Wu W. The effect of somatostatin analogues on postoperative outcomes following pancreatic surgery: A meta-analysis. PLoS One 2017; 12:e0188928. [PMID: 29211787 PMCID: PMC5718483 DOI: 10.1371/journal.pone.0188928] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 11/15/2017] [Indexed: 12/27/2022] Open
Abstract
Background Leakage from the pancreatic stump is a leading cause of morbidity following pancreatic surgery. It is essential to evaluate the effect of somatostatin analogues (SAs) following pancreatic surgery by analyzing all recent clinical trials. Data sources We performed a literature search in the Medline, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science databases up to May 29, 2016. Publication bias was assessed with Egger’s test. Study quality was assessed using the Jadad Composite Scale. Conclusions Twelve clinical trials involving 1703 patients from Jan 1st, 2000 to May 29th, 2016 were included in the study. With improvements in surgical management and peri-operative patient care, prophylactic use of somatostatin and its analogues reduced the overall incidence of pancreatic fistulas (RR 0.72, 95% CI 0.55–0.94; p = 0.02) and decreased the post-operative hospital stay after pancreatic surgery (the weighted mean difference was -1.06, 95% CI-1/88 to -0.23; p = 0.01). Other post-operative outcomes did not change significantly with the use of somatostatin analogues.
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Affiliation(s)
- Xianlin Han
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhiyan Xu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Shaobo Cao
- Department of Vascular Surgery, Wuhan Central Hospital, Tongji Medical College, Huazhong University of science and Technology, Wuhan, China
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Wenming Wu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- * E-mail:
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Kim SW, Kim JH. Low-dose radiation therapy for massive chylous leakage after subtotal gastrectomy. Radiat Oncol J 2017; 35:380-384. [PMID: 28881504 PMCID: PMC5769879 DOI: 10.3857/roj.2017.00178] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 04/12/2017] [Accepted: 04/13/2017] [Indexed: 12/11/2022] Open
Abstract
Massive chylous leakage is a rare postoperative complication that can prolong hospital stay and cause secondary morbidities. Conservative management strategies are the treatment of choice; however, radiation therapy (RT) can be used as an alternative for cases that are refractory to conservative treatment. Herein, we report a 69-year-old female patient who suffered from massive chylous leakage after subtotal gastrectomy. Due to persistent massive chylous leakage, she was scheduled to undergo low-dose RT. Radiation was delivered with a daily dose of 1 Gy, using an anterior-posterior and posterior-anterior beam arrangement. The clinical target volume encompassed the entire lymph node area of the D2 dissection. RT was completed at the total dose of 8 Gy because the amount of chylous leakage declined rapidly. Percutaneous drainage tube was removed after 3 days of RT. The patient did not complain of any symptoms related to massive chylous leakage 2 years after the completion of RT.
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Affiliation(s)
- Sang-Won Kim
- Department of Radiation Oncology, Konyang University College of Medicine, Daejeon, Korea
| | - Jung Hoon Kim
- Department of Radiation Oncology, Konyang University College of Medicine, Daejeon, Korea
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Randomized Controlled Trial of Pancreaticojejunostomy versus Stapler Closure of the Pancreatic Stump During Distal Pancreatectomy to Reduce Pancreatic Fistula. Ann Surg 2017; 264:180-7. [PMID: 26473652 PMCID: PMC4902322 DOI: 10.1097/sla.0000000000001395] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Objectives: The aim of this study was to evaluate in a multicenter randomized controlled trial (RCT) whether pancreaticojejunostomy (PJ) of pancreatic stump decreases the incidence of pancreatic fistula after distal pancreatectomy (DP) compared with stapler closure. Background: Several studies reported that PJ of pancreatic stump reduces the incidence of pancreatic fistula after DP. However, no RCT has confirmed the efficacy of PJ of pancreatic stump. Methods: One hundred thirty-six patients scheduled for DP were enrolled in this study between June 2011 and March 2014 at 6 high-volume surgical centers in Japan. Enrolled patients were randomized to either stapler closure or PJ. The primary endpoint was the incidence of pancreatic fistula based on the International Study Group on Pancreatic Fistula criteria. This RCT was registered with ClinicalTrials.gov (NCT01384617). Results: Sixty-one patients randomized to stapler and 62 patients randomized to PJ were analyzed by intention-to-treat. Pancreatic fistula occurred in 23 patients (37.7%) in the stapler closure group and 24 (38.7%) in the PJ group (P = 0.332) in intention-to-treat analysis. The incidence of clinically relevant pancreatic fistula (grade B or C) was 16.4% for stapler closure and 9.7% for PJ (P = 0.201). Mortality was zero in both groups. In a subgroup analysis for thickness of pancreas greater than 12 mm, the incidence of clinically relevant pancreatic fistula occurred in 22.2% of the patients in the stapler closure group and in 6.2% of the PJ group (P = 0.080). Conclusions: PJ of the pancreatic stump during DP does not reduce pancreatic fistula compared with stapler closure.
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Han IW, Kim H, Heo J, Oh MG, Choi YS, Lee SE, Lim CS. Excess intraoperative fluid volume administration is associated with pancreatic fistula after pancreaticoduodenectomy: A retrospective multicenter study. Medicine (Baltimore) 2017; 96:e6893. [PMID: 28562540 PMCID: PMC5459705 DOI: 10.1097/md.0000000000006893] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Recent studies on perioperative fluid administration in patients undergoing pancreaticoduodenectomy (PD) have suggested that increased fluid loads are associated with worse perioperative outcomes. The purpose of this study was to investigate the relationship between intraoperative fluid (IOF) administration and postoperative pancreatic fistula (POPF), and to determine additional risk factors affecting pancreatic fistula in patients undergoing PD.From 2005 to 2014, a total of 182 patients with various periampullary diseases after PD were reviewed retrospectively at Dongguk University Ilsan Hospital, Chung-Ang University Hospital, and Dongnam Institute of Radiological and Medical Sciences. Patients were assigned to high or low IOF groups based on more or less fluid administration for supplementation of estimated blood loss and maintenance volume (12.5 mL/kg/h) than planned, respectively. The associations between IOF administration, pancreatic fistula development, and perioperative outcomes were evaluated.A total of 98 patients were assigned to the high-IOF group, and 84 to the low-IOF group. Risk factors for pancreatic fistula after univariate analysis were assignment to the high-IOF group, higher preoperative serum hemoglobin level, ampullary or bile duct cancer, pylorus preserving PD, small pancreatic duct, duct-to-mucosa pancreatojejunostomy, use of a stent, and mesh application to pancreatojejunal anastomosis. Among these, assignment to the high-IOF group (hazard ratio [HR] = 5.501, 95% CI 1.624-18.632, P = .006) and a small (<4 mm) pancreatic duct (HR = 4.129, 95% CI 1.569-14.658, P = .035) were identified as independent risk factors for the development of pancreatic fistula after multivariate analysis. However, long-term survival rate did not differ according to IOF group or duct size.Excessive IOF volume administration is associated with an increased incidence of pancreatic fistula after pancreaticoduodenectomy.
