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Bhat P, Kaffes AJ, Lassen K, Aabakken L. Upper gastrointestinal endoscopy in the surgically altered patient. Dig Endosc 2024; 36:1077-1093. [PMID: 38952202 DOI: 10.1111/den.14823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 04/23/2024] [Indexed: 07/03/2024]
Abstract
As management of upper gastrointestinal malignancies improves, and with popularization of bariatric surgery, endoscopists are likely to meet patients with altered upper gastrointestinal anatomy. Short-term, the surgery can cause complications like bleeding, leaks, and fistulas, and longer-term problems such as intestinal or biliary anastomotic strictures or biliary stones can arise, all necessitating endoscopy. In addition, the usual upper gastrointestinal pathologies can also still occur. These patients pose unique challenges. To proceed, understanding the new layout of the upper gastrointestinal tract is essential. The endoscopist, armed with a clear plan for navigation, can readily diagnose and manage most commonly occurring conditions, such as marginal ulcers and proximal anastomotic strictures with standard endoscopic instruments. With complex reconstructions involving long segments of small bowel, such as Roux-en-Y gastric bypass, utilization of balloon-assisted enteroscopy may be necessary, mandating modification of procedures such as endoscopic retrograde cholangiopancreatography. Successful endoscopic management of patients with altered anatomy will require prior planning and preparation to ensure the appropriate equipment, setting, and skill set is provided.
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Affiliation(s)
- Purnima Bhat
- Gastroenterology and Hepatology Unit, Canberra Hospital, Canberra, Australia
- College of Health and Medicine, Australian National University, Canberra, Australia
| | - Arthur John Kaffes
- Interventional Endoscopy, Chris O'Brien Lifehouse, Sydney, Australia
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia
- Department of Medicine, University of Sydney, Sydney, Australia
| | - Kristoffer Lassen
- Department of HPB Surgery, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Lars Aabakken
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
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2
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Henry AC, Salaheddine Y, Holster JJ, Daamen LA, Bruno MJ, Derksen WJM, van Driel LMJW, van Eijck CH, van Lienden KP, Molenaar IQ, van Santvoort HC, Vleggaar FP, Groot Koerkamp B, Verdonk RC. Late cholangitis after pancreatoduodenectomy: A common complication with or without anatomical biliary obstruction. Surgery 2024; 176:1207-1214. [PMID: 39054185 DOI: 10.1016/j.surg.2024.06.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 06/10/2024] [Accepted: 06/30/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Postoperative cholangitis is a common complication after pancreatoduodenectomy that can occur with or without anatomical biliary obstruction. This study aimed to investigate the incidence, diagnosis, treatment, and risk factors of cholangitis after pancreatoduodenectomy. METHODS We performed a retrospective cohort study of consecutive patients who underwent pancreatoduodenectomy in 2 Dutch tertiary pancreatic centers (2010-2019). Primary outcome was postoperative cholangitis, defined as systemic inflammation with abnormal liver tests without another focus of infection, at least 1 month after resection. Diagnostic and therapeutic strategies were evaluated. Two types of postoperative cholangitis were distinguished; obstructive cholangitis (benign stenosis of the hepaticojejunostomy) and nonobstructive cholangitis. Potential risk factors were identified using logistic regression analysis. RESULTS Postoperative cholangitis occurred in 93 of 900 patients (10.3%). Median time to first episode of cholangitis was 8 months (interquartile range 4-16) after pancreatoduodenectomy. Multiple episodes of cholangitis occurred in 44 patients (47.3%) and readmission was necessary in 83 patients (89.2%). No cholangitis-related mortality was observed. Obstructive cholangitis was seen in 37 patients (39.8%) and nonobstructive cholangitis in 56 patients (60.2%). Surgery was performed for cholangitis in 7 patients (7.5%) and consisted of revision of the hepaticojejunostomy or elongation of the biliary limb. Postoperative biliary leakage (odds ratio 2.56; 95% confidence interval 1.42-4.62; P = .0018) was independently associated with postoperative cholangitis. CONCLUSION Postoperative cholangitis unrelated to cancer recurrence was seen in 10% of patients after pancreatoduodenectomy. Nonobstructive cholangitis was more common than obstructive cholangitis. Postoperative biliary leakage was an independent risk factor.
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Affiliation(s)
- Anne Claire Henry
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Youcef Salaheddine
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jessica J Holster
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Lois A Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology & Hepatology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Wouter J M Derksen
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lydi M J W van Driel
- Department of Gastroenterology & Hepatology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Krijn P van Lienden
- Department of Radiology, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology & Hepatology, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands.
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Zohar N, Gorgov E, Yeo TP, Lavu H, Bowne W, Yeo CJ, Nevler A. Incisional hernia after major pancreatic resection: long term risk assessment from two distinct sources - A large multi-institutional network and a single high-volume center. HPB (Oxford) 2024:S1365-182X(24)02282-2. [PMID: 39327220 DOI: 10.1016/j.hpb.2024.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 08/06/2024] [Accepted: 08/29/2024] [Indexed: 09/28/2024]
Abstract
BACKGROUND Post-operative incisional hernia (IH) is a common complication following abdominal surgery. Data regarding IH after major pancreatic surgery are limited. We aim to evaluate the long-term risk of IH following major pancreatic resection. METHODS A dual-approach study: a large multi-institutional research network (RN) was investigated for IH incidence and risk factors in propensity-score matched survivors after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP), was complemented by a patient-reported questionnaire. RESULTS RN analysis identified 22,113 patients that underwent pancreatic surgery. 11.0% of PD patients and 8.6% of DP patients developed IH (P < 0.0001). IH rates were higher with open surgery compared with minimally invasive approaches in PD (OR = 1.56, P = 0.03) and DP (OR = 1.94, P = 0.003). BMI>35 was found to correlate with increased IH rates for PD and DP (OR = 1.87, and OR = 1.86, respectively, P < 0.0001 each), as did postoperative intraabdominal infections (P < 0.0001). Patient-based survey of 104 patients, revealed that 16 patients (15%) reported post-operative IH during the follow-up period. BMI≥30, SSI and intra-abdominal abscesses were associated with increased IH risk (P < 0.05). CONCLUSION Improved survival after pancreatic resection has led to an increased prevalence of long-term surgical sequela. In this study, we demonstrate significant rates of IH among long-term survivors and assess potential risk factors.
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Affiliation(s)
- Nitzan Zohar
- Jefferson Pancreas, Biliary and Related Cancer Centre, Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Eliyahu Gorgov
- Jefferson Pancreas, Biliary and Related Cancer Centre, Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Theresa P Yeo
- Jefferson Pancreas, Biliary and Related Cancer Centre, Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Harish Lavu
- Jefferson Pancreas, Biliary and Related Cancer Centre, Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Wilbur Bowne
- Jefferson Pancreas, Biliary and Related Cancer Centre, Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Charles J Yeo
- Jefferson Pancreas, Biliary and Related Cancer Centre, Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Avinoam Nevler
- Jefferson Pancreas, Biliary and Related Cancer Centre, Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA.
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Kato T, Watanabe Y, Oshima Y, Takase K, Watanabe Y, Okada K, Aikawa M, Okamoto K, Koyama I. Long-term outcomes and risk factors of pancreatic insufficiency after a pancreatoduodenectomy: A retrospective study. Surgery 2024; 176:880-889. [PMID: 38879380 DOI: 10.1016/j.surg.2024.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 04/14/2024] [Accepted: 04/27/2024] [Indexed: 08/18/2024]
Abstract
BACKGROUND An increasing number of patients are achieving long-term survival after pancreatoduodenectomy, meaning that risk assessments of endocrine and exocrine pancreatic insufficiency are needed. Herein, we investigated the risk factors for pancreatic insufficiency after pancreatoduodenectomy by incorporating pancreatic morphologic changes and perioperative factors. METHODS Patients who underwent pancreatoduodenectomy between January 2015 and December 2020 were enrolled in this single-center retrospective study. Clinicopathologic, surgical, and pancreatic morphologic factors were collected, and risk factors for exocrine pancreatic insufficiency and endocrine pancreatic insufficiency were analyzed. Exocrine pancreatic insufficiency was defined as steatorrhea requiring pancreatic enzymes and new onset steatosis, and endocrine pancreatic insufficiency was defined as postoperative new-onset diabetes mellitus. Multivariate analysis was performed. RESULTS Among the 206 patients enrolled, 14% and 24% developed endocrine pancreatic insufficiency and exocrine pancreatic insufficiency, respectively. Multivariate analysis revealed residual pancreatic stent 1 year postoperatively, lymph node metastasis, and postoperative pancreatic atrophy (P-atrophy) as independent risk factors for exocrine pancreatic insufficiency, whereas preoperative glycated hemoglobin levels, residual pancreatic stent, and postoperative main pancreatic duct dilatation were risk factors for endocrine pancreatic insufficiency. Subgroup analysis of pancreatic ductal adenocarcinoma revealed that exocrine pancreatic insufficiency in patients with pancreatic ductal adenocarcinoma was caused by preoperative decreased pancreatic function (high glycated hemoglobin and a low postoperative pancreatic fistula rate), whereas the high incidence of POPF influenced the development of exocrine pancreatic insufficiency in patients without pancreatic ductal adenocarcinoma. CONCLUSION Postoperative pancreatic atrophy and main pancreatic duct dilatation are risk factors for exocrine pancreatic insufficiency I and endocrine pancreatic insufficiency, respectively, and residual pancreatic stent affects both types of pancreatic dysfunction. Improving the surgical approach and stent management may help prevent these late complications.
