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Tang B, Wen Y, Li S, Ma J, Yang L, Duan N, Xiang C, Tian X, Dong J, Wang P, Wang X. Positive drain fluid culture on postoperative day one is associated with an increased risk of late postoperative pancreatic fistula after pancreaticoduodenectomy. Langenbecks Arch Surg 2025; 410:56. [PMID: 39875709 PMCID: PMC11775035 DOI: 10.1007/s00423-025-03621-y] [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: 10/25/2024] [Accepted: 01/16/2025] [Indexed: 01/30/2025]
Abstract
PURPOSE To investigate the risk factors for late postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy (PD), with a focus on positive drain fluid culture (DFC) results on postoperative day (POD) 1. METHODS Medical records of 198 patients who underwent PD with drain fluid amylase (DFA) on POD 5 < 3x upper limit of normal (ULN) were included. Late POPF was defined as POPF diagnosed post-POD 6, with DFA on POD 5 < 3xULN. Risk factors analyses were performed, with a focus on DFC on POD 1. RESULTS Nineteen patients (9.6%) were diagnosed with late POPF. Age > 65 years (OR: 4.019, P = 0.034) and positive DFC on POD 1 (OR: 10.151, P < 0.001) were identified as independent predictors of late POPF. Patients with positive DFC on POD 1 (n = 25) had higher rates of late POPF (44% vs. 4.6%, P < 0.001), postpancreatectomy hemorrhage (20% vs. 5.8%, P = 0.027) and Clavien-Dindo ≥ IIIa complications (44% vs. 6.4%, P < 0.001). The majority of patients (57.9%) with late POPF had positive DFC on POD 1 (11 of 19, 57.9%). The isolates from 11 patients with positive DFC on POD 1 yielded 12 microorganisms, the most prevalent of which were Enterobacter (n = 7), followed by Enterococcus (n = 3) and Staphylococcus (n = 2). Cefmetazole resistance was detected in 66.7% (8 of 12) of the microorganisms. CONCLUSION Age > 65 years and positive DFC on POD 1 were independent predictors of late POPF after PD. Positive DFC on POD 1 was associated with a higher rate of complications.
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Affiliation(s)
- Bingjun Tang
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yan Wen
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Sijia Li
- Department of Gastrointestinal Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Jiming Ma
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Liuqing Yang
- Department of Information administration, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Ning Duan
- Department of Clinical Laboratory, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Canhong Xiang
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Xiaodong Tian
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Jiahong Dong
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
- Key laboratory of Digital Intelligence Hepatology (Ministry of Education), School of Clinical Medicine, Tsinghua University, Beijing, China
- Research Unit of Precision Hepatobiliary Surgery Paradigm, Chinese Academy of Medical Sciences, Beijing, China
| | - Pengfei Wang
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China.
| | - Xuedong Wang
- Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China.
- Key laboratory of Digital Intelligence Hepatology (Ministry of Education), School of Clinical Medicine, Tsinghua University, Beijing, China.
- Research Unit of Precision Hepatobiliary Surgery Paradigm, Chinese Academy of Medical Sciences, Beijing, China.
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Zhou Y, Lu F, Lin X, Yang Y, Wang C, Fang H, Lin R, Huang H. Drainage posterior to pancreaticojejunostomy reduces the severity of postoperative pancreatic fistula after pancreaticoduodenectomy. World J Surg Oncol 2024; 22:315. [PMID: 39605037 PMCID: PMC11600557 DOI: 10.1186/s12957-024-03597-x] [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: 08/24/2024] [Accepted: 11/17/2024] [Indexed: 11/29/2024] Open
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) is a common postoperative complication after pancreaticoduodenectomy (PD) and is associated with severe complications. Drainage is an effective method to treat POPF and prevent POPF-related complications. However, controversy still exists about whether different drainage methods reduce the incidence or the severity of POPF after PD. METHODS A closed suction drainage was placed posterior to pancreaticojejunostomy in PD except for other routine drainage placements. A retrospective study was conducted to calculate the incidence and severity of CR-POPF and POPF-related complications and to evaluate the efficacy of this drainage method. RESULTS 295 patients who underwent PD were enrolled in this study, 130 patients in the trial group and 165 patients in the control group. The two groups were comparable in both preoperative and intraoperative characteristics. The overall incidence of CR-POPF was similar between the two groups. The trial group had a significantly decreased incidence of grade C POPF (0% vs. 3.6%, p < 0.05), post-pancreatectomy hemorrhage (PPH) (0% vs. 6.1%, p = 0.003), reoperation (0% vs. 3.6%, p = 0.036), intra-abdominal infection (13.1% vs. 25.5%, p = 0.008), and delayed gastric emptying (DGE) (2.3% vs. 8.5%, p = 0.024) than the control group. Subgroup analysis of patients with intermediate/high risk for CR-POPF mirrored these results. Logistic regression identified obstructive jaundice, biliary fistula, POPF, and DGE as independent risk factors for PPH and reoperation, though the results were not significant in multivariate analysis. CONCLUSIONS The drainage posterior to pancreaticojejunostomy reduces the severity of POPF and the incidence of POPF-related complications after PD.
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Affiliation(s)
- Yuan Zhou
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Fengchun Lu
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Xianchao Lin
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Yuanyuan Yang
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Congfei Wang
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Haizong Fang
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Ronggui Lin
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China.
| | - Heguang Huang
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China.
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Okamoto H, Yamamoto A, Kawashima K, Fukasawa T. Simpler and safer anastomosis by pancreaticogastrostomy using a linear stapler after pancreaticoduodenectomy. Medicine (Baltimore) 2024; 103:e40456. [PMID: 39533592 PMCID: PMC11557076 DOI: 10.1097/md.0000000000040456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2024] [Accepted: 10/22/2024] [Indexed: 11/16/2024] Open
Abstract
Postoperative pancreatic fistula (POPF) remains a major and serious problem after pancreaticoduodenectomy (PD). In its presence, pancreatic juice may leak from the main duct or branches of the pancreatic stump. To prevent this, we have applied a newly modified anastomosis of pancreaticogastrostomy (PG) using a linear stapler (stapled PG). Clinical records of 30 consecutive patients who underwent PD were reviewed between 2013 and 2023 at our community hospital. Regarding procedures, 12 stapled PGs and eighteen pancreaticojejunostomies (PJs) were performed after PD, from 2018 to 2023 and from 2013 to 2017, respectively. The pancreas was transected for long compression by a linear stapler, involving: pre-compression for 5 min, stapling for 5 min, and dissection for 5 min. After removal of the staples at the main duct opening of the pancreatic stump, PG anastomosis was performed. The outer layer was anastomosed by a straight single row pancreas-transfixing suture with the posterior gastric wall, and inner layer duct-to-mucosa anastomosis was also performed in a radial axis manner. Anastomosis of PJ was conducted without using a linear stapler. POPF was defined as a clinical manifestation of POPF (grade B/C) based on the ISGPF (International Study Group of Pancreatic Fistula) criteria. None of the 12 patients who had undergone stapled PG developed clinically relevant POPF, whereas 5 (27%) patients who had received PJ developed POPF. Three patients showed POPF grade B and 2 patients exhibited POPF grade C. Stapled PG after PD may reduce clinically relevant POPF. Because our sample size was small, the further accumulation of cases is required to validate this method.
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Affiliation(s)
- Hirotaka Okamoto
- Department of Surgery, Tsuru Municipal Hospital, Tsuru City, Yamanashi, Japan
| | - Atsushi Yamamoto
- Department of Surgery, Tsuru Municipal Hospital, Tsuru City, Yamanashi, Japan
| | - Kenji Kawashima
- Department of Surgery, Tsuru Municipal Hospital, Tsuru City, Yamanashi, Japan
| | - Toshio Fukasawa
- Department of Surgery, Tsuru Municipal Hospital, Tsuru City, Yamanashi, Japan
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Kimura N, Ishido K, Wakiya T, Nagase H, Odagiri T, Wakasa Y, Hakamada K. Revealing the role of early peripancreatic bacterial contamination and Enterococcus faecalis in pancreatic fistula development after pancreaticoduodenectomy: Implications for useful antibiotic prophylaxis-An observational cohort study. Pancreatology 2024; 24:630-642. [PMID: 38508910 DOI: 10.1016/j.pan.2024.03.008] [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: 01/03/2024] [Revised: 02/26/2024] [Accepted: 03/13/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Peripancreatic bacterial contamination (PBC) is a critical factor contributing to the development of clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD). Controlling pathogenic bacteria is essential in preventing CR-POPF; however, the precise relationship between specific bacteria and CR-POPF remains unclear. This study aimed to investigate the relationship between PBC and CR-POPF after PD, with a focus on identifying potentially causative bacteria. METHODS This prospective observational study enrolled 370 patients who underwent PD. Microbial cultures were routinely collected from peripancreatic drain fluid on postoperative days (PODs) 1, 3, and 6. Predictive factors for CR-POPF and the bacteria involved in PBC were investigated. RESULTS CR-POPF occurred in 86 (23.2%) patients. In multivariate analysis, PBC on POD1 (Odds ratio [OR] = 3.59; P = 0.005) was one of the main independent predictive factors for CR-POPF, while prophylactic use of antibiotics other than piperacillin/tazobactam independently influenced PBC on POD1 (OR = 2.95; P = 0.010). Notably, Enterococcus spp., particularly Enterococcus faecalis, were significantly isolated from PBC in patients with CR-POPF compared to those without CR-POPF on PODs 1 and 3 (P < 0.001), and they displayed high resistance to all cephalosporins. CONCLUSIONS Early PBC plays a pivotal role in the development of CR-POPF following PD. Prophylactic antibiotic administration, specifically targeting Enterococcus faecalis, may effectively mitigate early PBC and subsequently reduce the risk of CR-POPF. This research sheds light on the importance of bacterial control strategies in preventing CR-POPF after PD.