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Affiliation(s)
- In Woong Han
- Department of Surgery, Dongguk University, College of Medicine, Gyeongju, Gyeongsang Province
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Hongbeom Kim
- Department of Surgery, Dongguk University, College of Medicine, Gyeongju, Gyeongsang Province
| | - JinSeok Heo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Min Gu Oh
- Department of Surgery, Dongguk University, College of Medicine, Gyeongju, Gyeongsang Province
| | - Yoo Shin Choi
- Department of Surgery, Chung-Ang University College of Medicine
| | - Seung Eun Lee
- Department of Surgery, Chung-Ang University College of Medicine
| | - Chang-Sup Lim
- Departments of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
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Shrikhande SV, Sivasanker M, Vollmer CM, Friess H, Besselink MG, Fingerhut A, Yeo CJ, Fernandez-delCastillo C, Dervenis C, Halloran C, Gouma DJ, Radenkovic D, Asbun HJ, Neoptolemos JP, Izbicki JR, Lillemoe KD, Conlon KC, Fernandez-Cruz L, Montorsi M, Bockhorn M, Adham M, Charnley R, Carter R, Hackert T, Hartwig W, Miao Y, Sarr M, Bassi C, Büchler MW. Pancreatic anastomosis after pancreatoduodenectomy: A position statement by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2017; 161:1221-1234. [PMID: 28027816 DOI: 10.1016/j.surg.2016.11.021] [Citation(s) in RCA: 164] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 11/02/2016] [Accepted: 11/13/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (grades B and C of the ISGPS definition) remains the most troublesome complication after pancreatoduodenectomy. The approach to management of the pancreatic remnant via some form of pancreatico-enteric anastomosis determines the incidence and severity of clinically relevant postoperative pancreatic fistula. Despite numerous trials comparing diverse pancreatico-enteric anastomosis techniques and other adjunctive strategies (pancreatic duct stenting, somatostatin analogues, etc), currently, there is no clear consensus regarding the ideal method of pancreatico-enteric anastomosis. METHODS An international panel of pancreatic surgeons working in well-known, high-volume centers reviewed the best contemporary literature concerning pancreatico-enteric anastomosis and worked to develop a position statement on pancreatic anastomosis after pancreatoduodenectomy. RESULTS There is inherent risk assumed by creating a pancreatico-enteric anastomosis based on factors related to the gland (eg, parenchymal texture, disease pathology). None of the technical variations of pancreaticojejunal or pancreaticogastric anastomosis, such as duct-mucosa, invagination method, and binding technique, have been found to be consistently superior to another. Randomized trials and meta-analyses comparing pancreaticogastrostomy versus pancreaticojejunostomy yield conflicting results and are inherently prone to bias due to marked heterogeneity in the studies. The benefit of stenting the pancreatico-enteric anastomosis to decrease clinically relevant postoperative pancreatic fistula is not supported by high-level evidence. While controversial, somatostatin analogues appear to decrease perioperative complications but not mortality, although consistent data across the more than 20 studies addressing this topic are lacking. The Fistula Risk Score is useful for predicting postoperative pancreatic fistula as well as for comparing outcomes of pancreatico-enteric anastomosis across studies. CONCLUSION Currently, no specific technique can eliminate development of clinically relevant postoperative pancreatic fistula. While consistent practice of any standardized technique may decrease the rate of clinically relevant postoperative pancreatic fistula, experienced surgeons can have lower postoperative pancreatic fistula rates performing a variety of techniques depending on the clinical situation. There is no clear evidence on the benefit of internal or external stenting after pancreatico-enteric anastomosis. The use of somatostatin analogues may be important in decreasing morbidity after pancreatoduodenectomy, but it remains controversial. Future studies should focus on novel approaches to decrease the rate of clinically relevant postoperative pancreatic fistula with appropriate risk adjustment.
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Affiliation(s)
- Shailesh V Shrikhande
- Department of Gastrointestinal and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India.
| | - Masillamany Sivasanker
- Department of Gastrointestinal and HPB Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | | | - Helmut Friess
- Department of Surgery, Klinikum Rechts der Isar, Technische Universitat Munchen, Munich, Germany
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Abe Fingerhut
- Department of Digestive Surgery, University Hospital of Graz, Austria
| | - Charles J Yeo
- Department of Surgery, Jefferson Pancreas, Biliary and Related Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | | | | | - Christoper Halloran
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Dirk J Gouma
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Dejan Radenkovic
- First Surgical Clinic, Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
| | - Horacio J Asbun
- Department of General Surgery, Mayo Clinic, Jacksonville, FL
| | - John P Neoptolemos
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kevin C Conlon
- Professorial Surgical Unit, University of Dublin, Trinity College, Dublin, Ireland
| | - Laureano Fernandez-Cruz
- Department of Surgery, Clinic Hospital of Barcelona, University of Barcelona, Barcelona, Spain
| | - Marco Montorsi
- Department of Surgery, Humanitas University, Milan, Italy
| | - Max Bockhorn
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Mustapha Adham
- Department of Digestive & HPB Surgery, Hopital Edouard Herriot, HCL, UCBL1, Lyon, France
| | - Richard Charnley
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Ross Carter
- Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Werner Hartwig
- Department of Surgery, Klinikum Großhadern, University of Munich, Munich, Germany
| | - Yi Miao
- Pancreas Center, Nanjing Medical University, Nanjing, P.R. China
| | - Michael Sarr
- Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN
| | - Claudio Bassi
- Department of Surgery and Oncology, Pancreas Institute, University Hospital Trust of Verona, Verona, Italy
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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Shubert CR, Ferrone CR, Fernandez-del Castillo C, Kendrick ML, Farnell MB, Smoot RL, Truty MJ, Que FG. A multicenter randomized controlled trial comparing pancreatic leaks after TissueLink versus SEAMGUARD after distal pancreatectomy (PLATS) NCT01051856. J Surg Res 2016; 206:32-40. [DOI: 10.1016/j.jss.2016.06.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 05/06/2016] [Accepted: 06/10/2016] [Indexed: 10/21/2022]
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Abstract
