Optimizing prediction models for pancreatic fistula after pancreatectomy:Current status and future perspectives

Postoperative pancreatic fistula(POPF)is a frequent complication after pancre-atectomy,leading to increased morbidity and mortality.Optimizing prediction models for POPF has emerged as a critical focus in surgical research.Although over sixty models following pancreaticoduodenectomy,predominantly reliant on a variety of clinical,surgical,and radiological parameters,have been documented,their predictive accuracy remains suboptimal in external validation and across diverse populations.As models after distal pancreatectomy continue to be pro-gressively reported,their external validation is eagerly anticipated.Conversely,POPF prediction after central pancreatectomy is in its nascent stage,warranting urgent need for further development and validation.The potential of machine learning and big data analytics offers promising prospects for enhancing the accuracy of prediction models by incorporating an extensive array of variables and optimizing algorithm performance.Moreover,there is potential for the development of personalized prediction models based on patient-or pancreas-specific factors and postoperative serum or drain fluid biomarkers to improve accuracy in identifying individuals at risk of POPF.In the future,prospective multicenter studies and the integration of novel imaging technologies,such as artificial intelligence-based radiomics,may further refine predictive models.Addressing these issues is anticipated to revolutionize risk stratification,clinical decision-making,and postoperative management in patients undergoing pancre-atectomy.

Risk factors and managements of hemorrhage associated with pancreatic fistula after pancreaticoduodenectomy

BACKGROUND: Post-pancreaticoduodenectomy pancreatic fistula associated hemorrhage (PPFH) is one of the leading lethal complications. Our study was to analyze the risk factors and managements of hemorrhage associated with pancreatic fistula after pancreaticoduodenectomy, and to evaluate treatment options. METHOD: We analyzed 445 patients who underwent pancreaticoduodenectomy or pylorus-preserving pancreaticoduodenectomy and evaluated the relevance between clinical data and PPFH. RESULTS: The incidence of postoperative pancreatic fistula (POPF) was 27.42% (122/445), and the incidence of PPFH was 4.49% (20/445). Among the 20 patients with PPFH, 7 died and 13 were cured. Interventional angiographic therapy was performed for 10 patients and 5 were successfully treated. Relaparotomy was performed for 5 patients and 2 were successfully cured. Univariate logistic regression analysis indicated that several risk factors were related to PPFH: the nature of tumor (carcinoid/low-grade or high-grade malignancy), preoperative day 1. serum prealbumin, preoperative day 1 total bilirubin (TBIL), operative time, blood loss in the operation, operative method (vascular resection and revascularization), postoperative day 3 TBIL, biliary fistula, and the grade of POPF. The multivariate stepwise logistic regression analysis demonstrated that the nature of tumor and the grade of POPF were independently risk factors of PPFH. Receiver operating characteristic curve indicated that preoperative day 1 serum prealbumin level <173 mg/L and postoperative day 3 TBIL level.1.68.tmol/L were the risk factors of PPFH. CONCLUSIONS; The risk of PPFH was found to be increased with high potential malignancy and high grade of POPE Angiography-embolization is one of the major and effective therapies for PPFH. Extraluminal-intraluminal PPFH is more serious and needs more aggressive treatments.

Risk prediction platform for pancreatic fistula after pancreatoduodenectomy using artificial intelligence

BACKGROUND Despite advancements in operative technique and improvements in postoperative managements,postoperative pancreatic fistula(POPF)is a life-threatening complication following pancreatoduodenectomy(PD).There are some reports to predict POPF preoperatively or intraoperatively,but the accuracy of those is questionable.Artificial intelligence(AI)technology is being actively used in the medical field,but few studies have reported applying it to outcomes after PD.AIM To develop a risk prediction platform for POPF using an AI model.METHODS Medical records were reviewed from 1769 patients at Samsung Medical Center who underwent PD from 2007 to 2016.A total of 38 variables were inserted into AI-driven algorithms.The algorithms tested to make the risk prediction platform were random forest(RF)and a neural network(NN)with or without recursive feature elimination(RFE).The median imputation method was used for missing values.The area under the curve(AUC)was calculated to examine the discriminative power of algorithm for POPF prediction.RESULTS The number of POPFs was 221(12.5%)according to the International Study Group of Pancreatic Fistula definition 2016.After median imputation,AUCs using 38 variables were 0.68±0.02 with RF and 0.71±0.02 with NN.The maximal AUC using NN with RFE was 0.74.Sixteen risk factors for POPF were identified by AI algorithm:Pancreatic duct diameter,body mass index,preoperative serum albumin,lipase level,amount of intraoperative fluid infusion,age,platelet count,extrapancreatic location of tumor,combined venous resection,co-existing pancreatitis,neoadjuvant radiotherapy,American Society of Anesthesiologists’score,sex,soft texture of the pancreas,underlying heart disease,and preoperative endoscopic biliary decompression.We developed a web-based POPF prediction platform,and this application is freely available at http://popfrisk.smchbp.org.CONCLUSION This study is the first to predict POPF with multiple risk factors using AI.This platform is reliable(AUC 0.74),so it could be used to select patients who need especially intense therapy and to preoperatively establish an effective treatment strategy.

