Clinical and economic consequences of pancreatic fistula after elective pancreatic resection

BACKGROUND:Postoperative pancreatic fistula is the main cause of morbidity after pancreatic resection.This study aimed to quantify the clinical and economic consequences of pancreatic fistula in a medium-volume pancreatic surgery center.METHODS:Hospital records from patients who had undergone elective pancreatic resection in our department were identified.Pancreatic fistula was defined according to the International Study Group on Pancreatic Fistula(ISGPF).The consequences of pancreatic fistula were determined by treatment cost,hospital stay,and out-patient follow-up until the pancreatic fistula was completely healed.All costs of the treatment are calculated in Euros.The cost increase index was calculated for pancreatic fistula of grades A,B,and C as multiples of the total cost for the no fistula group.RESULTS:In 54 months,102 patients underwent elective pancreatic resections.Forty patients(39.2%) developed pancreatic fistula,and 54 patients(52.9%) had one or more complications.The median length of hospital stay for the no fistula,grades A,B,and C fistula groups was 12.5,14,20,and 59 days,respectively.The hospital stay of patients with fistula of grades B and C was significantly longer than that of patients with no fistula(P【0.001).The median total cost of the treatment was 4952,4679,8239,and 30 820 Euros in the no fistula,grades A,B,and C fistula groups,respectively.CONCLUSIONS:The grading recommended by the ISGPF is useful for comparing the clinical severity of fistula and for analyzing the clinical and economic consequences of pancreatic fistula.Pancreatic fistula prolongs the hospital stay and increases the cost of treatment in proportion to the severity of the fistula.

Pancreatic Castleman disease treated with laparoscopic distal pancreatectomy

BACKGROUND: Castleman disease is an uncommon lympho-proliferative disorder most frequently occurring in the mediastinum. Abdominal forms are less frequent, with pancreatic localization of the disease in particular being extremely rare. Only seventeen cases have been described in the world literature. METHOD: This report describes an interesting and unusual case of pancreatic Castleman disease treated with laparoscopic resection. RESULTS: A 48-year-old woman presented with epigastric pain. CT scan showed a well-encapsulated mass on the ventral border of the pancreas. Endosonography with fine needle aspiration biopsy was performed. Biopsy showed lymphoid elements and structures of a normal lymph node. The patient was treated with laparoscopic distal pancreatectomy. The pancreas was transected with a Ligasure device and the pancreatic stump was secured with a manual suture. One year after surgery the patient was complaint-free and showed no signs of recurrence of the disease. CONCLUSIONS: Laparoscopic distal pancreatectomy is a feasible and safe method for the treatment of lesions in the body and tail of the pancreas. Transection of the pancreas with a Ligasure device offers the advantages of low bleeding and low risk of pancreatic fistula.

Intra-abdominal drainage following pancreatic resection:A systematic review

AIM: To study all the aspects of drain management in pancreatic surgery.METHODS: We conducted a systematic review according to the PRISMA guidelines. We searched the Cochrane Central Registry of Controlled Trials,EMBASE,Web of Science,and Pub Med(MEDLINE) for relevant articles on drain management in pancreatic surgery. The reference lists of relevant studies were screened to retrieve any further studies. We included all articles that reported clinical studies on human subjects with elective pancreatic resection and that compared various strategies of intra-abdominal drain management,such as drain vs no drain,selective drain use,early vs late drain extraction,and the use of different types of drains. RESULTS: A total of 19 studies concerned with drain management in pancreatic surgery involving 4194 patients were selected for this systematic review. We included studies analyzing the outcomes of pancreatic resection with and without intra-abdominal drains,studies comparing early vs late drain removal and studies analyzing different types of drains. The majority of the studies reporting equal or superior results for pancreatic resection without drains were retrospective and observational with significant selection bias. One recent randomized trial reported higher postoperative morbidity and mortality with routine omission of intraabdominal drains. With respect to the timing of drain removal,all of the included studies reported superior results with early drain removal. Regarding the varioustypes of drains,there is insufficient evidence to determine which type of drain is more suitable following pancreatic resection. CONCLUSION: The prophylactic use of drains remains controversial. When drains are used,early removal is recommended. Further trials comparing types of drains are ongoing.

Long-term survival of a patient after resection of a gastrointestinal stromal tumor arising from the pancreas

BACKGROUND:Gastrointestinal stromal tumors (GISTs) may arise in any part of the gastrointestinal tract;extragastrointestinal locations are extremely rare.Only a few cases of extragastrointestinal stromal tumor arising from the pancreas were reported.None of the reports described a long-term follow-up of the patients.METHOD:This report describes an interesting and unusual case of GIST arising from the pancreas.RESULTS:A 74-year-old female presented with a palpable abdominal mass.CT scan showed a large mass 11×8×4 cm originating from the tail of the pancreas.Percutaneous biopsy revealed a GIST predominantly with spindle cells,but some parts also contained epitheloid cells.The patient was treated by distal pancreatic resection with splenectomy.Immunohistochemistry of the tumor showed a staining pattern characteristic of GIST.The patient has achieved a long-term survival of five years and six months without any sign of recurrence of the disease.CONCLUSION:This is the first reported case of an extragastrointestinal stromal tumor arising from the pancreas treated surgically,with a long-term survival.