BACKGROUND The use of surgical drains has been considered mandatory after pancreatic surgery. The role of prophylactic abdominal drainage to reduce postoperative complications after pancreatic surgery is controversial. OBJECTIVES To assess the benefits and harms of routine abdominal drainage after pancreatic surgery, compare the effects of different types of surgical drains, and evaluate the optimal time for drain removal. SEARCH METHODS For the initial version of this review, we searched the Cochrane Library (2015, Issue 3), MEDLINE (1946 to 9 April 2015), Embase (1980 to 9 April 2015), Science Citation Index Expanded (1900 to 9 April 2015), and Chinese Biomedical Literature Database (CBM) (1978 to 9 April 2015). For this updated review, we searched the Cochrane Library, MEDLINE, Embase, Science Citation Index Expanded, and CBM from 2015 to 28 August 2016. SELECTION CRITERIA We included all randomized controlled trials that compared abdominal drainage versus no drainage in people undergoing pancreatic surgery. We also included randomized controlled trials that compared different types of drains and different schedules for drain removal in people undergoing pancreatic surgery. DATA COLLECTION AND ANALYSIS We identified five trials (of 985 participants) which met our inclusion criteria. Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). For all analyses, we employed the random-effects model. MAIN RESULTS Drain use versus no drain useWe included three trials involving 711 participants who were randomized to the drainage group (N = 358) and the no drainage group (N = 353) after pancreatic surgery. There was inadequate evidence to establish the effect of drains on mortality at 30 days (2.2% with drains versus 3.4% no drains; RR 0.78, 95% CI 0.31 to 1.99; three studies; low-quality evidence), mortality at 90 days (2.9% versus 11.6%; RR 0.24, 95% CI 0.05 to 1.10; one study; low-quality evidence), intra-abdominal infection (7.3% versus 8.5%; RR 0.89, 95% CI 0.36 to 2.20; three studies; very low-quality evidence), wound infection (12.3% versus 13.3%; RR 0.92, 95% CI 0.63 to 1.36; three studies; low-quality evidence), morbidity (64.8% versus 62.0%; RR 1.04, 95% CI 0.93 to 1.16; three studies; moderate-quality evidence), length of hospital stay (MD -0.66 days, 95% CI -1.60 to 0.29; three studies; moderate-quality evidence), or additional open procedures for postoperative complications (11.5% versus 9.1%; RR 1.18, 95% CI 0.55 to 2.52; three studies). There was one drain-related complication in the drainage group (0.6%). Type of drainWe included one trial involving 160 participants who were randomized to the active drain group (N = 82) and the passive drain group (N = 78) after pancreatic surgery. There was no evidence of differences between the two groups in mortality at 30 days (1.2% with active drain versus 0% with passive drain), intra-abdominal infection (0% versus 2.6%), wound infection (6.1% versus 9.0%; RR 0.68, 95% CI 0.23 to 2.05), morbidity (22.0% versus 32.1%; RR 0.68, 95% CI 0.41 to 1.15), or additional open procedures for postoperative complications (1.2% versus 7.7%; RR 0.16, 95% CI 0.02 to 1.29). The active drain group was associated with shorter length of hospital stay (MD -1.90 days, 95% CI -3.67 to -0.13; 14.1% decrease of an 'average' length of hospital stay) than in the passive drain group. The quality of evidence was low, or very low. Early versus late drain removalWe included one trial involving 114 participants with a low risk of postoperative pancreatic fistula who were randomized to the early drain removal group (N = 57) and the late drain removal group (N = 57) after pancreatic surgery. There was no evidence of differences between the two groups in mortality at 30 days (0% for both groups) or additional open procedures for postoperative complications (0% with early drain removal versus 1.8% with late drain removal; RR 0.33, 95% CI 0.01 to 8.01). The early drain removal group was associated with lower rates of postoperative complications (38.5% versus 61.4%; RR 0.63, 95% CI 0.43 to 0.93), shorter length of hospital stay (MD -2.10 days, 95% CI -4.17 to -0.03; 21.5% decrease of an 'average' length of hospital stay), and hospital costs (17.0% decrease of 'average' hospital costs) than in the late drain removal group. The quality of evidence for each of the outcomes was low. AUTHORS' CONCLUSIONS It is unclear whether routine abdominal drainage has any effect on the reduction of mortality and postoperative complications after pancreatic surgery. In case of drain insertion, low-quality evidence suggests that active drainage may reduce hospital stay after pancreatic surgery, and early removal may be superior to late removal for people with low risk of postoperative pancreatic fistula.
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Affiliation(s)
| | - Jie Xia
- Chongqing Medical UniversityThe Key Laboratory of Molecular Biology on Infectious DiseasesChongqingChina450000
| | - Mingliang Lai
- Jiangjin Central HospitalDepartment of Clinical LaboratoryNo. 65, Jiang Zhou RoadChongqingChina402260
| | - Nansheng Cheng
- West China Hospital, Sichuan UniversityDepartment of Bile Duct SurgeryNo. 37, Guo Xue XiangChengduChina610041
| | - Sirong He
- Chongqing Medical UniversityDepartment of Immunology, College of Basic MedicineNo.1 Yixue RoadChongqingChina450000
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Laparoscopic Left Pancreatectomy in the United Kingdom: Analysis of a Six-Year Experience in a Single Tertiary Center. Pancreas 2016; 45:1204-7. [PMID: 26784910 DOI: 10.1097/mpa.0000000000000605] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVES Laparoscopic techniques have been slow to establish a role in pancreatic surgery. Worldwide, laparoscopic left pancreatectomy (LLP) is gaining in popularity; however, there remains little published data from the United Kingdom.We aimed to evaluate the results of LLP performed in a single UK pancreatic unit. METHODS Patients undergoing LLP for lesions in the body and tail of the pancreas between April 2009 and April 2015 were identified. Patient records were reviewed retrospectively. RESULTS Laparoscopic left pancreatectomy was performed on 46 patients, median age, 62 years (range, 19-84). The spleen was preserved in 27 patients (93% of planned), and 6 (13%) operations were converted to open. The overall morbidity rate was 39%; 28 patients had no complications. Significant complications were seen in 7 (15%) patients; this included 3 pancreatic fistula (6.5%) and 1 mortality (2%). Median length of stay was 6 days (range, 3-28). Histology revealed 15 neuroendocrine tumors, 8 adenocarcinomas, 4 mucinous cystadenomas, 1 intraductal papillary mucinous neoplasm, 2 metastases, and 16 other benign pathologies. CONCLUSIONS Laparoscopic pancreatic surgery has a low risk of significant complications. Our results offer encouragement to identify LLP as the gold standard approach for premalignant lesions. Further work should clarify the outcomes for malignant lesions.
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Roberts KJ, Karkhanis S, Pitchaimuthu M, Khan MS, Hodson J, Zia Z, Mehrzad H, Marudanayagam R, Muiesan P, Isaac J, Mirza D, Sutcliffe RP. Comparison of preoperative CT-based imaging parameters to predict postoperative pancreatic fistula. Clin Radiol 2016; 71:986-992. [PMID: 27426676 DOI: 10.1016/j.crad.2016.06.108] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 06/04/2016] [Accepted: 06/08/2016] [Indexed: 12/12/2022]
Abstract
AIM To review all reported methods of preoperative computed tomography (CT) in one patient cohort and to identify which were the strongest to predict postoperative pancreatic fistula (POPF) after pancreatoduodenectomy. MATERIALS AND METHODS Consecutive patients undergoing pancreatoduodenectomy were included if they had unenhanced CT images for review. Eighteen variables and two scores were tested. Receiver operator characteristics (ROC) were explored. RESULTS POPF affected 26 of 107 patients (24.3%). Nine variables were significantly related to POPF with pancreatic duct width having the largest area under the ROC curve (AUROC; 0.808, p<0.001). An obese body habitus was associated with POPF with six of nine related variables using data from CT images associated with POPF; of these intra-abdominal wall thickness yielded the largest AUROC (0.713, p=0.001). This corresponded to the finding that body mass index (BMI) was related to POPF (AUROC 0.705, p=0.002). The largest AUROC of all was associated with one of the predictive scores (0.828, p<0.001). Substituting BMI for intra-abdominal wall thickness in this score yielded a non-significant increase to predict POPF (AUROC 0.840, p=0.676). None of the assessments of organ density (in Hounsfield Units) were associated with POPF. CONCLUSION Data from preoperative CT imaging provides valuable information regarding a patient's risk of POPF. Obesity as assessed by CT images strongly relates to POPF, but the largest single risk factor for POPF is a narrow pancreatic duct.