Impaired immune reaction and increased lactate and C-reactive protein for early prediction of severe morbidity and pancreatic fistula after pancreatoduodenectomy

Background: Prediction of complications after pancreatoduodenectomy (PD) remains of interest. Blood parameters and biomarkers during rst and second postoperative days (POD1, POD2) may be early indi- cators of complications. Methods: This case-control study included 50 patients. Baseline, POD1 and POD2 values of leukocytes, neutrophils, lymphocytes, platelets, hemoglobin, C-reactive protein (CRP), procalcitonin and arterial lactate were compared between individuals presenting Clavien ≥ III morbidity, pancreatic stula (PF) or clinically relevant PF (CRPF) and those without these morbidities. Common variables reaching signi cance were further analyzed in order to calculate a predictive score. Results: Severe morbidity, PF and CRPF rates were 28.0%, 26.0% and 14.0%, respectively. Patients with severe morbidity had lower leukocytes on POD2 (P=0.04). Patients with PF presented higher CRP on POD2 (P=0.001), higher lactate on POD1 (P=0.007) and POD2 (P=0.008), and lower lymphocytes on POD1 (P=0.007) and POD2 (P=0.008). Patients with CRPF had lower leukocytes and neutrophils on POD1 (P =0.048, P =0.038), lower lymphocytes on POD1 (P =0.001) and POD2 (P =0.003), and higher CRP on POD2 (P =0.001). Baseline parameters and procalcitonin obtained no statistical associations. Score was de ned according to lymphocytes on POD1 < 650/μL and CRP on POD2 ≥ 250 mg/L allocating patients in 3 risk categories. PF and CRPF rates were statistically higher as risk category increased (P<0.001). Receiver operating characteristic curves and Hosmer Lemeshow tests showed a good accuracy. Conclusions: Impaired immunological reaction during early postoperative period (lower leukocytes and, particularly, lymphocytes) in response to surgical aggression would favor complications after PD. Likewise, acidosis (higher arterial lactate) could behave as risk factor of PF. An elevated CRP on POD2 is also an early biomarker of PF. Our novel score based on postoperative lymphocyte count and CRP seems reliable for early prediction of PF.

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.

Risk factors for pancreatic fistula following pancreaticoduodenectomy: A retrospective study in a Thai tertiary center

AIM To analyze the risk factors of postoperative pancreatic fistula following pancreaticoduodenectomy in a Thai tertiary care center.METHODS We retrospectively analyzed 179 patients who underwent pancreaticoduodenectomy at our hospital from January 2001 to December 2016. Pancreatic fistula were classified into three categories according to a definition made by an International Study Group on Pancreatic Fistula. The risk factors for pancreatic fistula were analyzed by univariate analysis and multivariate logistic regression analysis.RESULTS Pancreatic fistula were detected in 88/179 patients(49%) who underwent pancreaticoduodenectomy. Fifty-eight pancreatic fistula(65.9%) were grade A, 22 cases(25.0%) were grade B and eight cases(9.1%) were grade C. Clinically relevant pancreatic fistula were detected in 30/179 patients(16.7%). The 30-d mortality rate was 1.67%(3/179 patients). Multivariate logistic regression analysis revealed that soft pancreatic texture(odds ratio = 3.598, 95%CI: 1.77-7.32) was the most significant risk factor for pancreatic fistula. A preoperative serum bilirubin level of > 3 mg/d L was the most significant risk factor for clinically relevant pancreatic fistula according to univariate and multivariate analysis.CONCLUSION Soft pancreatic tissue is the most significant risk factor for postoperative pancreatic fistula. A high preoperative serum bilirubin level(> 3 mg/d L) is the most significant risk factor for clinically relevant pancreatic fistula.