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Affiliation(s)
- Tomotaka Kato
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Japan
| | - Yukihiro Watanabe
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Japan.
| | - Yuhei Oshima
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Japan
| | - Kenichiro Takase
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Japan
| | - Yuichiro Watanabe
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Japan
| | - Katsuya Okada
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Japan
| | - Masayasu Aikawa
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Japan
| | - Kojun Okamoto
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Japan
| | - Isamu Koyama
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Japan
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Viti V, Ginesini M, Ripolli A, Boggi U. Internal hernia through the Treitz fossa after robotic pancreatoduodenectomy: pathogenesis and preventive measures. Updates Surg 2024; 76:2071-2074. [PMID: 38802720 DOI: 10.1007/s13304-024-01877-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 05/05/2024] [Indexed: 05/29/2024]
Abstract
Internal hernia through the Treitz fossa following robotic pancreatoduodenectomy is a rare but potentially serious complication. In our review of 328 cases of robotic pancreatoduodenectomies, two patients (0.6%) required repeat surgery due to internal herniation of the entire small bowel through the Treitz fossa. This complication can present as afferent loop syndrome, with symptoms including nausea, vomiting, and abdominal distension, possibly leading to cholangitis and pancreatitis. Timely diagnosis and intervention are paramount, as conservative management often fails. Preventive measures involve closing the peritoneal defect in the Treitz fossa at the end of robotic pancreatoduodenectomy, particularly in lean patients with thin mesentery who are at increased risk of internal hernia due to increased mobility of the small bowel. This technical note elucidates the pathogenesis of Treitz hernia following robotic pancreatoduodenectomy and underscores the importance of closing the peritoneal breach to prevent this rare yet potentially serious complication.
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Affiliation(s)
- Virginia Viti
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy.
| | - Michael Ginesini
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Allegra Ripolli
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
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Sabogal JC, Conde Monroy D, Rey Chaves CE, Ayala D, González J. Delayed gastric emptying after pancreatoduodenectomy: an analysis of risk factors. Updates Surg 2024; 76:1247-1255. [PMID: 38598061 PMCID: PMC11341576 DOI: 10.1007/s13304-024-01795-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 02/25/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a frequent complication after pancreatoduodenectomy. Preoperative factors are limited and controversial. This study aims to identify associated factors related to this complication in the Colombian population. METHODS A retrospective review of a prospectively collected database was conducted. All patients over 18 years of age who underwent pancreaticoduodenectomy were included. Associations with DGE syndrome were evaluated with logistic regression analysis, Odds ratio, and b-coefficient were provided when appropriate. RESULTS 205 patients were included. Male patients constituted 54.15% (n = 111). 53 patients (25.85%) were diagnosed with DGE syndrome. Smoking habit (OR 17.58 p 0.00 95% CI 7.62-40.51), hydromorphone use > 0.6 mg/daily (OR 11.04 p 0.03 95% CI 1.26-96.66), bilirubin levels > 6 mg/dL (OR 2.51 p 0.02 95% CI 1.12-5.61), and pancreatic fistula type B (OR 2.72 p 0.02 CI 1.74-10.00). DISCUSSION Smoking history, opioid use (hydromorphone > 0.6 mg/Daily), type B pancreatic fistula, and bilirubin levels > 6 mg/dL should be considered as risk factors for DGE.
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Affiliation(s)
- Juan Carlos Sabogal
- Hepatobiliary and Pancreatic Surgery Department, Hospital Universitario Mayor, Méderi, Bogotá, Colombia
- School of Medicine, Universidad del Rosario, Bogotá, Colombia
| | - Danny Conde Monroy
- Hepatobiliary and Pancreatic Surgery Department, Hospital Universitario Mayor, Méderi, Bogotá, Colombia
- School of Medicine, Universidad del Rosario, Bogotá, Colombia
| | - Carlos Eduardo Rey Chaves
- Estudiante de Posgrado Cirugía General, Facultad de Medicina, Pontificia Universidad Javeriana, Carrera 6A #51A-48, 111711, Bogotá D.C, Colombia.
| | - Daniela Ayala
- Hepatobiliary and Pancreatic Surgery Department, Hospital Universitario Mayor, Méderi, Bogotá, Colombia
| | - Juliana González
- Hepatobiliary and Pancreatic Surgery Department, Hospital Universitario Mayor, Méderi, Bogotá, Colombia
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Gikandi A, Fong ZV, Qadan M, Narayan RR, Lwin T, Fernández-del Castillo C, Lillemoe KD, Ferrone CR. Do Complications After Pancreatoduodenectomy Have an Impact on Long-Term Quality of Life and Functional Outcomes? ANNALS OF SURGERY OPEN 2024; 5:e400. [PMID: 38911654 PMCID: PMC11191981 DOI: 10.1097/as9.0000000000000400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 02/15/2024] [Indexed: 06/25/2024] Open
Abstract
Objective Our aim was to assess whether complications after pancreatoduodenectomy (PD) impact long-term quality of life (QoL) and functional outcomes. Background There is an increasing number of long-term post-PD survivors, but few studies have evaluated long-term QoL outcomes. Methods The EORTC QLQ-C30 and QLQ-PAN26 questionnaires were administered to patients who survived >5 years post-PD. Clinical relevance (CR) was scored as small (5-10), moderate (10-20), or large (>20). Patients were stratified based on whether they experienced a complication during the index hospitalization. Results Of 305 patients >5 years post-PD survivors, with valid contact information, 248 completed the questionnaires, and 231 had complication data available. Twenty-nine percent of patients experienced a complication, of which 17 (7.4%) were grade 1, 27 (11.7%) were grade 2, and 25 (10.8%) were grade 3. Global health status and functional domain scores were similar between both groups. Patients experiencing complications reported lower fatigue (21.4 vs 28.1, P < 0.05, CR small) and diarrhea (15.9 vs 23.1, P < 0.05, CR small) symptom scores when compared to patients without complications. Patients experiencing complications also reported lower pancreatic pain (38.2 vs 43.4, P < 0.05, CR small) and altered bowel habits (30.1 vs 40.7, P < 0.01, CR moderate) symptom scores. There was a lower prevalence of worrying (36.2% vs 60.5%, P < 0.05) and bloating (42.0% vs 56.2%, P < 0.05) among PD survivors with complications. Conclusions Post-PD complication rates were not associated with long-term global QoL or functionality, and may be associated with less severe pancreas-specific symptoms.