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Affiliation(s)
- K J Roberts
- Department of HPB Surgery, University Hospitals Birmingham NHS Trust, Edgbaston B15 2TH, UK
| | - S Karkhanis
- Department of HPB Surgery, University Hospitals Birmingham NHS Trust, Edgbaston B15 2TH, UK.
| | - M Pitchaimuthu
- Department of HPB Surgery, University Hospitals Birmingham NHS Trust, Edgbaston B15 2TH, UK
| | - M S Khan
- Department of HPB Surgery, University Hospitals Birmingham NHS Trust, Edgbaston B15 2TH, UK
| | - J Hodson
- Department of HPB Surgery, University Hospitals Birmingham NHS Trust, Edgbaston B15 2TH, UK
| | - Z Zia
- Department of HPB Surgery, University Hospitals Birmingham NHS Trust, Edgbaston B15 2TH, UK
| | - H Mehrzad
- Department of HPB Surgery, University Hospitals Birmingham NHS Trust, Edgbaston B15 2TH, UK
| | - R Marudanayagam
- Department of HPB Surgery, University Hospitals Birmingham NHS Trust, Edgbaston B15 2TH, UK
| | - P Muiesan
- Department of HPB Surgery, University Hospitals Birmingham NHS Trust, Edgbaston B15 2TH, UK
| | - J Isaac
- Department of HPB Surgery, University Hospitals Birmingham NHS Trust, Edgbaston B15 2TH, UK
| | - D Mirza
- Department of HPB Surgery, University Hospitals Birmingham NHS Trust, Edgbaston B15 2TH, UK
| | - R P Sutcliffe
- Department of HPB Surgery, University Hospitals Birmingham NHS Trust, Edgbaston B15 2TH, UK
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Kollár D, Huszár T, Pohárnok Z, Cselovszky É, Oláh A. A Review of Techniques for Closure of the Pancreatic Remnant following Distal Pancreatectomy. Dig Surg 2016; 33:320-8. [PMID: 27215609 DOI: 10.1159/000445017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
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.
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Affiliation(s)
- Dániel Kollár
- Department of Surgery, Petz Aladx00E1;r Teaching Hospital, Gyx0151;r, Hungary
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Scoring System to Predict Pancreatic Fistula After Pancreaticoduodenectomy: A UK Multicenter Study. Ann Surg 2016; 261:1191-7. [PMID: 25371115 DOI: 10.1097/sla.0000000000000997] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To validate a preoperative predictive score of postoperative pancreatic fistula (POPF). Other risk factors for POPF were sought in an attempt to improve the score. BACKGROUND POPF is the major contributor to morbidity after pancreaticoduodenectomy (PD). A preoperative score [using body mass index (BMI) and pancreatic duct width] to predict POPF was tested upon a multicenter patient cohort to assess its performance. METHODS Patients undergoing PD at 8 UK centers were identified. The association between the score and other pre-, intra-, and postoperative variables with POPF was assessed. RESULTS A total of 630 patients underwent PD with 141 occurrences of POPF (22.4%). BMI, perirenal fat thickness, pancreatic duct width on computed tomography and at operation, bilirubin, pancreatojejunostomy technique, underlying pathology, T stage, N stage, R status, and gland firmness were all significantly associated with POPF. The score predicted POPF (P < 0.001) with a higher predictive score associated with increasing severity of POPF (P < 0.001). Stepwise multivariate analysis of pre-, intra-, and postoperative variables demonstrated that only the score was consistently associated with POPF. A table correlating the risk score to actual risk of POPF was created. CONCLUSIONS The predictive score performed well and could not be improved. This provides opportunities for individualizing patient consent and selection, and treatment and research applications.
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Kitahata Y, Kawai M, Yamaue H. Clinical trials to reduce pancreatic fistula after pancreatic surgery-review of randomized controlled trials. Transl Gastroenterol Hepatol 2016; 1:4. [PMID: 28138572 DOI: 10.21037/tgh.2016.03.19] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 03/01/2016] [Indexed: 12/17/2022] Open
Abstract
Pancreatic fistula is one of severe postoperative complications that occur after pancreatic surgery, such as pancreaticoduodenectomy (PD) and distal pancreatectomy (DP). Because pancreatic fistula is associated with a higher incidence of life-threatening complications. In order to evaluate procedure or postoperative management to reduce pancreatic fistula after pancreatic surgery, we summarized some randomized controlled trials (RCTs) regarding pancreaticoenterostomy during PD, pancreatic duct stent during PD, procedure to resect pancreatic parenchyma during DP, and somatostatin and somatostatin analogues after pancreatic surgery. At first, we reviewed nine RCTs to compare pancreaticogastrostomy (PG) with pancreaticojejunostomy (PJ) during PD. Next, we reviewed five RCTs, to evaluate the impact of pancreatic duct stent during PD. Regarding DP, we reviewed six RCTs to evaluate appropriate procedure to reduce pancreatic fistula after DP. Finally, we reviewed eight RCTs to evaluate the impact of somatostatin and somatostatin analogues after pancreatic surgery to reduce pancreatic fistula. The best way to prevent pancreatic fistula after pancreatic surgery remains still controversial. However, several RCTs clarify a useful procedure to reduce in reducing the incidence of pancreatic fistula after pancreatic surgery. Further RCTs to study innovative approaches remain a high priority for pancreatic surgeons to prevent pancreatic fistula after pancreatic surgery.
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Affiliation(s)
- Yuji Kitahata
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Manabu Kawai
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
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Cheng Y, Ye M, Xiong X, Peng S, Wu HM, Cheng N, Gong J. Fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery. Cochrane Database Syst Rev 2016; 2:CD009621. [PMID: 26876721 DOI: 10.1002/14651858.cd009621.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula is one of the most frequent and potentially life-threatening complications following pancreatic resections. Fibrin sealants are introduced to reduce postoperative pancreatic fistula by some surgeons. However, the use of fibrin sealants during pancreatic surgery is controversial. OBJECTIVES To assess the safety, effectiveness, and potential adverse effects of fibrin sealants for the prevention of postoperative pancreatic fistula following pancreatic surgery. SEARCH METHODS We searched The Cochrane Library (2015, Issue 7), MEDLINE (1946 to 26 August 2015), EMBASE (1980 to 26 August 2015), Science Citation Index Expanded (1900 to 26 August 2015), and Chinese Biomedical Literature Database (CBM) (1978 to 26 August 2015). SELECTION CRITERIA We included all randomized controlled trials that compared fibrin sealant group (fibrin glue or fibrin sealant patch) versus control group (no fibrin sealant or placebo) in people undergoing pancreatic surgery. DATA COLLECTION AND ANALYSIS Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes (or a Peto odds ratio for very rare outcomes), and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). MAIN RESULTS We included nine trials involving 1095 participants who were randomized to the fibrin sealant group (N = 550) and the control group (N = 545) after pancreatic surgery. All of the trials were at high risk of bias. There was no evidence of differences in overall postoperative pancreatic fistula (fibrin sealant 29.6%; control 31.0%; RR 0.93, 95% CI 0.71 to 1.21; P = 0.58; nine studies; low-quality evidence), postoperative mortality (3.1% versus 2.1%; Peto OR 1.29, 95% CI 0.59 to 2.82; P = 0.53; eight studies; very low-quality evidence), overall postoperative morbidity (29.6% versus 28.9%; RR 1.04, 95% CI 0.82 to 1.32; P = 0.77; five studies), reoperation rate (8.7% versus 10.7%; RR 0.80, 95% CI 0.53 to 1.21; P = 0.29; five studies), or length of hospital stay (12.9 days versus 13.1 days; MD -0.73 days, 95% CI -2.20 to 0.74; P = 0.331; six studies) between the groups. The proportion of postoperative pancreatic fistula that was clinically significant was not mentioned in most trials. On inclusion of trials that clearly distinguished clinically significant fistulas, there was inadequate evidence to establish the effect of fibrin sealants on clinically significant postoperative pancreatic fistula (9.4% versus 13.4%; RR 0.72, 95% CI 0.42 to 1.21; P = 0.21; three studies). Quality of life and cost effectiveness were not reported in any of the trials. AUTHORS' CONCLUSIONS Based on the current available evidence, fibrin sealants do not seem to prevent postoperative pancreatic fistula in people undergoing pancreatic surgery.