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Affiliation(s)
- Norihisa Kimura
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan.
| | - Keinosuke Ishido
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan
| | - Taiichi Wakiya
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan
| | - Hayato Nagase
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan
| | - Tadashi Odagiri
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan
| | - Yusuke Wakasa
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan
| | - Kenichi Hakamada
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan
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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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Pang T, Wu Z, Zeng H, Zhang X, Hu M, Cao L. Analysis of the risk factors for secondary hemorrhage after abdominal surgery. Front Surg 2023; 10:1091162. [PMID: 37346762 PMCID: PMC10279872 DOI: 10.3389/fsurg.2023.1091162] [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: 11/06/2022] [Accepted: 02/24/2023] [Indexed: 06/23/2023] Open
Abstract
Introduction This study aimed to conduct a clinical review and analysis to recommend options for the prevention and treatment of postoperative hemorrhage. Patients and Methods A total of 138 patients who experienced postoperative hemorrhage after abdominal surgery in the period between January 2015 and December 2020 at the Sir Run Run Shaw Hospital, affiliated to Zhejiang University School of Medicine, participated in this study. They were divided into a group with primary bleeding only and a secondary bleeding group. Univariate and multivariate statistical analyses were performed, followed by plotting of cumulative hazard and survival curves for the two groups. Results The main factors of interest found to be associated with secondary hemorrhage were duration of the operation, the time of the first bleeding incident, intervention time, performance of combined organ resection, use of surgical intervention, occurrence of abdominal infection, admission to the intensive care unit (ICU), postoperative length of stay, and total hospitalization expenses. Among these, a long operative duration (>5 h) and an extended intervention time (>5 h) were identified as independent predictors of risk of secondary hemorrhage. Conclusions Secondary hemorrhage after abdominal surgery is mainly associated with subjective human factors, and it is an important cause of poor prognosis and even death. Proper reductions in operation time and implementation of a quick response to bleeding are the key factors in tackling bleeding. Further reduction in the rates of postoperative hemorrhage and mortality will require a concerted effort by surgeons in terms of both intraoperative surgical techniques and postoperative management.
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Affiliation(s)
- Tianshu Pang
- Department of General Surgery, School of Medicine, Sir RunRun Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Zhengrong Wu
- Department of General Surgery, School of Medicine, Sir RunRun Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Hongfen Zeng
- Department of Nursing, School of Medicine, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Xiangyu Zhang
- Department of General Surgery, School of Medicine, Sir RunRun Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Mengya Hu
- Department of Nursing, School of Medicine, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Liping Cao
- Department of General Surgery, School of Medicine, Sir RunRun Shaw Hospital, Zhejiang University, Hangzhou, China
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Lin R, Liu Y, Lin X, Lu F, Yang Y, Wang C, Fang H, Chen Y, Huang H. A randomized controlled trial evaluating effects of prophylactic irrigation-suction near pancreaticojejunostomy on postoperative pancreatic fistula after pancreaticoduodenectomy. Langenbecks Arch Surg 2023; 408:137. [PMID: 37010643 DOI: 10.1007/s00423-023-02873-w] [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: 03/15/2022] [Accepted: 03/30/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND Clinically relevant postoperative pancreatic fistula (CR-POPF) is a common complication after pancreaticoduodenectomy (PD). However, whether irrigation-suction (IS) decreases the incidence and severity of CR-POPF has not yet been well elucidated. METHODS One hundred and twenty patients with planned PD were enrolled in the study at a high-volume pancreatic center in China from August 2018 to January 2020. A randomized controlled trial (RCT) was conducted to evaluate whether irrigation-suction (IS) decreases the incidence and severity of CR-POPF and other postoperative complications after PD. The primary endpoint was the incidence of CR-POPF, and the secondary endpoints were other postoperative complications. RESULTS Sixty patients were assigned to the control group and 60 patients to the IS group. The IS group had a comparable POPF rate (15.0% vs. 18.3%, p = 0.806) but a lower incidence of intra-abdominal infection (8.3% vs. 25.0%, p = 0.033) than the control group. The incidences of other postoperative complications were comparable in the two groups. The subgroup analysis for patients with intermediate/high risks for POPF also showed an equivalent POPF rate (17.0% vs. 20.4%, p = 0.800) and a significantly decreased incidence of intra-abdominal infection (8.5% vs. 27.8%, p = 0.020) in the IS group than that in the control group. The logistic regression models indicated that POPF was an independent risk factor for intra-abdominal infection (OR 0.049, 95% CI 0.013-0.182, p = 0.000). CONCLUSIONS Irrigation-suction near pancreaticojejunostomy does not reduce the incidence or severity of postoperative pancreatic fistula but decreases the incidence of intra-abdominal infection after pancreaticoduodenectomy.
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Affiliation(s)
- Ronggui Lin
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Yuhuang Liu
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Xianchao Lin
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Fengchun Lu
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Yuanyuan Yang
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Congfei Wang
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Haizong Fang
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Yanchang Chen
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China
| | - Heguang Huang
- Department of General Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People's Republic of China.
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Positive drain fluid culture on postoperative day 1 predicts clinically relevant pancreatic fistula in early drain removal with higher drain fluid amylase after pancreaticoduodenectomy. Surgery 2023; 173:511-520. [PMID: 36402610 DOI: 10.1016/j.surg.2022.10.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 09/07/2022] [Accepted: 10/05/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND This study aimed to clarify the risk factors of clinically relevant pancreatic fistula after early drain removal with higher drain fluid amylase after pancreaticoduodenectomy. Clinical evaluation of early drain removal with a higher drain fluid amylase after pancreaticoduodenectomy has been controversial. The safety and effectiveness have not been sufficiently examined. METHODS Between 2015 and 2020, prophylactic surgical drains were prospectively removed on postoperative day 4 regardless of drain fluid amylase level in 364 study-eligible patients who underwent pancreaticoduodenectomy. Patients were classified according to drain fluid amylase on postoperative day 1: 281 patients with drain fluid amylase <4,000 U/L, and 83 patients with drain fluid amylase ≥4,000 U/L. RESULTS Clinically relevant pancreatic fistula occurred in 40 of 364 enrolled patients (11.0%). In the entire cohort, male, positive postoperative day 1 drain fluid culture, and postoperative day 1 drain fluid amylase ≥4,000 U/L were independent risk factors for clinically relevant pancreatic fistula after early drain removal. When stratifying by 4,000 U/L of postoperative day 1 drain fluid amylase, the rate of clinically relevant pancreatic fistula in postoperative day 1 drain fluid amylase <4,000 U/L was significantly lower than that in postoperative day 1 drain fluid amylase ≥4,000 U/L (4% vs 35%, P < .001) after early drain removal. Moreover, in postoperative day 1 drain fluid amylase <4,000 U/L, positive postoperative day 1 drain fluid culture did not develop clinically relevant pancreatic fistula after early drain removal. However, in postoperative day 1 drain fluid amylase ≥4,000 U/L, multivariate analysis clarified that positive postoperative day 1 drain fluid culture was the only independent risk factor of clinically relevant pancreatic fistula after early drain removal (odds ratio 26.27, 95% confidence interval 5.59-123.56, P = .001). CONCLUSION Positive drain fluid culture on postoperative day 1 might predict clinically relevant pancreatic fistula in early drain removal with a higher drain fluid amylase.