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Affiliation(s)
- Ajami Gikandi
- From the Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Zhi Ven Fong
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Motaz Qadan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Raja R. Narayan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Thinzar Lwin
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | | | - Keith D. Lillemoe
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Beger HG. [Premalignant cystic neoplasms and neuroendocrine tumors of the pancreatic head-Is the Kausch-Whipple resection an adequate treatment?]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:461-465. [PMID: 38568302 PMCID: PMC11096214 DOI: 10.1007/s00104-024-02070-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 05/16/2024]
Abstract
Currently, the most frequently used surgical treatment for symptomatic, benign, premalignant cystic and neuroendocrine neoplasms of the pancreatic head is the Whipple procedure or pylorus-preserving pancreatoduodenectomy (PD). However, when performed for treatment of benign tumors, PD is a multiorgan resection involving loss of pancreatic and extrapancreatic tissue and functions. PD for benign neoplasm is associated with the risk of considerable early postoperative complications and an in-hospital mortality of up to 5%. Following the Whipple procedure a new onset of diabetes mellitus is observed in 14-20% and new exocrine insufficiency in 25-45%, leading to metabolic dysfunction and impairment of quality of life persisting after resection of benign tumors. Symptomatic neoplasms are indication for surgery. Patients with asymptomatic pancreatic tumors are treated according to the criteria of surveillance protocols. The goal of surgical treatment for asymptomatic patients is, according to the guideline criteria, interruption of the surveillance program before the development of an advanced stage cancer associated with the neoplasm. Tumor enucleation and duodenum-preserving pancreatic head resection, either total or partial, are parenchyma-sparing resections for benign neoplasms of the pancreatic head. The first choice for small tumors is enucleation; however, enucleation is associated with an increased risk of pancreatic fistula B + C following pancreatic main duct injury. Duodenum-preserving total or partial pancreatic head resection has the advantage of low postoperative surgery-related complications, a mortality of < 0.5% and maintenance of the endocrine and exocrine pancreatic functions. Parenchyma-sparing pancreatic head resections should replace classical Whipple procedures for neoplasms of the pancreatic head.
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Affiliation(s)
- Hans G Beger
- c/o Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland.
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Narvaez Salas D, Roldan-Vasquez E, Negrete Ocampo R, Ballagan Escobar R, Roldan Crespo J. Surgical treatment of pancreaticojejunal stenosis after pancreaticoduodenectomy: case report. J Surg Case Rep 2024; 2024:rjae239. [PMID: 38863956 PMCID: PMC11165309 DOI: 10.1093/jscr/rjae239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 03/07/2024] [Indexed: 06/13/2024] Open
Abstract
Pancreaticoduodenectomy is established as the procedure of choice for malignant tumor pathologies of the head of the pancreas or ampulla, where the patient's life prognosis is low. Complications after pancreaticoduodenectomy (e.g. pancreatic fistulas, hemorrhages, or intra-abdominal collection) are well described in the literature and are generally acute. However, there is still a small risk for late complications (e.g. pancreatitis, pancreatic insufficiency), and due to its low incidence, there has not been a consensus on the treatment. We present the case of an 18-year-old female with recurrent bouts of acute pancreatitis as a late complication of a pancreaticoduodenectomy plus pancreatojejunal anastomosis due to a pseudopapillary tumor of the pancreas. The complication was managed though surgical revision consisting of dilation and stent placement in the stenosis. The patient had an adequate postoperative evolution without further complications. Despite the advances in the surgical field, pancreaticoduodenectomy represents a highly complex surgery with high morbidity and mortality rates. The late complications of this surgery are under continuous study due to its low incidence associated with low patient survival.
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Affiliation(s)
- David Narvaez Salas
- Departamento de Cirugía General, Hospital Vozandes Quito, Quito 170521, Ecuador
| | | | - Ricardo Negrete Ocampo
- Department of General Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
| | - Romina Ballagan Escobar
- School of Medicine, Colegio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito 170901, Ecuador
| | - Juan Roldan Crespo
- Department of General Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, United States
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Justo Alonso I, Marcacuzco Quinto A, Caso Maestro O, Alonso Murillo L, Rioja Conde P, Fernández Fernández C, Jiménez Romero C. Whipple's cephalic pancreaticoduodenectomy versus pyloric-preserving pancreaticoduodenectomy. Retrospective study. Cir Esp 2024; 102:265-274. [PMID: 38493929 DOI: 10.1016/j.cireng.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 02/07/2024] [Indexed: 03/19/2024]
Abstract
INTRODUCTION Controversy exists in the literature as to the best technique for pancreaticoduodenectomy (PD), whether pyloric preservation (PP-CPD) or Whipple's technique (with antrectomy [W-CPD]), the former being associated with a higher frequency of delayed gastric emptying (DGE). METHODS Retrospective and comparative study between PP-CPD technique (n = 124 patients) and W-CPD technique (n = 126 patients), in patients who were operated for tumors of the pancreatic head and periampullary region between the period 2012 and 2023. RESULTS Surgical time was longer, although not significant, with the W-CPD technique. Pancreatic and peripancreatic tumor invasion (p = 0.031) and number of lymph nodes resected (p < 0.0001) reached statistical significance in W-CPD, although there was no significant difference between the groups in terms of lymph node tumor invasion. Regarding postoperative morbimortality (medical complications, postoperative pancreatic fistula [POPF], hemorrhage, RVG, re-interventions, in-hospital mortality, Clavien-Dindo complications), ICU and hospital stay, no statistically significant differences were observed between the groups. During follow-up, no significant differences were observed between the groups for morbidity and mortality at 90 days and survival at 1, 3 and 5 years. Binary logistic regression analysis for DGE showed that binary relevant POPF grade B/C was a significant risk factor for DGE. CONCLUSIONS Postoperative morbidity and mortality and long-term survival were not significantly different with PP-CPD and W-CPD, but POPF grade B/C was a risk factor for DGE grade C.
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Affiliation(s)
- Iago Justo Alonso
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Instituto de Investigación (imas12), Spain; Departamento de Cirugía, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Alberto Marcacuzco Quinto
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Instituto de Investigación (imas12), Spain; Departamento de Cirugía, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Oscar Caso Maestro
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Instituto de Investigación (imas12), Spain; Departamento de Cirugía, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Laura Alonso Murillo
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Instituto de Investigación (imas12), Spain; Departamento de Cirugía, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Paula Rioja Conde
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Instituto de Investigación (imas12), Spain; Departamento de Cirugía, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Clara Fernández Fernández
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Instituto de Investigación (imas12), Spain; Departamento de Cirugía, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Carlos Jiménez Romero
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Instituto de Investigación (imas12), Spain; Departamento de Cirugía, Facultad de Medicina, Universidad Complutense, Madrid, Spain.
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Joseph EA, Bowers KD, Marcus R, Aryal B, Schiffman SC, Wagner PL, Chalikonda S, Bartlett DL, Allen CJ. Assessing the long-term priorities of pancreaticoduodenectomy survivors. HPB (Oxford) 2024; 26:703-710. [PMID: 38443235 DOI: 10.1016/j.hpb.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/13/2023] [Accepted: 02/23/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND This study assessed the long-term quality of life (QOL) and priorities of pancreaticoduodenectomy (PD) survivors. METHODS Survivors were surveyed via internet-based support groups. The relative importance of longevity, experience, costs, and QOL were assessed. RESULTS The PD cohort (n = 247, 35%) was 60 ± 12 years, 71% female, and 93% white. With moderate agreement, patients ranked survival most important, followed by functional and emotional well-being; costs and experience were least important (W = 35.7%, p < 0.001). Well-being improved throughout survivorship (P-QOL: 39 ± 12 at ≤3 mo vs 43 ± 12 at >10 y, p = 0.170; M-QOL: 38 ± 13 at ≤3 mo vs 44 ± 16 at >10 y; p = 0.015) but remained below the general population (p < 0.001). PD patients with benign diagnoses ranked functional independence as most important (2.00 ± 1.13 vs 2.63 ± 1.19, p < 0.001, W = 41.1%); PD patients with malignant diagnoses regarded overall survival most important (2.10 ± 1.20 vs 1.82 ± 1.22, p < 0.16, W = 35.1%). The mean rank order of priorities remained concordant between short-term (<1 year) and long-term (>5 years) survivors. CONCLUSION PD survivors experience long-term mental and physical health impairments, underscoring the importance of functional and emotional support. Survivors place paramount importance on overall survival, functional independence, and emotional well-being. Cancer survivors prioritize longevity, while survivors of chronic benign conditions prioritize functional independence.
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Affiliation(s)
- Edward A Joseph
- Allegheny Health Network Singer Research Institute, Pittsburgh, PA, USA
| | - Kara D Bowers
- Institute of Surgery, Division of Surgical Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Rebecca Marcus
- Institute of Surgery, Division of Surgical Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Bibek Aryal
- Allegheny Health Network Singer Research Institute, Pittsburgh, PA, USA
| | - Suzanne C Schiffman
- Institute of Surgery, Division of Surgical Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Patrick L Wagner
- Institute of Surgery, Division of Surgical Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Sricharan Chalikonda
- Institute of Surgery, Division of Surgical Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - David L Bartlett
- Cancer Institute, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Casey J Allen
- Institute of Surgery, Division of Surgical Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA.