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Affiliation(s)
- Yao Cheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital, Chongqing Medical University, No. 74, Lin Jiang Road, Chongqing, Chongqing, China, 400010
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Hu BY, Leng JJ, Wan T, Zhang WZ. Application of single-layer mucosa-to-mucosa pancreaticojejunal anastomosis in pancreaticoduodenectomy. World J Gastrointest Surg 2015; 7:335-344. [PMID: 26649157 PMCID: PMC4663388 DOI: 10.4240/wjgs.v7.i11.335] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 08/25/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the simplicity, reliability, and safety of the application of single-layer mucosa-to-mucosa pancreaticojejunal anastomosis in pancreaticoduodenectomy.
METHODS: A retrospective analysis was performed on the data of patients who received pancreaticoduodenectomy completed by the same surgical group between January 2011 and April 2014 in the General Hospital of the People’s Liberation Army. In total, 51 cases received single-layer mucosa-to-mucosa pancreaticojejunal anastomosis and 51 cases received double-layer pancreaticojejunal anastomosis. The diagnoses of pancreatic fistula and clinically relevant pancreatic fistula after pancreaticoduodenectomy were judged strictly by the International Study Group on pancreatic fistula definition. The preoperative and intraoperative data of these two groups were compared. χ2 test and Fisher’s exact test were used to analyze the incidences of pancreatic fistula, peritoneal catheterization, abdominal infection and overall complications between the single-layer anastomosis group and double-layer anastomosis group. Rank sum test were used to analyze the difference in operation time, pancreaticojejunal anastomosis time, postoperative hospitalization time, total hospitalization time and hospitalization expenses between the single-layer anastomosis group and double-layer anastomosis group.
RESULTS: Patients with grade A pancreatic fistula accounted for 15.69% (8/51) vs 15.69% (8/51) (P = 1.0000), and patients with grades B and C pancreatic fistula accounted for 9.80% (5/51) vs 52.94% (27/51) (P = 0.0000) in the single-layer and double-layer anastomosis groups. Although there was no significant difference in the percentage of patients with grade A pancreatic fistula, there was a significant difference in the percentage of patients with grades B and C pancreatic fistula between the two groups. The operation time (220.059 ± 60.602 min vs 379.412 ± 90.761 min, P = 0.000), pancreaticojejunal anastomosis time (17.922 ± 5.145 min vs 31.333 ± 7.776 min, P = 0.000), postoperative hospitalization time (18.588 ± 5.285 d vs 26.373 ± 15.815 d, P = 0.003), total hospitalization time (25.627 ± 6.551 d vs 33.706 ± 15.899 d, P = 0.002), hospitalization expenses (116787.667 ± 31900.927 yuan vs 162788.608 ± 129732.500 yuan, P = 0.001), as well as the incidences of pancreatic fistula [13/51 (25.49%) vs 35/51 (68.63%), P = 0.0000], peritoneal catheterization [0/51 (0%) vs 6/51 (11.76%), P = 0.0354], abdominal infection [1/51 (1.96%) vs 11/51 (21.57%), P = 0.0021], and overall complications [21/51 (41.18%) vs 37/51 (72.55%), P = 0.0014] in the single-layer anastomosis group were all lower than those in the double-layer anastomosis group.
CONCLUSION: Single-layer mucosa-to-mucosa pancreaticojejunal anastomosis appears to be a simple, reliable, and safe method. Use of this method could reduce the postoperative incidence of complications.
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Vallance AE, Young AL, Macutkiewicz C, Roberts KJ, Smith AM. Calculating the risk of a pancreatic fistula after a pancreaticoduodenectomy: a systematic review. HPB (Oxford) 2015; 17:1040-8. [PMID: 26456948 PMCID: PMC4605344 DOI: 10.1111/hpb.12503] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 07/16/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND A post-operative pancreatic fistula (POPF) is a major cause of morbidity and mortality after a pancreaticoduodenectomy (PD). This systematic review aimed to identify all scoring systems to predict POPF after a PD, consider their clinical applicability and assess the study quality. METHOD An electronic search was performed of Medline (1946-2014) and EMBASE (1996-2014) databases. Results were screened according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and quality assessed according to the QUIPS (quality in prognostic studies) tool. RESULTS Six eligible scoring systems were identified. Five studies used the International Study Group on Pancreatic Fistula (ISGPF) definition. The proposed scores feature between two and five variables and of the 16 total variables, the majority (12) featured in only one score. Three scores could be fully completed pre-operatively whereas 1 score included intra-operative and two studies post-operative variables. Four scores were internally validated and of these, two scores have been subject to subsequent multicentre review. The median QUIPS score was 38 out of 50 (range 16-50). CONCLUSION These scores show potential in calculating the individualized patient risk of POPF. There is, however, much variation in current scoring systems and further validation in large multicentre cohorts is now needed.
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Affiliation(s)
| | | | | | - Keith J Roberts
- University Hospitals Birmingham NHS Foundation TrustBirmingham, UK
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Peng S, Cheng Y, Yang C, Lu J, Wu S, Zhou R, Cheng N. Prophylactic abdominal drainage for pancreatic surgery. Cochrane Database Syst Rev 2015:CD010583. [PMID: 26292656 DOI: 10.1002/14651858.cd010583.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The use of surgical drains has been considered mandatory after pancreatic surgery. The role of prophylactic abdominal drainage to reduce postoperative complications after pancreatic surgery is controversial. OBJECTIVES To assess the benefits and harms of routine abdominal drainage after pancreatic surgery, compare the effects of different types of surgical drains, and evaluate the optimal time for drain removal. SEARCH METHODS We searched The Cochrane Library (2015, Issue 3), MEDLINE (1946 to 9 April 2015), EMBASE (1980 to 9 April 2015), Science Citation Index Expanded (1900 to 9 April 2015), and Chinese Biomedical Literature Database (CBM) (1978 to 9 April 2015). SELECTION CRITERIA We included all randomized controlled trials that compared abdominal drainage versus no drainage in patients undergoing pancreatic surgery. We also included randomized controlled trials that compared different types of drains and different schedules for drain removal in patients undergoing pancreatic surgery. DATA COLLECTION AND ANALYSIS Two review authors independently identified the trials for inclusion, collected the data, and assessed the risk of bias. We performed the meta-analyses using Review Manager 5. We calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). For all analyses, we employed the random-effects model. MAIN RESULTS Drain use versus no drain useWe included two trials involving 316 participants who were randomized to the drainage group (N = 156) and the no drainage group (N = 160) after pancreatic surgery. Both trials were at high risk of bias. There was inadequate evidence to establish the effect of drains on mortality at 30 days (drains 1.3%; no drains 3.8%; RR 0.44; 95% CI 0.05 to 3.94; two studies; very low-quality evidence), mortality at 90 days (2.9% versus 11.6%; RR 0.24; 95% CI 0.05 to 1.10; one study; very low-quality evidence), intra-abdominal infection (8.3% versus 14.4%; RR 0.61; 95% CI 0.25 to 1.46; two studies), wound infection (10.9% versus 11.9%; RR 0.91; 95% CI 0.45 to 1.86; two studies), morbidity (67.3% versus 65.0%; RR 1.02; 95% CI 0.88 to 1.19; two studies), length of hospital stay (MD -0.97 days; 95% CI -1.41 to -0.53; two studies), or additional open procedures for postoperative complications (6.3% versus 6.4%; RR 0.90, 95% CI 0.15 to 5.32; two studies). There was one drain-related complication in the drainage group (0.6%). The quality of evidence was low, or very low. Type of drainThere were no randomized controlled trials comparing one type of drain versus another. Early versus late drain removalWe included one trial involving 114 participants with a low risk of postoperative pancreatic fistula who were randomized to the early drain removal group (N = 57) and the late drain removal group (N = 57) after pancreatic surgery. The trial was at high risk of bias. There was no evidence of differences between the two groups in the mortality at 30 days (0% for both groups) or additional open procedures for postoperative complications (0% versus 1.8%; RR 0.33; 95% CI 0.01 to 8.01). The early drain removal group was associated with lower rates of postoperative complications (38.5% versus 61.4%; RR 0.63; 95% CI 0.43 to 0.93), shorter length of hospital stay (MD -2.10 days; 95% CI -4.17 to -0.03; 21.5% decrease of an 'average' length of hospital stay) and hospital costs (17.0% decrease of 'average' hospital costs) than in the late drain removal group. The quality of evidence for each of the outcomes was low. AUTHORS' CONCLUSIONS It is not clear whether routine abdominal drainage has any effect on the reduction of mortality and postoperative complications after pancreatic surgery. In case of drain insertion, low-quality evidence suggests that early removal may be superior to late removal for patients with low risk of postoperative pancreatic fistula.