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Rykina-Tameeva N, Samra JS, Sahni S, Mittal A. Drain fluid biomarkers for prediction and diagnosis of clinically relevant postoperative pancreatic fistula: A narrative review. World J Gastrointest Surg 2022; 14:1089-1106. [PMID: 36386401 PMCID: PMC9640330 DOI: 10.4240/wjgs.v14.i10.1089] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 09/16/2022] [Accepted: 10/14/2022] [Indexed: 02/07/2023] Open
Abstract
Clinically relevant postoperative pancreatic fistula (CR-POPF) has continued to compromise patient recovery post-pancreatectomy despite decades of research seeking to improve risk prediction and diagnosis. The current diagnostic criteria for CR-POPF requires elevated drain fluid amylase to present alongside POPF-related complications including infection, haemorrhage and organ failure. These worrying sequelae necessitate earlier and easily obtainable biomarkers capable of reflecting evolving CR-POPF. Drain fluid has recently emerged as a promising source of biomarkers as it is derived from the pancreas and hence, capable of reflecting its postoperative condition. The present review aims to summarise the current knowledge of CR-POPF drain fluid biomarkers and identify gaps in the field to invigorate future research in this critical area of clinical need. These findings may provide robust diagnostic alternatives for CR-POPF and hence, to clarify their clinical utility require further reports detailing their diagnostic and/or predictive accuracy.
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Affiliation(s)
| | - Jaswinder S Samra
- Northern Clinical School, University of Sydney, St Leonards 2065, Australia
| | - Sumit Sahni
- Northern Clinical School, University of Sydney, St Leonards 2065, Australia
| | - Anubhav Mittal
- Northern Clinical School, University of Sydney, St Leonards 2065, Australia
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A Comprehensive Review of the Current and Future Role of the Microbiome in Pancreatic Ductal Adenocarcinoma. Cancers (Basel) 2022; 14:cancers14041020. [PMID: 35205769 PMCID: PMC8870349 DOI: 10.3390/cancers14041020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/11/2022] [Accepted: 02/15/2022] [Indexed: 02/07/2023] Open
Abstract
Simple Summary This review summarizes the current literature related to the microbiome and pancreatic ductal adenocarcinoma (PDAC). The aim of this review is to explore the current role of the microbiome in the disease process, screening/diagnostics and to postulate the future role with regards to therapeutic strategies including chemotherapy, immunotherapy and surgery. We further explore the future of microbiome modulation (faecal microbiome transplants, bacterial consortiums, anti-microbials and probiotics), their applications and how we can improve the future of microbiome modulation in a bid to improve PDAC outcomes. Abstract Pancreatic ductal adenocarcinoma (PDAC) is expected to become the second most common cause of cancer death in the USA by 2030, yet progress continues to lag behind that of other cancers, with only 9% of patients surviving beyond 5 years. Long-term survivorship of PDAC and improving survival has, until recently, escaped our understanding. One recent frontier in the cancer field is the microbiome. The microbiome collectively refers to the extensive community of bacteria and fungi that colonise us. It is estimated that there is one to ten prokaryotic cells for each human somatic cell, yet, the significance of this community in health and disease has, until recently, been overlooked. This review examines the role of the microbiome in PDAC and how it may alter survival outcomes. We evaluate the possibility of employing microbiomic signatures as biomarkers of PDAC. Ultimately this review analyses whether the microbiome may be amenable to targeting and consequently altering the natural history of PDAC.
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11
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Zaitsu Y, Nishizaki T, Izumi T, Taniguchi D, Kajiwara Y, Oshiro Y, Minami K. Pancreatic enzymatic mediastinitis followed by total gastrectomy with splenectomy: report of two cases. Surg Case Rep 2021; 7:149. [PMID: 34175974 PMCID: PMC8236423 DOI: 10.1186/s40792-021-01240-5] [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: 04/28/2021] [Accepted: 06/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute mediastinitis is a rare disease that rapidly progresses with a high mortality rate. Its most common cause is direct injury of the mediastinum, including iatrogenic causes such as cardiac surgery or upper endoscopy. Enzymatic mediastinitis is a rare complication of a pancreatic fistula caused by the inflammatory digestion of the parietal peritoneum spreading to the mediastinum. Here, we present two cases of enzymatic mediastinitis caused by total gastrectomy with splenectomy. One of them was successfully treated and cured after early diagnosis and transabdominal drainage. CASE PRESENTATION Case 1 was that of a 60-year-old man (body mass index [BMI] 27) with a medical history of diabetes and hypertension who was diagnosed with advanced gastric cancer in the upper body of the stomach. A total gastrectomy with splenectomy was performed. The patient experienced acute respiratory failure 24 h after surgery. Pulmonary embolism was suspected, so a computed tomography (CT) scan was performed; however, no relevant causes were found. Although he was immediately intubated and treated with catecholamine, he died in the intensive care unit (ICU) 40 h after surgery. Post-mortem findings revealed retroperitonitis caused by a pancreatic fistula spreading towards the mediastinum, causing severe mediastinitis; a review of the CT scan revealed pneumomediastinum. We concluded that the cause of death was enzymatic mediastinitis due to post-gastrectomy pancreatic fistula. Case 2 involved a 61-year-old man (BMI 25) with a medical history of appendicitis who was diagnosed with advanced gastric cancer at the gastric angle between the lesser curvature and the pylorus, spreading to the upper body of the stomach. A total gastrectomy with splenectomy was also performed. The patient had a high fever 3 days after the surgery, and a CT scan revealed pneumomediastinum, indicating mediastinitis. As the inflammation was below the bronchial bifurcation, we chose a transabdominal approach for drainage. The patient was successfully treated and discharged. CONCLUSION Acute mediastinitis caused by gastrectomy is rare. The acknowledgment of abdominal surgery as a cause of mediastinitis is important. In treating mediastinitis caused by abdominal surgery, transabdominal drainage may be a minimally invasive yet effective method if the inflammation is mainly located below the bifurcation of the trachea.
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Affiliation(s)
- Yoko Zaitsu
- Department of Gastroenterological Surgery, The Cancer Institute Hospital Of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Takashi Nishizaki
- Department of Surgery, Matsuyama Red Cross Hospital, 1 Bunkyo-Cho, Matsuyama, Ehime, 790-8524, Japan
| | - Takuma Izumi
- Department of Surgery, Matsuyama Red Cross Hospital, 1 Bunkyo-Cho, Matsuyama, Ehime, 790-8524, Japan
| | - Daisuke Taniguchi
- Department of Surgery, Matsuyama Red Cross Hospital, 1 Bunkyo-Cho, Matsuyama, Ehime, 790-8524, Japan
| | - Yuichiro Kajiwara
- Department of Surgery, Matsuyama Red Cross Hospital, 1 Bunkyo-Cho, Matsuyama, Ehime, 790-8524, Japan
| | - Yumi Oshiro
- Department of Diagnostic Pathology, Matsuyama Red Cross Hospital, 1 Bunkyo-Cho, Matsuyama, Ehime, 790-8524, Japan
| | - Kazuhito Minami
- Department of Surgery, Matsuyama Red Cross Hospital, 1 Bunkyo-Cho, Matsuyama, Ehime, 790-8524, Japan
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Chen W, Zhang K, Zhang Z, Lu Z, Zhang D, Liu J, Yang Y, Leng Y, Zhang Y, Zhang W, Jiang K, Zhuang G, Miao Y, Liu Y. Pancreatoduodenectomy within 2 weeks after endoscopic retrograde cholangio-pancreatography increases the risk of organ/space surgical site infections: a 5-year retrospective cohort study in a high-volume centre. Gland Surg 2021; 10:1852-1864. [PMID: 34268070 PMCID: PMC8258873 DOI: 10.21037/gs-20-826] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 05/18/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Organ/space surgical site infections (OSSI) after pancreaticoduodenectomy (PD) are not rare events. The role of diagnosis and treatment for pancreatic and biliary diseases with an endoscopic retrograde cholangio-pancreatography (ERCP) procedure is currently controversial. However, the ERCP procedure might play a role in surgical outcomes after PD. METHODS We conducted a retrospective cohort study for patients who underwent PD in the First Affiliated Hospital with the Nanjing Medical University from 1st September 2012 to 31st January 2018. The relationship between ERCP exposure and OSSI after PD was analyzed by univariate and forward stepwise multivariate logistic regression model. RESULTS Of the 1,365 patients who underwent PD, 136 developed OSSI (10.0%). We found that ERCP exposure before PD (EEBPD) was significantly associated with an increased incidence rate of post-operative pancreas fistula (POPF) [24.2% (23/95) vs. 14.9% (189/1,270), risk ratio (RR) =1.63, 95% confidence interval (CI), 1.11-2.38, P=0.015]. Hypertension, a higher level of preoperative low-density lipoprotein (LDL) and creatinine (Cr) were associated with elevated risks of post-operative OSSI [adjusted odds ratio (Adj-OR) (95% CI) were 1.59 (1.09-2.32), 1.70 (1.16-2.51), 1.99 (1.36-2.92)], whereas a preoperatively higher level of aspartate aminotransferase (AST) would decrease the risk [Adj-OR (95% CI), 0.62 (0.42-0.91)]. Remarkably, EEBPD would significantly increase and more than double the OSSI risk [Adj-OR (95% CI), 2.56 (1.46-4.47)] especially if it was within 14 days before surgery (Spearman =-0.698, P<0.001). CONCLUSIONS ERCP, as an independent risk factor, significantly increased the risk of post-operative OSSI after PD if it is performed within 14 days prior to surgery. Our findings would assist clinical decision-making, and improve OSSI control and prevention.