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12
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Suzuki R, Konishi Y, Makino K, Wakui Y, Mino K, Kawamura H, Morita R, Kakisaka T, Abo D, Taketomi A. Treatment of delayed pancreatic fistula associated with anastomosis breakdown after pancreaticoduodenectomy using percutaneous interventions. Clin J Gastroenterol 2024; 17:356-362. [PMID: 38108998 DOI: 10.1007/s12328-023-01900-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 11/17/2023] [Indexed: 12/19/2023]
Abstract
We here present a rare case of development of a postoperative pancreatic fistula and breakdown of the pancreaticojejunal anastomosis 8 months after pancreaticoduodenectomy. A 70-year-old man underwent pancreaticoduodenectomy for distal cholangiocarcinoma and initially recovered well. However, 8 months later, he developed abdominal pain and distention and was admitted to our institution with suspected pancreatitis. On the 17th day of hospitalization, he suddenly bled from the jejunal loop and a fluid collection was detected near the pancreaticojejunal anastomosis site. The fluid collection was drained percutaneously. Subsequent fistulography confirmed breakdown of the pancreaticojejunal anastomosis. Considering the patient's overall condition and the presence of postoperative adhesions, we decided to manage him conservatively. An additional drain tube was placed percutaneously from the site of the anastomotic breakdown into the lumen of the jejunum, along with the tube draining the fluid collection, creating a completely new fistula. This facilitated the flow of pancreatic fluid into the jejunum and was removed 192 days after placement. During a 6-month follow-up, there were no recurrences of pancreatitis or a pancreatic fistula. This case highlights the efficacy of percutaneous drainage and creation of an internal fistula as a management strategy for delayed pancreatic fistula and anastomotic breakdown following pancreaticoduodenectomy.
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Affiliation(s)
- Reimi Suzuki
- Department of Surgery, National Hospital Organization Hokkaido Medical Center, 1-1, Yamanote-5-7, Nishi-ku, Sapporo, 063-0005, Japan.
| | - Yuji Konishi
- Department of Surgery, National Hospital Organization Hokkaido Medical Center, 1-1, Yamanote-5-7, Nishi-ku, Sapporo, 063-0005, Japan
| | - Kai Makino
- Department of Surgery, National Hospital Organization Hokkaido Medical Center, 1-1, Yamanote-5-7, Nishi-ku, Sapporo, 063-0005, Japan
| | - Yosuke Wakui
- Department of Surgery, National Hospital Organization Hokkaido Medical Center, 1-1, Yamanote-5-7, Nishi-ku, Sapporo, 063-0005, Japan
| | - Kazuhiro Mino
- Department of Surgery, National Hospital Organization Hokkaido Medical Center, 1-1, Yamanote-5-7, Nishi-ku, Sapporo, 063-0005, Japan
| | - Hideki Kawamura
- Department of Surgery, National Hospital Organization Hokkaido Medical Center, 1-1, Yamanote-5-7, Nishi-ku, Sapporo, 063-0005, Japan
| | - Ryo Morita
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Sapporo, Japan
| | - Tatsuhiko Kakisaka
- Department of Gastroenterological Surgery I, Hokkaido University, Sapporo, Japan
| | - Daisuke Abo
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Sapporo, Japan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery I, Hokkaido University, Sapporo, Japan
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13
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Krueger CM, Patrzyk M, Hipp J, Adam U, Köckerling F, Riediger H. Incisional hernia repair following pancreatic surgery-open vs laparoscopic approach. Hernia 2024; 28:155-165. [PMID: 37904038 PMCID: PMC10891208 DOI: 10.1007/s10029-023-02901-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 09/22/2023] [Indexed: 11/01/2023]
Abstract
INTRODUCTION For pancreatic procedures, transverse and midline or combined approaches are used. Having an increased morbidity after pancreatic surgery, these patients have an increased risk of developing an incisional hernia. In the following, we will analyze how the results of incisional hernia surgery after pancreatic surgery are presented in the Herniamed Registry. METHODS Hospitals and surgeons from Germany, Austria and Switzerland can voluntarily enter all routinely performed hernia operations prospectively into the Herniamed Registry. All patients sign a special informed consent declaration that they agree to the documentation of their treatment in the Herniamed Registry. Perioperative complications (intraoperative complications, postoperative complications, complication-related reoperations and general complications) are recorded up to 30 days after surgery. After 1, 5, and 10 years, patients and primary care physicians are contacted and asked about any pain at rest, pain on exertion, chronic pain requiring treatment or recurrence. This retrospective analysis of prospectively collected data compares the outcomes of minimally invasive vs open techniques in incisional hernia repair after pancreatic surgery. RESULTS Relative to the total number of all incisional hernia patients in the Herniamed Registry, the proportion after pancreatic surgery with 1-year follow-up was 0.64% (n = 461) patients. 95% of previous pancreatic surgeries were open. Minimally invasive incisional hernia repair was performed in 17.1% and open repair in 82.9% of cases. 23.2% of the defects were larger than 10 cm and 32.8% were located laterally or were a combination of lateral and medial defects. Among the few differences between the collectives, a significantly higher rate of defect closure (58.1% vs 25.3%; p < 0.001) and drainage (72.8% vs 13.9%; p < 0.001) was found in the open repairs, and larger meshes were seen in the minimally invasive procedures (340.6 cm2 vs 259.6 cm2; p < 0.001). No difference deemed a risk factor for chronic postoperative pain was seen in the rate of preoperative pain between the open and minimally invasive procedures (Appendix Table 4) No significant differences were found in either the perioperative complications or at 1-year follow-up. CONCLUSIONS Incisional hernias after complex pancreatic surgery can be repaired safely and with a low recurrence rate in both open and minimally invasive techniques.
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Affiliation(s)
- C M Krueger
- Department of Surgery, Centre of Robotics, Immanuel Clinic Ruedersdorf, University Clinic of Brandenburg Medical School, Brandenburg, Germany.
| | - M Patrzyk
- Department of Surgery, Clinic for General, Visceral, Vascular and Thoracic Surgery, Greifswald University Medical Centre, Greifswald, Germany
| | - J Hipp
- Department of General and Visceral Surgery, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg/Breisgau, Germany
| | - U Adam
- Department for Surgery, Vivantes-Humboldt-Hospital, Academic Teaching Hospital of Charité University Medicine, Berlin, Germany
| | - F Köckerling
- Department for Surgery, Vivantes-Humboldt-Hospital, Academic Teaching Hospital of Charité University Medicine, Berlin, Germany
| | - H Riediger
- Department for Surgery, Vivantes-Humboldt-Hospital, Academic Teaching Hospital of Charité University Medicine, Berlin, Germany
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Martinez-Esteban A, Barron-Cervantes NM, Avila-Sanchez P, Chan-Nuñez C. Intussusception of Gastrojejunostomy After Pancreatoduodenectomy With Billroth II Reconstruction. Cureus 2024; 16:e51880. [PMID: 38327972 PMCID: PMC10849266 DOI: 10.7759/cureus.51880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2024] [Indexed: 02/09/2024] Open
Abstract
Gastrojejunal anastomosis or gastrojejunostomy (GJ) is a surgical procedure used for allowing gastric emptying, especially in cases where complex reconstructions are needed. One of the less common complications but one of the most relevant in morbidity is the intussusception of the GJ. It requires a high index of suspicion, preoperative optimization of the patient, diagnostic corroboration, and identification of associated complications with the use of contrasted imaging. It was described for the first time by Bozzi in 1914; currently, multiple cases have been described in the literature, being more frequent in bariatric surgeries and reconstructions after distal gastrectomy. In hepatopancreaticobiliary surgery, it is an even uncommon complication. We present the case of a 60-year-old man with intussusception of the efferent loop of the GJ after a pylorus-preserving pancreatoduodenectomy with a Billroth II reconstruction in the setting of malignancy of the extrahepatic bile duct along with our emergency surgical treatment.