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Affiliation(s)
- Su Peng
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan, China, 610041
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Sandini M, Bernasconi DP, Ippolito D, Nespoli L, Baini M, Barbaro S, Fior D, Gianotti L. Preoperative Computed Tomography to Predict and Stratify the Risk of Severe Pancreatic Fistula After Pancreatoduodenectomy. Medicine (Baltimore) 2015; 94:e1152. [PMID: 26252274 PMCID: PMC4616578 DOI: 10.1097/md.0000000000001152] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 05/26/2015] [Accepted: 06/21/2015] [Indexed: 02/05/2023] Open
Abstract
The aim of this article is to assess whether measures of abdominal fat distribution, visceral density, and antropometric parameters obtained from computed tomography (CT) may predict postoperative pancreatic fistula (POPF) occurrence.We analyzed 117 patients who underwent pancreatoduodenectomy (PD) and had a preoperative CT scan as staging in our center. CT images were processed to obtain measures of total fat volume (TFV), visceral fat volume (VFV), density of spleen, and pancreas, and diameter of pancreatic duct. The predictive ability of each parameter was investigated by receiver-operating characteristic (ROC) curves methodology and assessing optimal cutoff thresholds. A stepwise selection method was used to determine the best predictive model.Clinically relevant (grades B and C) POPF occurred in 24 patients (20.5%). Areas under ROC-curves showed that none of the parameters was per se significantly predictive. The multivariate analysis revealed that a VFV >2334 cm, TFV >4408 cm, pancreas/spleen density ratio <0.707, and pancreatic duct diameter <5 mm were predictive of POPF. The risk of POPF progressively increased with the number of factors involved and age.It is possible to deduce objective information on the risk of POPF from a simple and routine preoperative radiologic workup.
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Affiliation(s)
- Marta Sandini
- From the Department of Surgery and Translational Medicine (MS, LN, MB, SB, LG), Milano-Bicocca University, San Gerardo Hospital; Department of Health Sciences (DPB), Center of Biostatistics for Clinical Epidemiology, Milano-Bicocca University; Department of Radiology (DI, DF), San Gerardo Hospital, Monza, Italy; and International Research Center in Hepato-Biliary-Pancreatic Diseases, Monza, Italy (LG)
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Anderson R, Dunki-Jacobs E, Burnett N, Scoggins C, McMasters K, Martin RCG. A cost analysis of somatostatin use in the prevention of pancreatic fistula after pancreatectomy. World J Surg 2015; 38:2138-44. [PMID: 24663483 DOI: 10.1007/s00268-014-2512-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Studies have shown that somatostatin reduces the occurrence of postoperative pancreatic fistula. However, no study to date has analyzed the cost effectiveness of this treatment. The purpose of this study was to analyze the cost effectiveness of prophylactic somatostatin use with respect to pancreatectomy. METHODS Review of prospectively collected 2002 patient hepato-pancreatico-biliary database from January 2007 to May 2012. Patients received somatostatin prophylactically at the discretion of their surgeon. Data were analyzed using univariate analysis to determine if somatostatin had an effect on imaging costs, lab costs, "other" costs, PT/OT costs, surgery costs, room and board costs, and total hospital costs. RESULTS A total of 179 patients underwent pancreatectomy at a single teaching institution. Median total hospital costs were 90,673.50 (59,979-743,667) for patients who developed a postoperative pancreatic fistula versus 86,563 (39,190-463,601) for those who did not (p = 0.004). Median total hospital costs were 89,369 (39,190-743,667) for patients who were administered somatostatin versus 85,291 (40,092-463,601) for patients who did not (p = 0.821). CONCLUSIONS Pancreatic fistulas significantly increase hospital costs, and somatostatin has been shown to decrease the rate of pancreatic fistula formation. Somatostatin has no significant effect on hospital costs.
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Affiliation(s)
- R Anderson
- Department of Surgery, Division of Surgical Oncology, University of Louisville School of Medicine, 315 E. Broadway - #312, Louisville, KY, 40202, USA
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An analysis of risk factors for pancreatic fistula after robotic pancreaticoduodenectomy: outcomes from a consecutive series of standardized pancreatic reconstructions. Surg Endosc 2015; 30:1523-9. [DOI: 10.1007/s00464-015-4366-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 06/15/2015] [Indexed: 12/18/2022]
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Sánchez Cabús S, Fernández-Cruz L. [Surgery for pancreatic cancer: Evidence-based surgical strategies]. Cir Esp 2015; 93:423-35. [PMID: 25957457 DOI: 10.1016/j.ciresp.2015.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 03/27/2015] [Indexed: 11/29/2022]
Abstract
Pancreatic cancer surgery represents a challenge for surgeons due to its technical complexity, the potential complications that may appear, and ultimately because of its poor survival. The aim of this article is to summarize the scientific evidence regarding the surgical treatment of pancreatic cancer in order to help surgeons in the decision making process in the management of these patients .Here we will review such fundamental issues as the need for a biopsy before surgery, the type of pancreatic anastomosis leading to better results, and the need for placement of drains after pancreatic surgery will be discussed.
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Jin K, Zhou H, Zhang J, Wang W, Sun Y, Ruan C, Hu Z, Wang Y. Systematic review and meta-analysis of somatostatin analogues in the prevention of postoperative complication after pancreaticoduodenectomy. Dig Surg 2015; 32:196-207. [PMID: 25872003 DOI: 10.1159/000381032] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Accepted: 02/15/2015] [Indexed: 01/04/2023]
Abstract
BACKGROUND The use of somatostatin analogues (SAs) following pancreaticoduodenectomy (PD) is controversial. METHOD Literature databases were searched systematically for relevant articles. A meta-analysis of all randomized controlled trials (RCTs) evaluating prophylactic SAs in PD was performed. RESULTS Fifteen RCTs involving 1,352 patients were included. There was a towards reduced incidences of pancreatic fistulas (p = 0.26), clinically significant pancreatic fistulas (p = 0.08), and bleeding (p = 0.05) in prophylactic SAs group. In subgroup analyses, prophylactic somatostatin significantly reduced the incidence of pancreatic fistulas(p = 0.02), with a nonsignificant trend toward reduced incidence of clinically significantly pancreatic fistulas (p = 0.06).Pasireotide significantly reduced the incidence of clinically significantly pancreatic fistulas (p = 0.03). Octreotide had no influence on the incidence of pancreatic fistulas. CONCLUSION The current best evidence suggests prophylactic treatment with somatostatin or pasireotide has a potential role in reducing the incidence of pancreatic fistulas, while octreotide had no influence on the incidence of pancreatic fistulas.High-quality RCTs assessing the role of somatostatin and pasireotide are required for further verification.