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Affiliation(s)
- Wensen Chen
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
- Office of Infection Management, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Kai Zhang
- Pancreas Center, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Pancreas Institute of Nanjing Medical University, Nanjing, China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zipeng Lu
- Pancreas Center, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Pancreas Institute of Nanjing Medical University, Nanjing, China
| | - Daoquan Zhang
- Department of Endoscopy, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Juan Liu
- Office of Infection Management, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yue Yang
- Office of Infection Management, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yinzhi Leng
- Department of Infection, Nanjing Traditional Chinese Medicine Hospital, Nanjing, China
| | - Yongxiang Zhang
- Office of Infection Management, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Weihong Zhang
- Office of Infection Management, Jiangsu Province Hospital & Jiangsu Shengze Hospital, Suzhou, China
| | - Kuirong Jiang
- Pancreas Center, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Pancreas Institute of Nanjing Medical University, Nanjing, China
| | - Guihua Zhuang
- Department of Epidemiology and Biostatistics, School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Yi Miao
- Pancreas Center, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Pancreas Institute of Nanjing Medical University, Nanjing, China
| | - Yun Liu
- Department of Geriatrics Endocrinology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Department of Medical Informatics, School of Biomedical Engineering and Informatics, Nanjing Medical University, Nanjing, China
- Institute of Medical Informatics and Management, Nanjing Medical University, Nanjing, China
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13
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Ohgi K, Yamamoto Y, Sugiura T, Okamura Y, Ito T, Ashida R, Uesaka K. The clinical impact and risk factors of latent pancreatic fistula after pancreatoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:1002-1010. [DOI: 10.1002/jhbp.820] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/29/2020] [Accepted: 08/07/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Katsuhisa Ohgi
- Division of Hepato‐Biliary‐Pancreatic Surgery Shizuoka Cancer Center Shizuoka Japan
| | - Yusuke Yamamoto
- Division of Hepato‐Biliary‐Pancreatic Surgery Shizuoka Cancer Center Shizuoka Japan
| | - Teiichi Sugiura
- Division of Hepato‐Biliary‐Pancreatic Surgery Shizuoka Cancer Center Shizuoka Japan
| | - Yukiyasu Okamura
- Division of Hepato‐Biliary‐Pancreatic Surgery Shizuoka Cancer Center Shizuoka Japan
| | - Takaaki Ito
- Division of Hepato‐Biliary‐Pancreatic Surgery Shizuoka Cancer Center Shizuoka Japan
| | - Ryo Ashida
- Division of Hepato‐Biliary‐Pancreatic Surgery Shizuoka Cancer Center Shizuoka Japan
| | - Katsuhiko Uesaka
- Division of Hepato‐Biliary‐Pancreatic Surgery Shizuoka Cancer Center Shizuoka Japan
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14
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Hiraki M, Miyoshi A, Sadashima E, Shinkai Y, Yasunami M, Manabe T, Kitahara K, Noshiro H. The novel early predictive marker presepsin for postoperative pancreatic fistula: A pilot study. Exp Ther Med 2020; 20:2298-2304. [PMID: 32765708 DOI: 10.3892/etm.2020.8919] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 03/26/2020] [Indexed: 12/13/2022] Open
Abstract
Postoperative pancreatic fistula (PF) is a major and serious complication that occurs after pancreaticoduodenectomy (PD). The aim of the current study was to evaluate the use of a novel biomarker, presepsin, for predicting clinically relevant postoperative pancreatic fistula (CR-POPF) after PD. A prospective pilot study was conducted using 30 consecutive patients who underwent PD. Risk factors and candidates for predictive biomarkers for CR-POPF were statistically analyzed. CR-POPF (grade B and C; determined according to the guidelines of the International Study Group of Pancreatic Fistula) occurred in 15 patients (50%). Univariate analysis revealed that certain underlying conditions, including non-pancreatic cancer, smaller pancreatic ducts and soft pancreas texture were significantly associated with CR-POPF (P=0.005, P=0.004 and P=0.014, respectively). Furthermore, on day 1 post surgery (POD1), white blood cell count (P=0.040), levels of serum amylase (P=0.002) and serum presepsin (P=0.012), and the concentration of presepsin in drainage fluid (P<0.001) were significantly increased in CR-POPF compared with non-CR-POPF cases. Receiver operating characteristic curve analyses revealed that, on POD1, serum amylase and the concentration of presepsin in drainage fluid had an area under the curve value exceeding 0.8. A multivariate logistic regression analysis revealed that a higher concentration of presepsin in the drainage fluid was an independent predictive marker for CR-POPF (odds ratio, 14.503; 95% confidence interval, 1.750-120.229; P=0.013). To the best of our knowledge, the present study demonstrated for the first time that presepsin concentration in drainage fluid is a useful marker of CR-POPF after PD.
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Affiliation(s)
- Masatsugu Hiraki
- Department of Surgery, Saga Medical Center Koseikan, Saga 840-8571, Japan
| | - Atsushi Miyoshi
- Department of Surgery, Saga Medical Center Koseikan, Saga 840-8571, Japan
| | - Eiji Sadashima
- Life Science Research Institution, Saga Medical Center Koseikan, Saga 840-8571, Japan
| | - Yukio Shinkai
- Clinical Laboratory, Saga Medical Center Koseikan, Saga 840-8571, Japan
| | - Michio Yasunami
- Clinical Laboratory, Saga Medical Center Koseikan, Saga 840-8571, Japan
| | - Tatsuya Manabe
- Department of Surgery, Saga University Faculty of Medicine, Saga 849-8501, Japan
| | - Kenji Kitahara
- Department of Surgery, Saga Medical Center Koseikan, Saga 840-8571, Japan
| | - Hirokazu Noshiro
- Department of Surgery, Saga University Faculty of Medicine, Saga 849-8501, Japan
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15
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Mizutani S, Murata M, Taniai N, Sukegawa M, Nakata R, Furuki H, Yoshida H. Förster resonance energy transfer (FRET)-Labeled nanoprobe enables real-time diagnosis of pancreatic juice activation due to postoperative pancreatic fistula. Pancreatology 2020; 20:960-967. [PMID: 32622759 DOI: 10.1016/j.pan.2020.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 05/13/2020] [Accepted: 06/01/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Postoperative pancreatic fistula (POPF) subsequent to pancreatectomy often causes activation of pancreatic juice, resulting in serious complications. In POPF, the types of pancreatic juices found are active and inactive, and the identification of these two types of pancreatic juice greatly contributes to the development of postoperative management after pancreatectomy. This study reports favorable results of the clinical application of the Förster resonance energy transfer (FRET) nanoprobe that was independently developed to distinguish between the active and inactive types of pancreatic juice. METHODS The FRET nanoprobe developed was a nanoprotein capsule. It exuded a red color when the capsule structure was maintained. When activated protease in the pancreatic juice acts on it, the capsules are reduced quantitatively and FRET is abolished, resulting in a change in color from red to green. Pancreatic juice activation can be measured by the FRET signal. A total of 117 drainage fluid samples from 16 postpancreatoduodenectomy cases were obtained and evaluated. RESULTS The diagnosis of pancreatic juice activation was possible using the FRET signal with a cut-off value of 1.6. Pancreatic juice activation was not associated with drainage fluid amylase (AMY) levels. The results demonstrated that pancreatic juice was activated when drainage fluid was infected. CONCLUSION The use of a FRET nanoprobe enabled real-time detection of the presence or absence of pancreatic juice activation in pancreatic fistula after pancreatic surgery. There was an adequate correlation between infection and pancreatic juice activation regardless of drain AMY levels.