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Affiliation(s)
| | | | - Pablo Avila-Sanchez
- Department of Hepato-Pancreato-Biliary Surgery, Instituto Nacional de Ciencias Medicas y Nutrición Salvador Zubirán, Mexico City, MEX
| | - Carlos Chan-Nuñez
- Department of Hepato-Pancreato-Biliary Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, MEX
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15
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Sakai H, Notake T, Shimizu A, Kubota K, Masuo H, Yoshizawa T, Hosoda K, Hayashi H, Yasukawa K, Soejima Y. Risk factors for postoperative cholangitis after pancreaticoduodenectomy and evaluation of internal stenting on hepaticojejunostomy: A single-center propensity score-based analysis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:1065-1077. [PMID: 36866510 DOI: 10.1002/jhbp.1322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/04/2023] [Accepted: 02/28/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND/PURPOSE This retrospective study aimed to investigate the risk factors for postoperative cholangitis (POC) after pancreaticoduodenectomy (PD) and the efficacy of stenting on hepaticojejunostomy (HJ). METHODS We investigated 162 patients. Postoperative cholangitis occurring before and after discharge was defined as early-onset POC (E-POC) and late-onset POC (L-POC), respectively. Risk factors for E-POC and L-POC were identified using univariate and multivariate logistic regression analyses. Propensity score matching (PSM) between the stenting group (group S) and the non-stenting group (group NS), and subgroup analysis in patients with risk factors were performed to evaluate the efficacy of stenting on HJ in preventing POC. RESULTS Body mass index (BMI) ≥ 25 kg/m2 and preoperative non-biliary drainage (BD) were risk factors for E-POC and L-POC, respectively. PSM analysis revealed that E-POC occurrence was significantly higher in group S than in group NS (P = .045). In the preoperative non-BD group (n = 69), E-POC occurrence was significantly higher in group S than in group NS (P = .025). CONCLUSIONS BMI ≥ 25 kg/m2 and preoperative non-BD status were risk factors for E-POC and L-POC, respectively. Stenting on HJ implants did not prevent POC after PD.
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Affiliation(s)
- Hiroki Sakai
- Department of Surgery, Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tsuyoshi Notake
- Department of Surgery, Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Akira Shimizu
- Department of Surgery, Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Koji Kubota
- Department of Surgery, Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hitoshi Masuo
- Department of Surgery, Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takahiro Yoshizawa
- Department of Surgery, Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kiyotaka Hosoda
- Department of Surgery, Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hikaru Hayashi
- Department of Surgery, Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Koya Yasukawa
- Department of Surgery, Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yuji Soejima
- Department of Surgery, Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Shinshu University School of Medicine, Matsumoto, Japan
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16
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González-Abós C, Pineda C, Arrocha C, Farguell J, Gil I, Ausania F. Incisional Hernia Following Open Pancreaticoduodenectomy: Incidence and Risk Factors at a Tertiary Care Centre. Curr Oncol 2023; 30:7089-7098. [PMID: 37622995 PMCID: PMC10453869 DOI: 10.3390/curroncol30080514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/20/2023] [Accepted: 07/22/2023] [Indexed: 08/26/2023] Open
Abstract
(1) Background: Incisional hernia (IH) is one of the most common complications following open abdominal surgery. There is scarce evidence on its real incidence following pancreatic surgery. The purpose of this study is to evaluate the incidence and the risk factors associated with IH development in patients undergoing pancreaticoduodenectomy (PD). (2) Methods: We retrospectively reviewed all patients undergoing PD between 2014 and 2020 at our centre. Data were extracted from a prospectively held database, including perioperative and long-term factors. We performed univariate and multivariate analysis to detect those factors potentially associated with IH development. (3) Results: The incidence of IH was 8.8% (19/213 patients). Median age was 67 (33-85) years. BMI was 24.9 (14-41) and 184 patients (86.4%) underwent PD for malignant disease. Median follow-up was 23 (6-111) months. Median time to IH development was 31 (13-89) months. Six (31.5%) patients required surgical repair. Following univariate and multivariate analysis, preoperative hypoalbuminemia (OR 3.4, 95% CI 1.24-9.16, p = 0.01) and BMI ≥ 30 kg/m2 (OR 2.6, 95% CI 1.06-8.14, p = 0.049) were the only factors independently associated with the development of IH. (4) Conclusions: The incidence of IH following PD was 8.8% in a tertiary care center. Preoperative hypoalbuminemia and obesity are independently associated with IH occurrence following PD.
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Affiliation(s)
- Carolina González-Abós
- Department of HBP and Transplant Surgery, Hospital Clínic, University of Barcelona, 08036 Barcelona, Spain (J.F.); (I.G.); (F.A.)
- Gene Therapy and Cancer, Institut d’Investigacions Biomediques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Catalina Pineda
- Department of HBP and Transplant Surgery, Hospital Clínic, University of Barcelona, 08036 Barcelona, Spain (J.F.); (I.G.); (F.A.)
| | - Carlos Arrocha
- Department of HBP and Transplant Surgery, Hospital Clínic, University of Barcelona, 08036 Barcelona, Spain (J.F.); (I.G.); (F.A.)
| | - Jordi Farguell
- Department of HBP and Transplant Surgery, Hospital Clínic, University of Barcelona, 08036 Barcelona, Spain (J.F.); (I.G.); (F.A.)
| | - Ignacio Gil
- Department of HBP and Transplant Surgery, Hospital Clínic, University of Barcelona, 08036 Barcelona, Spain (J.F.); (I.G.); (F.A.)
| | - Fabio Ausania
- Department of HBP and Transplant Surgery, Hospital Clínic, University of Barcelona, 08036 Barcelona, Spain (J.F.); (I.G.); (F.A.)
- Gene Therapy and Cancer, Institut d’Investigacions Biomediques August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain
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17
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Schleimer LE, Chabot JA, Kluger MD. Innovation in the Surgical Management of Pancreatic Cystic Neoplasms: Same Operations, Narrower Indications, and an Individualized Approach to Decision-Making. Gastrointest Endosc Clin N Am 2023; 33:655-677. [PMID: 37245941 DOI: 10.1016/j.giec.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Historically, the management of pancreatic cystic neoplasms (PCN) has been operative. Early intervention for premalignant lesions, including intraductal papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms (MCN), offers an opportunity to prevent pancreatic cancer-with potential decrement to patients' short-term and long-term health. The operations performed have remained fundamentally the same, with most patients undergoing pancreatoduodenectomy or distal pancreatectomy using oncologic principles. The role of parenchymal-sparing resection and total pancreatectomy remains controversial. We review innovations in the surgical management of PCN, focusing on the evolution of evidence-based guidelines, short-term and long-term outcomes, and individualized risk-benefit assessment.
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Affiliation(s)
- Lauren E Schleimer
- Department of Surgery, Columbia University Irving Medical Center, 177 Fort Washington Avenue, 8 Garden South, New York, NY 10032, USA. https://twitter.com/lschleim
| | - John A Chabot
- Division of GI/Endocrine Surgery, Department of Surgery, Herbert Irving Pavilion, Columbia University Irving Medical Center, Columbia University, Vagelos College of Physicians & Surgeons, 161 Fort Washington Avenue, Suite 819, New York, NY 10032, USA
| | - Michael D Kluger
- Division of GI/Endocrine Surgery, Department of Surgery, Herbert Irving Pavilion, Columbia University Irving Medical Center, Columbia University, Vagelos College of Physicians & Surgeons, 161 Fort Washington Avenue, Suite 823, New York, NY 10032, USA.
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18
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Mavroeidis VK, Russell TB, Clark J, Adebayo D, Bowles M, Briggs C, Denson J, Aroori S. Pancreatoduodenectomy for suspected malignancy: nonmalignant histology confers increased risk of serious morbidity. Ann R Coll Surg Engl 2023; 105:446-454. [PMID: 35904332 PMCID: PMC10149251 DOI: 10.1308/rcsann.2022.0055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND/AIMS A tissue diagnosis is not always obtained prior to pancreatoduodenectomy (PD) and a proportion of patients are found to have noncancerous histology postoperatively. It is unknown if these patients have different outcomes when compared with those who have malignancy confirmed. METHODS A retrospective paired case matched control study was undertaken. Patients who underwent PD for suspected malignancy but ultimately had nonmalignant histology were identified. Each was matched to a confirmed malignant control using the following criteria: age, gender, body mass index, American Society of Anesthesiologists grade, neoadjuvant treatment, preoperative serum bilirubin, preoperative biliary stenting and type of pancreatic anastomosis. Matching was blinded to the measured outcomes, which included perioperative morbidity and mortality. RESULTS Forty-five cases were compared with 45 well-matched controls. There was no difference in 30- or 90-day mortality, or length of stay. While overall morbidity rates were the same, patients with nonmalignant disease were more likely to experience major (Clavien-Dindo grade III-IV) morbidity (40.0% versus 17.8%, p = 0.0352). Independently, rates of clinically relevant pancreatic fistula (CR-POPF) were higher in the nonmalignant group (22.2% versus 4.44%, p = 0.0131). CONCLUSIONS In our study, PD patients with nonmalignant histology had significantly higher incidence of major morbidity and CR-POPF when compared with those who had malignancy confirmed. This should be considered when planning the management of patients with known or presumed benign/premalignant disease.