Risk Factors and Management of Postoperative Pancreatic Fistula Following Pancreaticoduodenectomy:Single-center Experience

Pancreatic fistula(PF)remains the most frequent complication after pan­creaticoduodenectomy(PD).This study was undertaken to explore the risk factors of postoperative PF following PD and discuss the management of PF in our center.A single-center respective study,involving 241 patients who underwent PD between September 2015 and June 2018,was conducted.Differences in the demographic data,preoperative,intraoperative and postoperative variables between the group with PF[International Study Group on Pancreatic Surgery(ISGPS)grade B/C]and the group without PF(no PF and ISGPS grade BL)were evaluated.The diagnosis and grading of PF were in strict accordance with ISGPS.Risk factors were analyzed by univariate analysis and multivariate logistic regression analysis.The results showed that postoperative PF occurred in 50(20.7%)of the patients;25(10.4%)patients had a PF type BL,46(19.1%)patients developed a PF type B and 4(1.6%)had a PF type C.Univariate analysis showed that fasting blood glucose(P=0.02),pancreatic texture(P<0.001)and pancreatic duct diameter(P=0.01)were correlated with PF.Multivariate logistic regression analysis identified one independent risk factor for postoperative PF:soft pancreatic texture(OR=3.251,P=0.002).Among the cases,there were three postoperative deaths,giving a 60-day hospital mortality rate of 1.2%(3/241),and the mortality related to PF was 4.0%(2/50).One of the patients died from multiple organ failure caused by postoperative abdominal hemorrhage.In conclusion,soft pancreatic texture is an independent risk factor for PF.Surgeons should be well aware of this risk factor when performing a PD.

Risk factors for postoperative pancreatic fistula in patients with insulinomas:analysis of 292 consecutive cases

BACKGROUND: Pancreatic fistula (PF) remains the most challenging complication in pancreatic surgery, yet few published studies have focused on the risk factors for postoperative PF in patients undergoing surgery for insulinomas. METHODS: From January 1990 to February 2010, a total of 292 patients with insulinomas underwent surgery at Peking Union Medical College Hospital. Demographic data, intraoperative procedures, and postoperative data were collected. Particular attention was paid to variables associated with PF as defined by the International Study Group of Pancreatic Fistula (ISGPF). Univariate and multivariate analyses were used to identify possible risk factors for PP. RESULTS: PF was found in 132 (45.2%) patients, of whom 90 were classified into ISGPF grade A, 33 grade B, and 9 grade C. Multivariate analysis showed that male patients (OR=2.56; P=0.007) and operative time > 180 minutes (OR=3.756; P < 0.0001) were independent risk factors for clinical PF. Pancreatic resection with stapler was a protective factor for both total PF (OR=0.022; P=0.010) and clinical PF (OR=0.097; P=0.007). CONCLUSIONS: Male gender and operative time > 180 minutes were independent risk factors for clinical PF, while pancreatic resection with a stapler was a protective factor. Whether body mass index (BMI) and other variables during operation are risk factors of PF needs further study. (Hepatobiliary Pancreat Dis Int 2012;11:102-106)

Delayed internal pancreatic fistula with pancreatic pleural effusion postsplenectomy

The occurrence of pancreatic pleural effusion,secondary to an internal pancreatic fistula,is a rare clinical syndrome and diagnosis is often missed.The key to the diagnosis is a dramatically elevated pleural fluid amylase.This pancreatic pleural effusion is also called a pancreatic pleural fistula.It is characterized by profuse pleural fluid and has a tendency to recur.Here we report a case of delayed internal pancreatic fistula with pancreatic pleural effusion emerging after splenectomy.From the treatment of this case,we conclude that the symptoms and signs of a subphrenic effusion are often obscure;abdominal computed tomography may be required to look for occult,intra-abdominal infection;and active conservative treatment should be carried out in the early period of this complication to reduce the need for endoscopy or surgery.

Pancreatic fistula after central pancreatectomy: case series and review of the literature

BACKGROUND: Postoperative pancreatic fistula is one of the most common complications after pancreatectomy. This study aimed to assess the occurrence and severity of pancreatic fistula after central pancreatectomy.METHODS: The medical records of 13 patients who had undergone central pancreatectomy were retrospectively studied together with a literature review of studies including at least five cases of central pancreatectomy. Pancreatic fistula was defined and graded according to the recommendations of the International Study Group on Pancreatic Fistula (ISGPF).RESULTS: No death was observed in the 13 patients. Pancreatic fistula developed in 7 patients and was successfully treated nonoperatively. None of these patients required re-operation. A total of 40 studies involving 867 patients who underwent central pancreatectomy were reviewed. The overall pancreatic fistula rate of the patients was 33.4% (0-100%). Of 279 patients, 250(89.6%) had grade A or B fistulae of ISGPF and were treated nonoperatively, and the remaining 29 (10.4%) had grade C fistulae of ISGPF. In 194 patients, 15 (7.7%) were re-operated upon. Only one patient with grade C fistula of ISGPF died from multiple organ failure after re-operation.CONCLUSION: Despite the relatively high occurrence, most pancreatic fistulae after central pancreatectomy are recognized a grade A or B fistula of ISGPF, which can be treated conservatively or by mini-invasive approaches.