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Affiliation(s)
- Satoshi Mizutani
- Digestive Surgery, Nippon Medical School Musashikosugi Hospital, 211-8533, 1-396, Kosugicho, Nakaharaku, Kawasaki, Kanagawa, Japan.
| | - Masaharu Murata
- Center for Advanced Medical Innovation, Kyushu University, Fukuoka, Japan
| | - Nobuhiko Taniai
- Digestive Surgery, Nippon Medical School Musashikosugi Hospital, 211-8533, 1-396, Kosugicho, Nakaharaku, Kawasaki, Kanagawa, Japan
| | - Makoto Sukegawa
- Digestive Surgery, Nippon Medical School Musashikosugi Hospital, 211-8533, 1-396, Kosugicho, Nakaharaku, Kawasaki, Kanagawa, Japan
| | - Ryosuke Nakata
- Digestive Surgery, Nippon Medical School Musashikosugi Hospital, 211-8533, 1-396, Kosugicho, Nakaharaku, Kawasaki, Kanagawa, Japan
| | - Hiroyasu Furuki
- Digestive Surgery, Nippon Medical School Musashikosugi Hospital, 211-8533, 1-396, Kosugicho, Nakaharaku, Kawasaki, Kanagawa, Japan
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16
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Nakamura K, Sho M, Kinoshita S, Akahori T, Nagai M, Nakagawa K, Takagi T, Ikeda N. New insight into the association between bile infection and clinically relevant pancreatic fistula in patients undergoing pancreatoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:992-1001. [PMID: 32506812 DOI: 10.1002/jhbp.781] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/30/2020] [Accepted: 05/21/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND The association between bacterial infection and clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD) has not been fully elucidated. METHODS Microbiological data for intraoperative bile culture (BC) and drain culture on postoperative day 4 (DC) were collected. The study population was classified into the following three groups: P1 (positive BC and DC), P2 (positive BC and negative DC), and N (negative BC). A total of 209 patients (P1: 38, P2: 72, and N: 99) who underwent PD between May 2013 and May 2018 met the inclusion criteria of the study. RESULTS The rate of CR-POPF was significantly higher in the P1 group (34.2%) than in the P2 (12.5%; P = .007) and N groups (14.1%; P = .008). Between P1 and P2 groups, a significant difference was observed in the proportion of Enterococcus faecalis grown in BC (42.1% vs 4.2%; P < .001). Multivariable logistic regression analysis showed that the presence of E faecalis in bile was independently associated with CR-POPF. CONCLUSIONS The detection of both bile and postoperative abdominal fluid infections can be more accurate in predicting CR-POPF. Furthermore, the presence of E faecalis in bile may serve as a novel surrogate marker for CR-POPF.
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Affiliation(s)
- Kota Nakamura
- Department of Surgery, Nara Medical University, Kashihara, Japan
| | - Masayuki Sho
- Department of Surgery, Nara Medical University, Kashihara, Japan
| | | | - Takahiro Akahori
- Department of Surgery, Nara Medical University, Kashihara, Japan
| | - Minako Nagai
- Department of Surgery, Nara Medical University, Kashihara, Japan
| | - Kenji Nakagawa
- Department of Surgery, Nara Medical University, Kashihara, Japan
| | - Tadataka Takagi
- Department of Surgery, Nara Medical University, Kashihara, Japan
| | - Naoya Ikeda
- Department of Surgery, Nara Medical University, Kashihara, Japan
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17
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Søreide K, Roalsø M, Aunan JR. Is There a Trojan Horse to Aggressive Pancreatic Cancer Biology? A Review of the Trypsin-PAR2 Axis to Proliferation, Early Invasion, and Metastasis. J Pancreat Cancer 2020; 6:12-20. [PMID: 32064449 PMCID: PMC7014313 DOI: 10.1089/pancan.2019.0014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Purpose: Pancreatic cancer is one of the most lethal of solid tumors and is associated with aggressive cancer biology. The purpose is to review the role of trypsin and effect on molecular and cellular processes potentially explaining the aggressive biology in pancreatic cancer. Methods: A narrative literature review of studies investigating trypsin and its effect on protease systems in cancer, with special reference to pancreatic cancer biology. Results: Proteases, such as trypsin, provides a significant advantage to developing tumors through the ability to remodel the extracellular matrix, promote cell invasion and migration, and facilitate angiogenesis. Trypsin is a digestive enzyme produced by the exocrine pancreas that is also related to mechanisms of proliferation, invasion and metastasis. Several of these mechanisms may be co-regulated or influenced by activation of proteinase-activated receptor 2 (PAR-2). The current role in pancreatic cancer is not clear but emerging data suggest several potential mechanisms. Trypsin may act as a Trojan horse in the pancreatic gland, facilitating several molecular pathways from the onset, which leads to rapid progression of the disease. Pancreatic cancer cell lines containing PAR-2 proliferate upon exposure to trypsin, whereas cancer cell lines not containing PAR-2 fail to proliferate upon trypsin expression. Several mechanisms of action include a proinflammatory environment, signals inducing proliferation and migration, and direct and indirect evidence for mechanisms promoting invasion and metastasis. Novel techniques (such as organoid models) and increased understanding of mechanisms (such as the microbiome) may yield improved understanding into the role of trypsin in pancreatic carcinogenesis. Conclusion: Trypsin is naturally present in the pancreatic gland and may experience pathological activation intracellularly and in the neoplastic environment, which speeds up molecular mechanisms of proliferation, invasion, and metastasis. Further investigation of these processes will provide important insights into how pancreatic cancer evolves, and suggest new ways for treatment.
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Affiliation(s)
- Kjetil Søreide
- Gastrointestinal Translational Research Unit, Laboratory for Molecular Medicine, Stavanger University Hospital, Stavanger, Norway.,Department of Gastrointestinal Surgery, HPB Unit, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Marcus Roalsø
- Gastrointestinal Translational Research Unit, Laboratory for Molecular Medicine, Stavanger University Hospital, Stavanger, Norway.,Department of Gastrointestinal Surgery, HPB Unit, Stavanger University Hospital, Stavanger, Norway.,Faculty of Health and Medicine, University of Stavanger, Stavanger, Norway
| | - Jan Rune Aunan
- Gastrointestinal Translational Research Unit, Laboratory for Molecular Medicine, Stavanger University Hospital, Stavanger, Norway.,Department of Gastrointestinal Surgery, HPB Unit, Stavanger University Hospital, Stavanger, Norway
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18
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Goel N, Nadler A, Reddy S, Hoffman JP, Pitt HA. Biliary microbiome in pancreatic cancer: alterations with neoadjuvant therapy. HPB (Oxford) 2019; 21:1753-1760. [PMID: 31101398 DOI: 10.1016/j.hpb.2019.04.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 01/14/2019] [Accepted: 04/10/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Neoadjuvant therapy for pancreatic cancer is being employed more commonly. Most of these patients undergo biliary stenting which results in bacterial colonization and more surgical site infections (SSIs). However, the influence of neoadjuvant therapy on the biliary microbiome has not been studied. METHODS From 2007 to 2017, patients at our institution who underwent pancreatoduodenectomy (PD) and had operative bile cultures were studied. Patient demographics, stent placement, bile cultures, bacterial sensitivities, SSIs and clinically-relevant postoperative pancreatic fistulas (CR-POPF) were analyzed. Patients who underwent neoadjuvant therapy were compared to those who went directly to surgery. Standard statistical analyses were performed. RESULTS Eighty-three patients received neoadjuvant therapy while 89 underwent surgery alone. Patients who received neoadjuvant therapy were more likely to have enterococci (45 vs 22%, p < 0.01), and Klebsiella (37 vs 19%, p < 0.01) in their bile. Resistance to cephalosporins was more common in those who received neoadjuvant therapy (76 vs 60%, p < 0.05). Neoadjuvant therapy did not affect the incidence of SSIs or CR-POPFs. CONCLUSION The biliary microbiome is altered in patients undergoing pancreatoduodenectomy (PD) after neoadjuvant therapy. Most patients undergoing PD with a biliary stent have microorganisms resistant to cephalosporins. Antibiotic prophylaxis in these patients should cover enterococci and gram-negative bacteria.
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Affiliation(s)
- Neha Goel
- Department of Surgery, Fox Chase Cancer Center, USA
| | | | - Sanjay Reddy
- Department of Surgery, Fox Chase Cancer Center, USA
| | | | - Henry A Pitt
- Temple University Health System, USA; Lewis Katz School of Medicine at Temple University, USA.