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Affiliation(s)
- VK Mavroeidis
- University Hospitals Plymouth NHS Trust, UKPreliminary findings presented at the 2015 E-AHPBA Congress, Manchester, United Kingdom, UK
| | - TB Russell
- University Hospitals Plymouth NHS Trust, UKPreliminary findings presented at the 2015 E-AHPBA Congress, Manchester, United Kingdom, UK
| | - J Clark
- University Hospitals Plymouth NHS Trust, UKPreliminary findings presented at the 2015 E-AHPBA Congress, Manchester, United Kingdom, UK
| | - D Adebayo
- University Hospitals Plymouth NHS Trust, UKPreliminary findings presented at the 2015 E-AHPBA Congress, Manchester, United Kingdom, UK
| | - M Bowles
- University Hospitals Plymouth NHS Trust, UKPreliminary findings presented at the 2015 E-AHPBA Congress, Manchester, United Kingdom, UK
| | - C Briggs
- University Hospitals Plymouth NHS Trust, UKPreliminary findings presented at the 2015 E-AHPBA Congress, Manchester, United Kingdom, UK
| | - J Denson
- University Hospitals Plymouth NHS Trust, UKPreliminary findings presented at the 2015 E-AHPBA Congress, Manchester, United Kingdom, UK
| | - S Aroori
- University Hospitals Plymouth NHS Trust, UKPreliminary findings presented at the 2015 E-AHPBA Congress, Manchester, United Kingdom, UK
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19
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Junker S, Jacobsen A, Merkel S, Denz A, Krautz C, Weber GF, Grützmann R, Brunner M. Transverse Incision for Pancreatoduodenectomy Reduces Wound Complications: A Single-Center Analysis of 399 Patients. J Clin Med 2023; 12:jcm12082800. [PMID: 37109136 PMCID: PMC10143640 DOI: 10.3390/jcm12082800] [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: 03/27/2023] [Revised: 04/04/2023] [Accepted: 04/04/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Even if the minimally invasive approach is advancing in pancreatic surgery, the open approach is still the standard for a pancreatoduodenectomy. There are two types of incisions used: the midline incision (MI) and transverse incision (TI). The aim of this study was to compare these two incision types, especially regarding wound complications. METHODS A retrospective review of 399 patients who underwent a pancreatoduodenectomy at the University Hospital Erlangen between 2012 and 2021 was performed. A total of 169 patients with MIs were compared with 230 patients with TIs, with a focus on postoperative fascial dehiscence, postoperative superficial surgical site infection (SSSI) and the occurrence of incisional hernias during follow-up. RESULTS Postoperative fascial dehiscence, postoperative SSSI and incisional hernias occurred in 3%, 8% and 5% of patients, respectively. Postoperative SSSI and incisional hernias were significantly less frequent in the TI group (SSI: 5% vs. 12%, p = 0.024; incisional hernia: 2% vs. 8%, p = 0.041). A multivariate analysis confirmed the TI type as an independent protective factor for the occurrence of SSSI and incisional hernias (HR 0.45 (95% CI = 0.20-0.99), p = 0.046 and HR 0.18 (95% CI = 0.04-0.92), p = 0.039, respectively). CONCLUSION Our data suggest that the transverse incision for pancreatoduodenectomy is associated with reduced wound complications. This finding should be confirmed by a randomized controlled trial.
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Affiliation(s)
- Stefanie Junker
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Anne Jacobsen
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Susanne Merkel
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Axel Denz
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Christian Krautz
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Georg F Weber
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Robert Grützmann
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054 Erlangen, Germany
| | - Maximilian Brunner
- Department of General and Visceral Surgery, Friedrich-Alexander-University, Krankenhausstraße 12, 91054 Erlangen, Germany
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20
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Salaheddine Y, Henry AC, Daamen LA, Derksen WJM, van Lienden KP, Molenaar IQ, van Santvoort HC, Vleggaar FP, Verdonk RC. Risk Factors for Cholangitis After Pancreatoduodenectomy: A Systematic Review. Dig Dis Sci 2023:10.1007/s10620-023-07929-x. [PMID: 37024745 DOI: 10.1007/s10620-023-07929-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 03/14/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Cholangitis is a late complication after pancreatoduodenectomy with considerable clinical impact and is difficult to treat. The aim of this systematic review was to provide an overview of the literature identifying risk factors for postoperative cholangitis. METHODS A systematic search of the databases PUBMED and EMBASE was performed to identify all studies reporting on possible risk factors for cholangitis following pancreatoduodenectomy. Data on patient, peri- and postoperative characteristics were collected. Risk of bias assessment was done according to the methodological index for non-randomized studies (MINORS) criteria. RESULTS In total, 464 studies were identified. Eight studies met the inclusion criteria for this analysis. The definition of postoperative cholangitis was inconsistent, with four studies using the Tokyo Guidelines, whereas other studies used different definitions. Data on 26 potential risk factors concerning the patient, peri- and postoperative characteristics were analyzed. Five factors were significantly associated with cholangitis in two or more studies: high body mass index, duration of surgery, benign disease, postoperative pancreatic fistula, and postoperative serum alkaline phosphatase. CONCLUSION Multiple potential risk factors for postoperative cholangitis were identified, with large discrepancies between studies. Prospective research, with consensus on the definition, is required to determine the true relevance of these risk factors.
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Affiliation(s)
- Youcef Salaheddine
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anne Claire Henry
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lois A Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wouter J M Derksen
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Krijn P van Lienden
- Department of Radiology, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology & Hepatology, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands.
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21
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Kato T, Ono Y, Oba A, Sato T, Ito H, Inoue Y, Saiura A, Takahashi Y. Treatment Strategy of Pancreas-Sparing Distal Duodenectomy for Distal Duodenal Malignancies with Adjustable Dissection Levels According to Disease Progression (with Video). World J Surg 2023; 47:1752-1761. [PMID: 36941481 DOI: 10.1007/s00268-023-06981-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Pancreas-sparing distal duodenectomy (PSDD) is a favorable option for distal duodenal neoplasms, and its procedure, including the extent of lymphadenectomy, should be modified according to the malignancy of the tumor. However, there are no coherent reports on the details of this procedure or long-term outcomes after each resection. METHODS This study included 24 patients who underwent PSDD at our institution between January 2009 and October 2020. Patients were divided into two groups according to the tumor progression: nine with (Lv-II) and fifteen without (Lv-I) mesopancreas dissection. Postoperative outcomes were compared between the two groups. RESULTS Two groups had similar operation times, blood loss, hospital stay, and the rate of delayed gastric emptying (DGE): 40% versus 44%. There were no Clavien-Dindo classification ≥ III complications in the Lv-II group. The Lv-II group had a larger number of examined lymph nodes (median: 29), and three (33%) patients had lymph node metastasis. No local recurrence was observed, although two patients in the Lv-II group had liver metastasis. The 5-year overall survival rates of the Lv-I and Lv-II groups were 100% and 78%, respectively. None of the patients had an impaired nutrition status after one year of surgery, and no rehospitalization was observed in either group. CONCLUSION Although PSDD with or without mesopancreas dissection entailed a high risk of DGE, this procedure showed favorable long-term outcomes and may be an alternative to pancreatoduodenectomy in patients with distal duodenal neoplasms.