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Zovak M, Mužina Mišić D, Glavčić G. Pancreatic surgery: evolution and current tailored approach. Hepatobiliary Surg Nutr 2014; 3:247-58. [PMID: 25392836 DOI: 10.3978/j.issn.2304-3881.2014.09.06] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 08/21/2014] [Indexed: 12/17/2022]
Abstract
Surgical resection of pancreatic cancer offers the only chance for prolonged survival. Pancretic resections are technically challenging, and are accompanied by a substantial risk for postoperative complications, the most significant complication being a pancreatic fistula. Risk factors for development of pancreatic leakage are now well known, and several prophylactic pharmacological measures, as well as technical interventions have been suggested in prevention of pancreatic fistula. With better postoperative care and improved radiological interventions, most frequently complications can be managed conservatively. This review also attempts to address some of the controversies related to optimal management of the pancreatic remnant after pancreaticoduodenectomy.
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Affiliation(s)
- Mario Zovak
- Department of Surgery, University Clinical Hospital "Sisters of Charity", Zagreb, Croatia
| | - Dubravka Mužina Mišić
- Department of Surgery, University Clinical Hospital "Sisters of Charity", Zagreb, Croatia
| | - Goran Glavčić
- Department of Surgery, University Clinical Hospital "Sisters of Charity", Zagreb, Croatia
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Ryska M, Rudis J. Pancreatic fistula and postoperative pancreatitis after pancreatoduodenectomy for pancreatic cancer. Hepatobiliary Surg Nutr 2014; 3:268-75. [PMID: 25392838 DOI: 10.3978/j.issn.2304-3881.2014.09.05] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 09/09/2014] [Indexed: 12/23/2022]
Abstract
The most serious complication after pancreatoduodenectomy (PD) is pancreatic fistula (PF) type C, either as a consequence or independently from postoperative pancreatitis (PP). Differentiating between these two types of complications is often very difficult, if not impossible. The most significant factor in early diagnosis of PP after PD is an abrupt change in clinical status. In our retrospective study we also observed significantly higher levels of serum concentrations of CRP and AMS comparing to PF without PP. Based on our findings, CT scan is not beneficial in the early diagnosis of PP. Meantime PF type C is indication to operative revision with mostly drainage procedure which is obviously not much technically demanding, there are no definite guidelines on how to proceed in PP. Therefore the surgeon's experience determines not only whether PP will be diagnosed early enough and will be differentiated from PF without PP, but also whether a completion pancreatectomy will be performed in indicated cases.
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Affiliation(s)
- Miroslav Ryska
- Department of Surgery, 2nd Faculty of Medicine, Charles University and Central Military Hospital, Prague, Czech Republic
| | - Jan Rudis
- Department of Surgery, 2nd Faculty of Medicine, Charles University and Central Military Hospital, Prague, Czech Republic
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Xu C, Yang X, Luo X, Shen F, Wu M, Tan W, Jiang X. "Wrapping the gastroduodenal artery stump" during pancreatoduodenectomy reduced the stump hemorrhage incidence after operation. Chin J Cancer Res 2014; 26:299-308. [PMID: 25035657 DOI: 10.3978/j.issn.1000-9604.2014.06.08] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 06/05/2014] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE After pancreaticoduodenectomy (PD), the postoperative gastroduodenal artery stump (GDAS) hemorrhage is one of the most serious complications. The purpose of this study is to determine whether wrapping the GDAS during PD could decrease the postoperative GDAS hemorrhage incidence. METHODS A retrospective review involving 280 patients who underwent PD from 2005 to 2012 was performed. Wrapping the GDAS during PD was defined as "Wrapping the GDAS using the teres hepatis ligamentum during PD". A total of 140 patients accepted the "wrapping" procedure (wrapping group). The other 140 patients didn't apply the procedure (non-wrapping group). Age, sex, preoperative data, estimated intraoperative blood loss, postoperative complications, pathologic parameters and hospitalization time were compared between two groups. RESULTS There were no significant differences in patient characteristics between two groups. After wrapping, the incidence of postoperative GDAS bleeding decreased significantly (1/140 vs. 9/140, P=0.01). The rates of the other complications (such as intra-abdominal infection pancreatic fistula, billiary fistula, gastrointestinal bleeding, et al.) showed no significant differences. CONCLUSIONS Wrapping the GDAS during PD significantly reduced the postoperative GDAS hemorrhage incidence. And the "wrapping" had no obvious influence on other complications.
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Affiliation(s)
- Chang Xu
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Chang-Hai road 225, Shanghai 200438, China
| | - Xinwei Yang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Chang-Hai road 225, Shanghai 200438, China
| | - Xiangji Luo
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Chang-Hai road 225, Shanghai 200438, China
| | - Feng Shen
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Chang-Hai road 225, Shanghai 200438, China
| | - Mengchao Wu
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Chang-Hai road 225, Shanghai 200438, China
| | - Weifeng Tan
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Chang-Hai road 225, Shanghai 200438, China
| | - Xiaoqing Jiang
- Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, Chang-Hai road 225, Shanghai 200438, China
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Roberts KJ, Hodson J, Mehrzad H, Marudanayagam R, Sutcliffe RP, Muiesan P, Isaac J, Bramhall SR, Mirza DF. A preoperative predictive score of pancreatic fistula following pancreatoduodenectomy. HPB (Oxford) 2014; 16:620-8. [PMID: 24246089 PMCID: PMC4105899 DOI: 10.1111/hpb.12186] [Citation(s) in RCA: 130] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 09/03/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Various factors are related to the occurrence of postoperative pancreatic fistula (POPF) following pancreatoduodenectomy (PD). Some of the strongest are identified intra- or postoperatively, which limits their utility in predicting this complication. The preoperative prediction of POPF permits an individualized approach to patient consent and selection, and may influence postoperative management. This study sought to develop and test a score to predict POPF. METHODS A post hoc analysis of a prospectively maintained database was conducted. Consecutive patients were randomly selected to modelling and validation sets at a ratio of 2 :1, respectively. Patient data, preoperative blood tests and physical characteristics of the gland (assessed from preoperative computed tomography images) were subjected to univariate and multivariate analysis in the modelling set of patients. A score predictive of POPF was designed and tested in the validation set. RESULTS Postoperative pancreatic fistula occurred in 77 of 325 (23.7%) patients. The occurrence of POPF was associated with 12 factors. On multivariate analysis, body mass index and pancreatic duct width were independently associated with POPF. A risk score to predict POPF was designed (area under the receiver operating characteristic curve: 0.832, 95% confidence interval 0.768-0.897; P < 0.001) and successfully tested upon the validation set. CONCLUSIONS Preoperative assessment of a patient's risk for POPF is possible using simple measurements. The present risk score is a valid tool with which to predict POPF in patients undergoing PD.