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19
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Drain Contamination after Distal Pancreatectomy: Incidence, Risk Factors, and Association with Postoperative Pancreatic Fistula. J Gastrointest Surg 2019; 23:2449-2458. [PMID: 30815778 DOI: 10.1007/s11605-019-04155-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 02/05/2019] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Distal pancreatectomy (DP) remains associated with significant morbidity, but little data is available about the clinical significance of drain contamination. We explored the incidence, risk factors, and association with surgical outcomes of positive drainage culture (PDC) after DP. In addition, the predictive capacity of early PDC for postoperative pancreatic fistula (POPF) was evaluated. METHODS We retrospectively analyzed our prospectively collected database of patients who underwent DP between January 2005 and December 2015. Surveillance drainage cultures for microorganisms were conducted until drain removal or positive culture. The relationships between clinical variables and PDC were examined. RESULTS Of 480 consecutive cases who underwent DP, 176 (36.7%) had PDC. One hundred twelve patients (23.3%) developed POPF according to the 2016 ISGPS definition, with the 90-day mortality rate of 0.2%. Staphylococcus spp. was the most frequent isolate. Thirty-eight (21.6%) patients had PDC within 3 days after surgery, and 129 (73.3%) within the first 7 days of operation. Body mass index (BMI) ≥ 25 kg/m2 and massive intraoperative blood loss were independent predictors for PDC. PDC had a negative impact on surgical outcomes, including POPF. Early PDC was identified as a newly independent risk factor for POPF. Compared with other microorganisms, those contaminated with Staphylococcus and Klebsiella had higher incidences of POPF. CONCLUSIONS PDC occurs commonly after DP and plays a critical role in the development of surgical morbidities including POPF. Extreme caution is warranted in patients involving contamination with specific types of microorganisms.
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21
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Hori T, Ogawa K, Yamamoto H, Harada H, Matsumura K, Yamamoto M, Yamada M, Yazawa T, Kuriyama K, Tani M, Yasukawa D, Kamada Y, Aisu Y, Tani R, Aoyama R, Nakayama S, Sasaki Y, Nishimoto K, Zaima M. Impact of continuous local lavage on pancreatic juice-related postoperative complications: Three case reports. World J Clin Cases 2019; 7:2526-2535. [PMID: 31559288 PMCID: PMC6745316 DOI: 10.12998/wjcc.v7.i17.2526] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 07/10/2019] [Accepted: 07/20/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Postoperative pancreatic leakage readily results in intractable pancreatic fistula and subsequent intraperitoneal abscess. This refractory complication can be fatal; therefore, intensive treatment is important. Continuous local lavage (CLL) has recently been reevaluated as effective treatment for severe infected pancreatitis, and we report three patients with postoperative intractable pancreatic fistula successfully treated by CLL. We also discuss our institutional protocol for CLL for postoperative pancreatic fistula.
CASE SUMMARY The first patient underwent subtotal stomach-preserving pancreaticoduodenectomy, and pancreatic leakage was observed postoperatively. Intractable pancreatic fistula led to intraperitoneal abscess, and CLL near the pancreaticojejunostomy site was instituted from postoperative day (POD) 8. The abscess resolved after 7 d of CLL. The second patient underwent distal pancreatectomy. Pancreatic leakage was observed, and intractable pancreatic fistula led to intraperitoneal abscess near the pancreatic stump. CLL was instituted from POD 9, and the abscess resolved after 4 d of CLL. The third patient underwent aneurysmectomy and splenectomy with wide exposure of the pancreatic parenchyma. Endoscopic retrograde pancreatic drainage was performed on POD 15 to treat pancreatic fistula; however, intraperitoneal abscess was detected on POD 59. We performed CLL endoscopically via the transgastric route because the percutaneous approach was difficult. CLL was instituted from POD 63, and the abscess resolved after 1 wk of CLL.
CONCLUSION CLL has therapeutic potential for postoperative pancreatic fistula.
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Affiliation(s)
- Tomohide Hori
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Japan
| | - Kohei Ogawa
- Department of Hepatobiliary Pancreatic and Breast Surgery, Ehime University, Toon 791-0295, Japan
| | - Hidekazu Yamamoto
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Japan
| | - Hideki Harada
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Japan
| | - Kazuyoshi Matsumura
- Department of Gastroenterology and Hepatology, Shiga General Hospital, Moriyama 524-8524, Japan
| | | | - Masahiro Yamada
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Japan
| | - Takefumi Yazawa
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Japan
| | - Katsutoshi Kuriyama
- Department of Gastroenterology and Hepatology, Shiga General Hospital, Moriyama 524-8524, Japan
| | - Masaki Tani
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Japan
| | - Daiki Yasukawa
- Department of Surgery, Shiga University of Medical Science, Otsu 520-2192, Japan
| | - Yasuyuki Kamada
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Japan
| | - Yuki Aisu
- Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto 606-8507, Japan
| | - Ryotaro Tani
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Japan
| | - Ryuhei Aoyama
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Japan
| | - Shinnosuke Nakayama
- Department of Gastroenterology and Hepatology, Shiga General Hospital, Moriyama 524-8524, Japan
| | - Yudai Sasaki
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Japan
| | - Koki Nishimoto
- Department of Gastroenterology and Hepatology, Shiga General Hospital, Moriyama 524-8524, Japan
| | - Masazumi Zaima
- Department of Surgery, Shiga General Hospital, Moriyama 524-8524, Japan
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Bacterial smear test of drainage fluid after pancreaticoduodenectomy can predict postoperative pancreatic fistula. Pancreatology 2019; 19:274-279. [PMID: 30718188 DOI: 10.1016/j.pan.2019.01.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 01/21/2019] [Accepted: 01/23/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES It is widely accepted that postoperative pancreatic fistula (POPF) accompanied by bacterial infection results in a worse outcome than POPF alone. However, few studies evaluating predictive indicators of POPF have focused on bacterial infection. METHODS A consecutive 100 patients who underwent pancreaticoduodenectomy at our institute for periampullary disease were enrolled. POPF was assessed according to the International Study Group of Pancreatic Fistula consensus guidelines; grades B and C were defined as clinically relevant POPF (CR-POPF). The patients' characteristics, perioperative surgical factors, and laboratory data including the results of culture and smear testing performed using drainage fluid on postoperative days (PODs) 1 and 3 were analyzed. RESULTS The overall incidence of CR-POPF was 25%. Univariate analyses revealed that the factors associated with CR-POPF were male sex, soft pancreas, MPD diameter, higher serum C-reactive protein concentration and white blood cell count on POD 3, higher amylase concentration in drainage fluid, and culture and/or smear positivity of drainage fluid. Multivariate analysis newly revealed that the smear positivity of drainage fluid on POD 3 was the independent risk factors for CR-POPF (p = 0.027). CONCLUSIONS Smear positivity of drainage fluid on POD 3 after pancreaticoduodenectomy may be a new predictor of CR-POPF.
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Loos M, Strobel O, Legominski M, Dietrich M, Hinz U, Brenner T, Heininger A, Weigand MA, Büchler MW, Hackert T. Postoperative pancreatic fistula: Microbial growth determines outcome. Surgery 2018; 164:1185-1190. [PMID: 30217397 DOI: 10.1016/j.surg.2018.07.024] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/07/2018] [Accepted: 07/11/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula is a dangerous complication in pancreatic surgery. This study assessed the impact of microbiologic pathogens detected in postoperative pancreatic fistula on clinical outcomes after partial pancreatoduodenectomy and distal pancreatectomy. METHODS Microorganisms in postoperative pancreatic fistula were identified by microbiologic analyses from abdominal drains or intraoperative swabs during relaparotomy. Demographic, operative, and microbiologic data, as well as postoperative outcomes were examined. RESULTS Of 2,752 patients undergoing partial pancreatoduodenectomy and distal pancreatectomy, 256 patients with clinically relevant postoperative pancreatic fistula (International Study Group of Pancreatic Surgery [ISGPS] grades B and C) were identified (9.3%) and microbiologic cultures were positive in 210 patients (82.0%), with a higher rate after partial pancreatoduodenectomy (95.8%) than after distal pancreatectomy (64.3%; P < .001). Microbiologic spectra differed distinctively between partial pancreatoduodenectomy and distal pancreatectomy. Detection of microorganisms in postoperative pancreatic fistula resulted in a higher morbidity and mortality, including postpancreatectomy hemorrhage (42.4% vs 21.7%; P = .009), sepsis (38.1% vs 6.5%; P < .001), wound infection (30.0% vs 6.5%; P = .001), reoperation (48.1% vs 10.9%; P < .001), hospital stay (median 42 vs 26 days; P < .001), and overall 90-day mortality (19.5% vs 4.3%; P = .013) and was identified as an independent risk factor for sepsis, wound infection, and reoperation in the multivariate analysis. CONCLUSION Detection of microorganisms in postoperative pancreatic fistula is frequent after pancreatic resection and indicates a turning point in the development of postoperative pancreatic fistula into a life-threatening condition. Whether early anti-infective therapy in combination with interventional measures or a surgical reintervention are warranted, has yet to be elucidated.