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Affiliation(s)
- Tomotaka Kato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yoshihiro Ono
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Atsushi Oba
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takafumi Sato
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Hiromichi Ito
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Akio Saiura
- Department of Hepatobiliary-Pancreatic Surgery, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
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22
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Mungo B, Hammad A, AlMasri S, Dogeas E, Nassour I, Singhi AD, Zeh HJ, Hogg ME, Lee KKW, Zureikat AH, Paniccia A. Pancreaticoduodenectomy for benign and premalignant pancreatic and ampullary disease: is robotic surgery the better approach? Surg Endosc 2023; 37:1157-1165. [PMID: 36138252 PMCID: PMC11189669 DOI: 10.1007/s00464-022-09632-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 09/11/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND The robotic platform is increasingly being utilized in pancreatic surgery, yet its overall merits and putative advantages remain to be adjudicated. We hypothesize that the benefits of minimally invasive pancreatic surgery are maximized in pancreatic benign and premalignant disease, in the setting of friable pancreatic tissue and small pancreatic duct. METHODS Retrospective analysis of our prospectively maintained pancreatic database of all consecutive patients who underwent pancreaticoduodenectomy (PD) for benign or premalignant conditions between 2010 and 2020. Peri-operative outcomes and long-term complications were compared between robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD). RESULTS One hundred and eighty eight (n = 188) patients met our inclusion criteria, of which 68 were OPD and 120 RPD. Malignant histologies were excluded. There were only minor differences in baseline characteristics between the two groups. Post-operative merits of the RPD included lower clinically relevant post-operative pancreatic fistula 10 (8.3%) vs 24 (35.3%), p < 0.001, fewer surgical site infections; 9 (7.5%) vs 11 (16.2%), p = 0.024, shorter operative time, greater lymph node yield; 29 (IQR 21, 38) vs 21 (IQR 13, 34), p = 0.001, and lower 90 days mortality; 1 (0.8%) vs 4 (5.9%), p = 0.039. Rates of long-term complications were similar, exception made for a higher occurrence of small bowel obstruction (SBO) 2 (1.7%) vs 4 (5.9%), p = 0.031 and need for surgical intervention for SBO 0 (0.0%) vs 2 (2.9%), p = 0.019 in the OPD group. CONCLUSION Our study suggests that RPD benefits include lower 90-day mortality, shorter LOS, and lower rates of selected complications compared to open pancreaticoduodenectomy.
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Affiliation(s)
- Benedetto Mungo
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Scaife Hall, Suite A425, 3550 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Abdulrahman Hammad
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Scaife Hall, Suite A425, 3550 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Samer AlMasri
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Scaife Hall, Suite A425, 3550 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Epameinondas Dogeas
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Scaife Hall, Suite A425, 3550 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Ibrahim Nassour
- Division of Surgical Oncology, Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Aatur D Singhi
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Herbert J Zeh
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - Melissa E Hogg
- Department of Surgery, North Shore University, Chicago, IL, USA
| | - Kenneth K W Lee
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Scaife Hall, Suite A425, 3550 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Amer H Zureikat
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Scaife Hall, Suite A425, 3550 Terrace Street, Pittsburgh, PA, 15261, USA
| | - Alessandro Paniccia
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Scaife Hall, Suite A425, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.
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23
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Werba G, Napolitano MA, Sparks AD, Lin PP, Johnson LB, Vaziri K. Impact of preoperative biliary drainage on 30 Day outcomes of patients undergoing pancreaticoduodenectomy for malignancy. HPB (Oxford) 2022; 24:478-488. [PMID: 34538739 DOI: 10.1016/j.hpb.2021.08.942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 07/25/2021] [Accepted: 08/15/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Preoperative biliary drainage (PBD) has been advocated to address the plethora of physiologic derangements associated with cholestasis. However, available literature reports mixed outcomes and is based on largely outdated and/or single-institution studies. METHODS Patients undergoing PBD prior to pancreaticoduodenectomy (PD) for periampullary malignancy between 2014-2018 were identified in the ACS-NSQIP pancreatectomy dataset. Patients with PBD were propensity-score-matched to those without PBD and 30-day outcomes compared. RESULTS 8,970 patients met our inclusion criteria. 4,473 with obstruction and PBD were matched to 829 with no preoperative drainage procedure. In the non-jaundiced cohort, 711 stented patients were matched to 2,957 without prior intervention. PBD did not influence 30-day mortality (2.2% versus 2.4%) or major morbidity (19.8% versus 20%) in patients with obstructive jaundice. Superficial surgical site infections (SSIs) were more common with PBD (6.8% versus 9.2%), however, no differences in deep or organ-space SSIs were found. Patients without obstruction prior to PBD exhibited a 3-fold increase in wound dehiscence (0.5% versus 1.5%) additionally to increased superficial SSIs. CONCLUSION PBD was not associated with an increase in 30-day mortality or major morbidity but increased superficial SSIs. PBD should be limited to symptomatic, profoundly jaundiced patients or those with a delay prior to PD.
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Affiliation(s)
- Gregor Werba
- Department of Surgery, George Washington University, Washington, DC, USA.
| | | | - Andrew D Sparks
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Paul P Lin
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Lynt B Johnson
- Department of Surgery, George Washington University, Washington, DC, USA
| | - Khashayar Vaziri
- Department of Surgery, George Washington University, Washington, DC, USA
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24
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Khachfe HH, Habib JR, Chahrour MA, Harthi SA, Suhool A, Hallal AH, Jamali FJ. Pancreaticoduodenectomy (Whipple Procedure) research output: A 30-year bibliometric analysis. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2021.100053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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25
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Russell TB, Aroori S. Procedure‐specific morbidity of pancreatoduodenectomy: a systematic review of incidence and risk factors. ANZ J Surg 2022; 92:1347-1355. [DOI: 10.1111/ans.17473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/04/2022] [Accepted: 01/04/2022] [Indexed: 12/16/2022]
Affiliation(s)
- Thomas B Russell
- Department of HPB Surgery University Hospitals Plymouth NHS Trust Plymouth UK
| | - Somaiah Aroori
- Department of HPB Surgery University Hospitals Plymouth NHS Trust Plymouth UK
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26
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Franko J, Chamberlain DM, James AB, Collins A, Tee MC, Le VH, Frankova D. Rising Incidence of Peri-Operative Bactibilia among Patients Undergoing Complex Biliopancreatic Surgery. Surg Infect (Larchmt) 2021; 23:47-52. [PMID: 34619058 DOI: 10.1089/sur.2021.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Biliary instrumentation is associated with bactibilia and post-operative infection. Bactibilia incidence over time remains unknown. Patients and Methods: Consecutive patients with bilioenteric anastomosis surgery and available surveillance intra-operative bile duct cultures were evaluated for post-operative infection. The study period (2008-2019) was divided into quartiles to examine time-based trends. Results: Among 101 cases, 60 intra-operative bile duct cultures had no growth and 41 patients had documented at least one culture-positive isolate in their bile. Frequency of patients with culture-positive intra-operative bile increased over the study period (period 1, 1/28, 3.6% vs. period 2, 7/21, 33.3% vs. period 3, 15/26, 57.7% vs. period 4, 18/26, 69.2%; p < 0.001). Culture-positive post-operative infection (17/101; 16.8%) was not associated with intra-operative bile duct culture (p = 0.552), however, the same micro-organism isolate was identified on post-operative infection and intra-operative culture of bile duct bile among six of 17 patients (35.3%). Conclusions: We found an increasing incidence of bactibilia and post-operative culture-positive infections over the last decade. One-third of patients with a positive intra-operative bile duct culture experienced post-operative infection with the same organism, yet a clear link between bile colonization and post-operative infection was not established.
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Affiliation(s)
- Jan Franko
- MercyOne Medical Center, Des Moines, Iowa, USA
| | | | | | | | - May C Tee
- MercyOne Medical Center, Des Moines, Iowa, USA
| | - Viet H Le
- MercyOne Medical Center, Des Moines, Iowa, USA
| | - Daniela Frankova
- MercyOne Medical Center, Des Moines, Iowa, USA.,Des Moines University, Des Moines, Iowa, USA
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27
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Tonini V, Zanni M. Pancreatic cancer in 2021: What you need to know to win. World J Gastroenterol 2021; 27:5851-5889. [PMID: 34629806 PMCID: PMC8475010 DOI: 10.3748/wjg.v27.i35.5851] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 07/14/2021] [Accepted: 08/23/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic cancer is one of the solid tumors with the worst prognosis. Five-year survival rate is less than 10%. Surgical resection is the only potentially curative treatment, but the tumor is often diagnosed at an advanced stage of the disease and surgery could be performed in a very limited number of patients. Moreover, surgery is still associated with high post-operative morbidity, while other therapies still offer very disappointing results. This article reviews every aspect of pancreatic cancer, focusing on the elements that can improve prognosis. It was written with the aim of describing everything you need to know in 2021 in order to face this difficult challenge.