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Affiliation(s)
- Keith J Roberts
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals BirminghamBirmingham, UK
| | - James Hodson
- Department of Medical Statistics, University Hospitals BirminghamBirmingham, UK
| | - Homoyoon Mehrzad
- Department of Radiology, University Hospitals BirminghamBirmingham, UK
| | - Ravi Marudanayagam
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals BirminghamBirmingham, UK
| | - Robert P Sutcliffe
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals BirminghamBirmingham, UK
| | - Paolo Muiesan
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals BirminghamBirmingham, UK
| | - John Isaac
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals BirminghamBirmingham, UK
| | - Simon R Bramhall
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals BirminghamBirmingham, UK
| | - Darius F Mirza
- Hepatobiliary and Pancreatic Surgery Unit, University Hospitals BirminghamBirmingham, UK
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Hore T, Thomas M, Brown L, Sakowska M, Connor S. Is there an alternative to centralization for pancreatic resection in New Zealand? ANZ J Surg 2014; 86:332-6. [PMID: 24846497 DOI: 10.1111/ans.12688] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Internationally pancreatic surgery has become increasingly centralized; however, geographical and population distribution within New Zealand (NZ) limits the practicalities of such an approach. The aim of this study was to review the short-term outcomes of patients undergoing pancreatic surgery by a single hepato-pancreato-biliary trained surgeon in a centre that would meet the minimum criteria set by the NZ National Standards but not necessarily the definition of a high-volume surgeon/centre. METHODS A retrospective review of consecutive patients undergoing pancreatic resection within an enhanced recovery programme by a single surgeon between March 2005 and April 2013. Primary outcomes were 30-day morbidity and 90-day mortality. RESULTS A total of 156 patients who underwent a pancreatic resection were included. Eighty-two (53%) patients underwent a pancreaticoduodenectomy. Forty-seven (30%) underwent a left pancreatectomy. Overall, 30-day morbidity was 64% and overall 90-day mortality was 2.6%. Overall median length of stay was 11 (3-140) days. CONCLUSIONS Acceptable outcomes have been achieved for patients undergoing pancreatic resection within a centre that meets the criteria proposed by the NZ National Standards for treatment of pancreatic cancer.
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Affiliation(s)
- Todd Hore
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Megan Thomas
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Lisa Brown
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Magdalena Sakowska
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Saxon Connor
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
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Anderson RJ, Dunki-Jacobs E, Callender GG, Burnett N, Scoggins CR, McMasters KM, Martin RCG. Clinical evaluation of somatostatin use in pancreatic resections: Clinical efficacy or limited benefit? Surgery 2013; 154:755-60; discussion 760. [PMID: 24074412 DOI: 10.1016/j.surg.2013.07.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 07/02/2013] [Indexed: 01/11/2023]
Abstract
BACKGROUND The benefit of somatostatin for the prevention of pancreatic fistula has been debated widely in the literature. The aim of this study was to evaluate the efficacy of somatostatin in preventing pancreatic fistulas and improving postoperative outcomes after pancreatic resection. HYPOTHESIS Somatostatin improves postoperative outcomes after pancreatectomy. METHODS A review was performed of a prospectively collected 2002 patient hepatopancreaticobiliary database. Patients were included if they underwent pancreatectomy between October 1, 2000, and May 16, 2012. Patients received somatostatin prophylactically at the discretion of their surgeon. Data were analyzed using univariate and multivariate analysis to determine if somatostatin had any effect on pancreatic fistula formation, fistula severity, duration of stay, and readmission rates. RESULTS We identified 510 patients who underwent pancreatectomy. Overall, patients 30 (6%) developed postoperative pancreatic fistulas and 27 (5%) fistulas were of clinical significance (grade B or C). Somatostatin was administered prophylactically to 215 (42%) patients, 57 patients (11%) were readmitted; the median duration of stay was 9 days (range, 2-81). Pancreatic fistula developed in 7 patients (3%) who received somatostatin versus 23 (8%) who did not receive somatostatin (P = .031). Among patients receiving somatostatin, 6 fistulas (3%) were of clinical significance versus 21 fistulas (7%) for patients who did not receive somatostatin (P = .031). Readmission occurred in 27 patients (13%) who received somatostatin versus 30 patients (10%) who did not receive somatostatin (P = .398). The median duration of stay was 9 days (range, 2-48) for patients who received somatostatin versus 9 days (range, 2-81) for patients who did not receive somatostatin (P = .462). CONCLUSION Somatostatin use was associated with a significant decrease in both the rate of fistula formation and the number of clinically important fistulas in our pancreatectomy patients. Continued evaluation of somatostatin use in relation to both intraoperative predictors and costa are needed to better define the population that will gain clinical benefit and cost savings.
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Affiliation(s)
- Ryan James Anderson
- Department of Surgery, Division of Surgical Oncology, University of Louisville, Louisville, KY
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Miyai H, Hara M, Hayakawa T, Takeyama H. Establishment of a simple predictive scoring system for pancreatic fistula after laparoscopy-assisted gastrectomy. Dig Endosc 2013; 25:585-92. [PMID: 23461800 DOI: 10.1111/den.12042] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 12/25/2012] [Indexed: 01/14/2023]
Abstract
BACKGROUND The potential severity of postoperative pancreatic fistula (POPF) after laparoscopy-assisted gastrectomy (LAG) necessitates efforts to identify predictive factors for POPF. The aim of the present study was to identify predictive factors for POPF and to establish a predictive scoring system for POPF after LAG. PATIENTS AND METHODS Between June 2004 and March 2011, 277 gastric cancer patients who underwent curative resection with LAG were enrolled. POPF was defined according to the International Study Group for Pancreatic Fistula grading system. Risk factors for POPF were evaluated using logistic regression analysis, and a scoring system for POPF was established. RESULTS In the derivation cohort, multivariate analysis revealed the risk factors for POPF as patient age ≤70 years (5 points), amylase level of postoperative day 1 drainage fluid >454 IU/L(5 points), total number of retrieved lymph nodes >21 (5 points), body mass index >21.45 kg/m(2) (4 points), and operating time >337 min (2 points). In the validation cohort, at the cut-off point for high risk (score ≥15), the model had a negative predictive value of 94.5%, a positive predictive value of 57.4%, a sensitivity of 88.6%, and a specificity of 75.0% (C statistic = 0.857). CONCLUSION This study demonstrated that POPF after LAG is associated with specific preoperative and postoperative factors. With a simple predictive scoring system, patients at high risk for POPF can be accurately identified. This simple predictive scoring system will be useful for many clinicians to assess the risk of POPF after LAG and start treating at-risk patients earlier.
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Affiliation(s)
- Hirotaka Miyai
- Department of Gastroenterological Surgery, Nagoya City University, Nagoya, Japan
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Development of a novel rat model with pancreatic fistula and the prevention of this complication using tissue-engineered myoblast sheets. J Gastroenterol 2013. [PMID: 23179607 DOI: 10.1007/s00535-012-0706-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pancreatic fistula (PF) is one of the most important complications of pancreatic surgery. The aims of this study were to establish a PF model in rats and to investigate the efficacy of our new method for preventing PF, which utilizes myoblast sheets made using tissue engineering techniques. METHODS To establish a PF model, the rats underwent transection of each of four pancreatic ducts: the gastric, duodenal, common, and splenic ducts, respectively. Their ascitic amylase and lipase levels were then measured. To investigate the efficacy of myoblast sheets at preventing PF, a myoblast sheet was attached to the pancreatic stump in the PF models. The levels of amylase and lipase in both serum and ascites were then measured, and surgical specimens were investigated pathologically. RESULTS The new PF model established by transecting the splenic duct in rats may prove very useful. There were no significant differences in serum amylase and lipase levels between the myoblast sheet (+) group and the sheet (-) group. However, there were significant differences in ascitic amylase and lipase levels between the two groups (p < 0.05). Among the pathological findings, the number of inflammatory cells in the myoblast sheet group was smaller than that in the control group. In addition, the presence of the myoblast sheets on the surface of the pancreatic stump was confirmed by immunofluorescence staining. CONCLUSION Our data demonstrate the efficacy of the new rat model of PF presented herein, and that it might be possible to prevent PF using myoblast sheets.
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