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Affiliation(s)
- Martin Loos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - Matthias Legominski
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - Maximilian Dietrich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - Ulf Hinz
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - Thorsten Brenner
- Department of Anesthesiology, Heidelberg University Hospital, Germany
| | - Alexandra Heininger
- Department of Infectious Diseases, Institute of Medical Microbiology and Hygiene, University of Heidelberg, Germany
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany.
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
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24
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Yang F, Jin C, Li J, Di Y, Zhang J, Fu D. Clinical significance of drain fluid culture after pancreaticoduodenectomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2018; 25:508-517. [PMID: 30328297 DOI: 10.1002/jhbp.589] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The mechanism of infected postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy (PD) is undefined. Drain amylase has been used to predict POPF, whereas little data are available about the value of drain fluid culture. The aim was to investigate the incidence, risk factors and association with surgical outcomes of positive drainage culture (PDC) after PD. METHODS A single-center retrospective analysis was conducted of prospectively collected data from patients who underwent PD between January 2005 and December 2015. Drain fluid samples were obtained for microbiological analysis after surgery. Risk factors for PDC were evaluated, and its influence on surgical outcomes was explored. RESULTS Of 768 patients, 261 (34%) had PDC during the postoperative period. Among them, a total of 434 isolates were yielded. One hundred and seven (24.7%) were Gram-positive, 283 (65.2%) Gram-negative, and 44 (10.1%) fungi. Multivariate analysis revealed that body mass index (BMI) ≥25 kg/m2 , preoperative chemoradiation and intra-operative red blood cell transfusion were independent risk factors for PDC. PDC was associated with higher incidences of complications including POPF, major complications and reoperation, but with no correlation between the day of PDC and complications. BMI ≥25 kg/m2 , early PDC (≤3 days), main pancreatic duct <3 mm, and soft pancreas were revealed as independent predictors for POPF. There was a correlation between type of microorganisms and complications. CONCLUSION Considering the correlation between PDC and postoperative complications, preventive measures are crucial to improve outcomes after PD. Whether antibiotic treatment for early PDC will alter the clinical course of POPF needs further evaluation.
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Affiliation(s)
- Feng Yang
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
| | - Chen Jin
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
| | - Ji Li
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
| | - Yang Di
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
| | - Jing Zhang
- Department of Nursing, Huashan Hospital affiliated to Fudan University, Shanghai, China
| | - Deliang Fu
- Department of Pancreatic Surgery, Pancreatic Disease Institute, Huashan Hospital affiliated to Fudan University, 12 Central Urumqi Road, Shanghai, 200040, China
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25
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Gianotti L, Besselink MG, Sandini M, Hackert T, Conlon K, Gerritsen A, Griffin O, Fingerhut A, Probst P, Abu Hilal M, Marchegiani G, Nappo G, Zerbi A, Amodio A, Perinel J, Adham M, Raimondo M, Asbun HJ, Sato A, Takaori K, Shrikhande SV, Del Chiaro M, Bockhorn M, Izbicki JR, Dervenis C, Charnley RM, Martignoni ME, Friess H, de Pretis N, Radenkovic D, Montorsi M, Sarr MG, Vollmer CM, Frulloni L, Büchler MW, Bassi C. Nutritional support and therapy in pancreatic surgery: A position paper of the International Study Group on Pancreatic Surgery (ISGPS). Surgery 2018; 164:1035-1048. [PMID: 30029989 DOI: 10.1016/j.surg.2018.05.040] [Citation(s) in RCA: 145] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 05/28/2018] [Accepted: 05/29/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The optimal nutritional therapy in the field of pancreatic surgery is still debated. METHODS An international panel of recognized pancreatic surgeons and pancreatologists decided that the topic of nutritional support was of importance in pancreatic surgery. Thus, they reviewed the best contemporary literature and worked to develop a position paper to provide evidence supporting the integration of appropriate nutritional support into the overall management of patients undergoing pancreatic resection. Strength of recommendation and quality of evidence were based on the approach of the grading of recommendations assessment, development and evaluation Working Group. RESULTS The measurement of nutritional status should be part of routine preoperative assessment because malnutrition is a recognized risk factor for surgery-related complications. In addition to patient's weight loss and body mass index, measurement of sarcopenia and sarcopenic obesity should be considered in the preoperative evaluation because they are strong predictors of poor short-term and long-term outcomes. The available data do not show any definitive nutritional advantages for one specific type of gastrointestinal reconstruction technique after pancreatoduodenectomy over the others. Postoperative early resumption of oral intake is safe and should be encouraged within enhanced recovery protocols, but in the case of severe postoperative complications or poor tolerance of oral food after the operation, supplementary artificial nutrition should be started at once. At present, there is not enough evidence to show the benefit of avoiding oral intake in clinically stable patients who are complicated by a clinically irrelevant postoperative pancreatic fistula (a so-called biochemical leak), while special caution should be given to feeding patients with clinically relevant postoperative pancreatic fistula orally. When an artificial nutritional support is needed, enteral nutrition is preferred whenever possible over parenteral nutrition. After the operation, regardless of the type of pancreatic resection or technique of reconstruction, patients should be monitored carefully to assess for the presence of endocrine and exocrine pancreatic insufficiency. Although fecal elastase-1 is the most readily available clinical test for detection of pancreatic exocrine insufficiency, its sensitivity and specificity are low. Pancreatic enzyme replacement therapy should be initiated routinely after pancreatoduodenectomy and in patients with locally advanced disease and continued for at least 6 months after surgery, because untreated pancreatic exocrine insufficiency may result in severe nutritional derangement. CONCLUSION The importance of this position paper is the consensus reached on the topic. Concentrating on nutritional support and therapy is of utmost value in pancreatic surgery for both short- and long-term outcomes.
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Affiliation(s)
- Luca Gianotti
- School of Medicine and Surgery, University of Milan-Bicocca, and Department of Surgery, San Gerardo Hospital, Monza, Italy.