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Affiliation(s)
- Valeria Tonini
- Department of Medical Sciences and Surgery, University of Bologna- Emergency Surgery Unit, IRCCS Sant’Orsola Hospital, Bologna 40121, Italy
| | - Manuel Zanni
- University of Bologna, Emergency Surgery Unit, IRCCS Sant'Orsola Hospital, Bologna 40121, Italy
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28
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Gutierrez OB, Durso SC. An Elusive Case of Recurrent Gram-Negative Sepsis. Am J Med 2021; 134:1104-1106. [PMID: 33811880 DOI: 10.1016/j.amjmed.2021.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 01/27/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Olaya Brewer Gutierrez
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Samuel C Durso
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md.
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29
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Peltola E, Hannula P, Huhtala H, Metso S, Sand J, Laukkarinen J, Tiikkainen M, Sirén J, Soinio M, Nuutila P, Moilanen L, Laaksonen DE, Ebeling T, Arola J, Schalin-Jäntti C, Jaatinen P. Long-term morbidity and mortality in patients diagnosed with an insulinoma. Eur J Endocrinol 2021; 185:577-586. [PMID: 34374651 PMCID: PMC8784472 DOI: 10.1530/eje-21-0230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 08/06/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Insulinomas are rare functional pancreatic neuroendocrine tumours. As previous data on the long-term prognosis of insulinoma patients are scarce, we studied the morbidity and mortality in the Finnish insulinoma cohort. DESIGN Retrospective cohort study. METHODS Incidence of endocrine, cardiovascular, gastrointestinal and psychiatric disorders, and cancers was compared in all the patients diagnosed with an insulinoma in Finland during 1980-2010 (n = 79, including two patients with multiple endocrine neoplasia type 1 syndrome), vs 316 matched controls, using the Mantel-Haenszel method. Overall survival was analysed with Kaplan-Meier and Cox regression analyses. RESULTS The median length of follow-up was 10.7 years for the patients and 12.2 years for the controls. The long-term incidence of atrial fibrillation (rate ratio (RR): 2.07 (95% CI: 1.02-4.22)), intestinal obstruction (18.65 (2.09-166.86)), and possibly breast (4.46 (1.29-15.39) and kidney cancers (RR not applicable) was increased among insulinoma patients vs controls, P < 0.05 for all comparisons. Endocrine disorders and pancreatic diseases were more frequent in the patients during the first year after insulinoma diagnosis, but not later on. The survival of patients with a non-metastatic insulinoma (n = 70) was similar to that of controls, but for patients with distant metastases (n = 9), the survival was significantly impaired (median 3.4 years). CONCLUSIONS The long-term prognosis of patients with a non-metastatic insulinoma is similar to the general population, except for an increased incidence of atrial fibrillation, intestinal obstruction, and possibly breast and kidney cancers. These results need to be confirmed in future studies. Metastatic insulinomas entail a markedly decreased survival.
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Affiliation(s)
- Elina Peltola
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Division of Internal Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
- Correspondence should be addressed to E Peltola;
| | - Päivi Hannula
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Endocrinology, Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Saara Metso
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Endocrinology, Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Juhani Sand
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Johanna Laukkarinen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | | | - Jukka Sirén
- Surgery, Abdominal Center, Helsinki University Hospital, Helsinki, Finland
- Surgery, Abdominal Center, University of Helsinki, Helsinki, Finland
| | - Minna Soinio
- Department of Endocrinology, Division of Medicine, Turku University Hospital, Turku, Finland
| | - Pirjo Nuutila
- Department of Endocrinology, Division of Medicine, Turku University Hospital, Turku, Finland
- Turku PET Centre, University of Turku, Turku, Finland
| | - Leena Moilanen
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
| | | | - Tapani Ebeling
- Faculty of Medicine, University of Oulu, Oulu, Finland
- Endocrinology, Department of Medicine, Oulu University Hospital, Oulu, Finland
| | - Johanna Arola
- Pathology, HUSLAB, Helsinki University Hospital, Helsinki, Finland
- Pathology, University of Helsinki, Helsinki, Finland
| | - Camilla Schalin-Jäntti
- Endocrinology, Abdominal Center
- Endocrinology, Abdominal Center, University of Helsinki, Helsinki, Finland
| | - Pia Jaatinen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Division of Internal Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
- Endocrinology, Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
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30
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Nofi CP, Maloney C, Kallis MP, Levy AT, Nealon WH, Weiss MJ, DePeralta DK. Rare, long-term complication after pancreatoduodenectomy-a case report of cecal volvulus. J Surg Case Rep 2021; 2021:rjab202. [PMID: 34084448 PMCID: PMC8163421 DOI: 10.1093/jscr/rjab202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 04/21/2021] [Accepted: 04/23/2021] [Indexed: 11/23/2022] Open
Abstract
Complications after pancreatoduodenectomy are common, and range widely in timing of presentation, relation to pancreatobiliary pathology, and necessity of operative intervention. We present a case of a 74-year-old male with history of pancreatoduodenectomy for pancreatic adenocarcinoma who presented 11 months after index operation with cecal volvulus and required emergent right hemicolectomy. Prior history of pancreatoduodenectomy with mobilization of the right colon likely predisposed him to development of this surgical emergency. Patients have altered gastrointestinal anatomy after pancreatoduodenectomy and special care is necessary to protect the afferent biliopancreatic limb during intraoperative exploration, and particularly if right colectomy is necessary.
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Affiliation(s)
- Colleen P Nofi
- Northwell North Shore/Long Island Jewish, Department of Surgery, Queens, NY 11040, USA
| | - Caroline Maloney
- Northwell North Shore/Long Island Jewish, Department of Surgery, Queens, NY 11040, USA
| | - Michelle P Kallis
- Northwell North Shore/Long Island Jewish, Department of Surgery, Queens, NY 11040, USA
| | - Anna T Levy
- Northwell North Shore/Long Island Jewish, Department of Hematology/Oncology, Queens, NY 11040, USA
| | - William H Nealon
- Northwell North Shore/Long Island Jewish, Department of Surgery, Queens, NY 11040, USA
| | - Matthew J Weiss
- Northwell North Shore/Long Island Jewish, Department of Surgery, Queens, NY 11040, USA
| | - Danielle K DePeralta
- Northwell North Shore/Long Island Jewish, Department of Surgery, Queens, NY 11040, USA
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31
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Jung JH, Choi DW, Yoon S, Yoon SJ, Han IW, Heo JS, Shin SH. Three Thousand Consecutive Pancreaticoduodenectomies in a Tertiary Cancer Center: A Retrospective Observational Study. J Clin Med 2020; 9:jcm9082558. [PMID: 32784559 PMCID: PMC7465877 DOI: 10.3390/jcm9082558] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/05/2020] [Accepted: 08/05/2020] [Indexed: 01/06/2023] Open
Abstract
(1) Aim: To evaluate clinicopathological features and postoperative outcomes including survival in patients who underwent pancreaticoduodenectomy (PD) for periampullary diseases. (2) Methods: We retrospectively reviewed 3078 cases of PD performed in our center for 25 years. Periampullary diseases were divided into benign and malignancy groups. All cases were also classified by location. The time of 25 years was divided to different periods (5 years per period) to compare outcomes. Overall survival was compared between subdivided periods. (3) Results: Hospitalization became significantly shorter from 28.0 days in the 1st period to 13.8 days in the 5th period. Overall complication rate was significantly increased since the 3rd period. The rate without postoperative pancreatic fistula (POPF) was high at 98.7% in the 1st period. This might be because drain amylase on the 3rd day after PD was not routinely checked in the past. Thus, POPF was not detected. In survival analysis of adenocarcinoma of pancreas, bile duct, and ampulla, overall survival was found to be improved significantly in recent years. (4) Conclusions: Our study revealed that outcomes were improved with increasing number of PDs performed. Although POPF and overall complications showed increases more recently, those were detected and managed, resulting in shorter hospitalization and improved outcomes.
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Affiliation(s)
| | | | | | | | | | | | - Sang Hyun Shin
- Correspondence: ; Tel.: +82-2-3410-1089; Fax: +82-2-3410-6980
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