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Marta Sandini
- School of Medicine and Surgery, University of Milan-Bicocca, and Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Thilo Hackert
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - Kevin Conlon
- Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland
| | - Arja Gerritsen
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Oonagh Griffin
- Department of Surgery, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland
| | - Abe Fingerhut
- University of Graz Hospital, Surgical Research Unit, Graz, Austria
| | - Pascal Probst
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | | | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Gennaro Nappo
- Pancreatic Surgery Unit, Humanitas University, Humanitas Research Hospital, Milan, Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Humanitas University, Humanitas Research Hospital, Milan, Italy
| | - Antonio Amodio
- Unit of Gastroenterology, University of Verona Hospital Trust, Verona, Italy
| | - Julie Perinel
- Department of Digestive Surgery, E. Herriot Hospital, Hospices Civils de Lyon, Lyon-Sud Faculty of Medicine, Lyon, France
| | - Mustapha Adham
- Department of Digestive Surgery, E. Herriot Hospital, Hospices Civils de Lyon, Lyon-Sud Faculty of Medicine, Lyon, France
| | - Massimo Raimondo
- Division of General Surgery, Department of Surgery, Mayo Clinic, Jacksonville, FL
| | - Horacio J Asbun
- Division of General Surgery, Department of Surgery, Mayo Clinic, Jacksonville, FL
| | - Asahi Sato
- Division of Hepatobiliary-Pancreatic Surgery and Transplantation, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kyoichi Takaori
- Division of Hepatobiliary-Pancreatic Surgery and Transplantation, Department of Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Marco Del Chiaro
- Pancreatic Surgery Unit - Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC) - Karolinska Institutet at Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Maximilian Bockhorn
- Department of General, Visceral and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic-Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christos Dervenis
- University of Cyprus and Department of Surgical Oncology and HPB Surgery Metropolitan Hospital, Athens, Greece
| | - Richard M Charnley
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Marc E Martignoni
- Department of Surgery, Klinikum rechts der Isar, Technische Universität, München, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, Technische Universität, München, Germany
| | | | - Dejan Radenkovic
- Clinic for Digestive Surgery, Clinical Center of Serbia and School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marco Montorsi
- Department of Surgery, Humanitas University, Humanitas Research Hospital, Milan, Italy
| | - Michael G Sarr
- Department of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN
| | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Luca Frulloni
- Department of Medicine, University of Verona, Verona, Italy
| | - Markus W Büchler
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - Claudio Bassi
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
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26
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Contaminated drainage fluid and pancreatic fistula after pancreatoduodenectomy: A retrospective study. Int J Surg 2018. [DOI: 10.1016/j.ijsu.2018.02.057] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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27
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Computer tomographic assessment of postoperative peripancreatic collections after distal pancreatectomy. Langenbecks Arch Surg 2018; 403:349-357. [DOI: 10.1007/s00423-018-1668-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 03/19/2018] [Indexed: 01/04/2023]
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28
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Belmouhand M, Krohn PS, Svendsen LB, Henriksen A, Hansen CP, Achiam MP. The occurrence of Enterococcus faecium and faecalis Is significantly associated With anastomotic leakage After pancreaticoduodenectomy. Scand J Surg 2017; 107:107-113. [PMID: 28980499 DOI: 10.1177/1457496917731188] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Enterococcus has emerged as a virulent species; Enterococcus faecium especially has arisen as a source of nosocomial infections. Furthermore, specific Enterococcus faecalis species are significantly associated with anastomotic leakage in rodent studies. The objective of this study was to investigate whether the occurrence of Enterococci ( E. faecium and E. faecalis) obtained from drain samples was associated with leakage in humans undergoing pancreaticoduodenectomy. MATERIALS AND METHODS All patients undergoing pancreaticoduodenectomy had a peritoneal drain sample sent for culturing between postoperative days 3 and 10. Postoperative pancreatic fistulas were defined and classified according to the International Study Group of Pancreatic Fistula. Bile leakage was radiologically verified. Postoperative complications were classified according to the Dindo-Clavien classification. RESULTS A total of 70 patients were eligible and enrolled in this study. Anastomosis leakage was observed in 19 patients; 1 leakage corresponding to the hepaticojejunostomy and 18 pancreatic fistulas were identified. In total, 10 patients (53%) with leakage had Enterococci-positive drain samples versus 12 patients (24%) without leakage [odds ratio (OR) = 5.1, 95% confidence interval (CI) = 1.4-19.4, p = 0.02]. Preoperative biliary drainage with either endoscopic stenting or a percutaneous transhepatic cholangiography catheter was associated with the occurrence of Enterococci in drain samples (OR = 5.67, 95% CI = 1.8-12.9, p = 0.003), but preoperative biliary drainage was not associated with leakage (OR = 0.45, 95% CI = 0.1-1.7, p = 0.23). CONCLUSION Enterococci in drain sample cultures in patients undergoing pancreaticoduodenectomy occurs significantly more among patients with anastomotic leakage compared to patients without leakage.
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Affiliation(s)
- M Belmouhand
- Department of Surgical Gastroenterology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - P S Krohn
- Department of Surgical Gastroenterology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - L B Svendsen
- Department of Surgical Gastroenterology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - A Henriksen
- Department of Surgical Gastroenterology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - C P Hansen
- Department of Surgical Gastroenterology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - M P Achiam
- Department of Surgical Gastroenterology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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29
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Sato A, Masui T, Nakano K, Sankoda N, Anazawa T, Takaori K, Kawaguchi Y, Uemoto S. Abdominal contamination with Candida albicans after pancreaticoduodenectomy is related to hemorrhage associated with pancreatic fistulas. Pancreatology 2017; 17:484-489. [PMID: 28336225 DOI: 10.1016/j.pan.2017.03.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 03/06/2017] [Accepted: 03/17/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Pancreatic fistulas are one of the most frequent morbidities after pancreaticoduodenectomy. Several reports have suggested a relationship between bacterial infections and postoperative pancreatic fistulas, although details of the mechanisms involved in hemorrhage in association with the fistulas have not been elucidated. This study retrospectively examined the relationship between positive drainage culture and hemorrhage associated with pancreatic fistulas after pancreaticoduodenectomy. METHODS From January 2012 to December 2015, 142 consecutive patients underwent pancreaticoduodenectomy at our institution. We retrospectively reviewed the patients' demographic data, perioperative laboratory data, and drainage culture results. RESULTS Twenty-four (17%) patients had clinically relevant postoperative pancreatic fistulas, whereas thirty-four (24%) patients experienced positive drainage culture. Multivariable analysis revealed that positive drainage culture was independently associated with clinically relevant postoperative pancreatic fistulas (odds ratio, 18.1; 95% confidence interval, 5.5-72.2; P < 0.001). Additionally, the prevalence of Candida albicans in the lavage of eight patients significantly correlated with hemorrhage associated with pancreatic fistulas (odds ratio, 43.5; 95% confidence interval, 6.2-513.3; P < 0.001). Seventy-five percent (6/8) of these patients suffered potentially lethal hemorrhagic complications and needed intervention. CONCLUSIONS A positive abdominal drainage culture is associated with the development of pancreatic fistulas. Moreover, the presence of Candida albicans in drainage fluid may be a risk factor for hemorrhagic complications.
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Affiliation(s)
- Asahi Sato
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
| | - Toshihiko Masui
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Japan.
| | - Kenzo Nakano
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
| | - Nao Sankoda
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
| | - Takayuki Anazawa
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
| | - Kyoichi Takaori
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
| | - Yoshiya Kawaguchi
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
| | - Shinji Uemoto
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
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30
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Zhang JF, Zhu HY, Sun YW, Liu W, Huo YM, Liu DJ, Li J, Hua R. Pseudomonas aeruginosa Infection after Pancreatoduodenectomy: Risk Factors and Clinic Impacts. Surg Infect (Larchmt) 2015; 16:769-74. [PMID: 26237502 DOI: 10.1089/sur.2015.041] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Pseudomonas aeruginosa (P. aeruginosa) is a leading cause of nosocomial infections, which is difficult to treat because of limited susceptibility to antimicrobial agents. In China, isolation rates of P. aeruginosa were observed to increase by year. The incidence of infectious complications after pancreatoduodenectomy (PD) were high. However, there was no data available regarding P. aeruginosa infection in patients undergoing PD. This study evaluated the risk factors and clinical impacts of P. aeruginosa infection on patient after PD. METHODS 119 patients who underwent PD with post-operative infectious complications were monitored for P. aeruginosa infection. The patients were grouped as P. aeruginosa infection and non-P. aeruginosa infection. Univariable and multivariable analyses were used to identify risk factors for P. aeruginosa infection. RESULTS 42 (35.3%) of the119 patients were P. aeruginosa positive after PD. The sites of P. aeruginosa infection included (1) abdominal drain fluid (76%); (2) sputum (7%); (3) central line catheter tip cultures (2%); and (4) combination of sites (14%). Pseudomonas aeruginosa isolates were susceptible to Polymyxin B, Amikacin and Gentamicin, resistant to Aztreonam Piperacillin-tazobactam, Imipenem and Ceftazidime. History of diabetes mellitus (OR=2.981, P=0.023), pancreatic fistula (OR=4.699, P=0.001), use of carbapenems (OR=3.236, P=0.013), and fluoroquinolones (OR=2.940, P=0.044), antibiotics, and length of ICU stay (OR=2.133, P=0.022) independently predicted post-operative P. aeruginosa infection. Pseudomonas aeruginosa infection was related to severe post-operative complications, including delayed gastric emptying and post-pancreatectomy hemorrhage, but was not related to not 30-d mortality or a longer post-operative stay. CONCLUSIONS This analytic study highlights the prevalence and high drug resistance of P. aeruginosa after PD. Pseudomonas aeruginosa infection was related to severe post-operative complications but not 30-d mortality. Measures to combat P. aeruginosa infection would likely decrease the accidence of P. aeruginosa infection and benefit patients' outcomes.
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Affiliation(s)
- Jun-Feng Zhang
- 1 Department of Biliary-Pancreatic Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University , Shanghai, China
| | - Hong-Yan Zhu
- 2 Department of General Surgery, The First People's Hospital of Suqian, Suqian City , Jiangsu Province, China
| | - Yong-Wei Sun
- 1 Department of Biliary-Pancreatic Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University , Shanghai, China
| | - Wei Liu
- 1 Department of Biliary-Pancreatic Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University , Shanghai, China
| | - Yan-Miao Huo
- 1 Department of Biliary-Pancreatic Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University , Shanghai, China
| | - De-Jun Liu
- 1 Department of Biliary-Pancreatic Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University , Shanghai, China
| | - Jiao Li
- 1 Department of Biliary-Pancreatic Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University , Shanghai, China
| | - Rong Hua
- 1 Department of Biliary-Pancreatic Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University , Shanghai, China
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