Total closure of pancreatic section for end-to-side pancreaticojejunostomy decreases incidence of pancreatic fistula in pancreaticoduodenectomy

BACKGROUND： Postoperative pancreatic fistula （POPF） is a serious complication and results in prolonged hospitalization and high mortality. The present study aimed to evaluate the safety and effectiveness of total closure of pancreatic section for end-to-side pancreaticojejunostomy in pancreaticoduodenectomy （PD）. METHODS： This was a prospective randomized clinical trial comparing the outcomes of PD between patients who un- derwent total closure of pancreatic section for end-to-side pancreaticojejunostomy （Group A） vs those who underwent conventional pancreaticojejunostomy （Group B）. The primary endpoint was the incidence of pancreatic fistula. Secondary endpoints were morbidity and mortality rates. RESULTS： One hundred twenty-three patients were included in this study. The POPF rate was significantly lower in Group A than that in Group B （4.8% vs 16.7%, P〈0.05）. About 38.3% patients in Group B developed one or more complications; this rate was 14.3% in Group A （P〈0.01）. The wound/abdomi- nal infection rate was also much higher in Group B than that in Group A （20.0% vs 6.3%, P〈0.05）. Furthermore, the average hospital stays of the two groups were 18 days in Group A, and 24 days in Group B, respectively （P〈0.001）. However, there was no difference in the probability of mortality, biliary leakage,delayed gastric emptying, and pulmonary infection between the two groups. CONCLUSION： Total closure of pancreatic section for end-to- side pancreaticojejunostomy is a safe and effective method for pancreaticojejunostomy in PD.

Application of omental interposition to reduce pancreatic fistula and related complications in pancreaticoduodenectomy:A propensity score-matched study

BACKGROUND The life-threatening complications following pancreatoduodenectomy(PD),intraabdominal hemorrhage,and postoperative infection,are associated with leaks from the anastomosis of pancreaticoduodenectomy.Although several methods have attempted to reduce the postoperative pancreatic fistula(POPF)rate after PD,few have been considered effective.The safety and short-term clinical benefits of omental interposition remain controversial.AIM To investigate the safety and feasibility of omental interposition to reduce the POPF rate and related complications in pancreaticoduodenectomy.METHODS In total,196 consecutive patients underwent PD performed by the same surgical team.The patients were divided into two groups:An omental interposition group(127,64.8%)and a non-omental interposition group(69,35.2%).Propensity scorematched(PSM)analyses were performed to compare the severe complication rates and mortality between the two groups.RESULTS Following PSM,the clinically relevant POPF(CR-POPF,10.1%vs 24.6%;P=0.025)and delayed postpancreatectomy hemorrhage(1.4%vs 11.6%;P=0.016)rates were significantly lower in the omental interposition group.The omental interposition technique was associated with a shorter time to resume food intake(7 d vs 8 d;P=0.048)and shorter hospitalization period(16 d vs 21 d;P=0.031).Multivariate analyses showed that a high body mass index,nonapplication of omental interposition,and a main pancreatic duct diameter<3 mm were independent risk factors for CR-POPF.CONCLUSION The application of omental interposition is an effective and safe approach to reduce the CR-POPF rate and related complications after PD.

Preoperative diabetes as a protective factor for pancreatic fistula after pancreaticoduodenectomy: a meta-analysis

BACKGROUND： The role of diabetes mellitus （DM） in pancreatic fistula （PF） or clinical relevant PF （CR-PF） after pancreaticoduodenectomy （PD） or pylorus-preserving pancreaticoduodenectomy （PPPD） is unclear. We conducted a meta-analysis to investigate the relationship between DM and PF or CR-PF.DATA SOURCES： Embase, MEDLINE and Cochrane databases were searched systematically for relevant articles from January 2005 to June 2013. The selected studies that examined clinical risk factors of PF or CR-PF were included. We created pooled estimates for our outcomes using the random-effects model. RESULTS： Sixteen observational clinical studies were included. Pooling of PF rates from ten studies revealed that DM was associated with a decreased risk of PF （P=0.01）. CR-PF rates from 8 studies showed no significant difference between DM and control group （P=0.14）. CONCLUSIONS： DM is not a risk factor for PF in patients undergoing PD or PPPD. On the contrary, patients without DM are at a higher risk of PF because the pancreases in these patients have more fatty tissue and the pancreas is soft.

Ligamentum teres hepatis patch enhances the healing of pancreatic fistula after distal pancreatectomy

Pancreatic fistula is one of the most common complications after the distal pancreatectomy.Many methods have been tried to solve the problem,but no one is optimal,especially for the soft pancreatic stump cases.This study used ligamentum teres hepatis as a patch to cover the pancreatic stump.Between October 2010 and December 2012,seventyseven patients who had undergone distal pancreatectomy with a soft pancreatic stump were divided into two groups:group A(n=39,patients received conventional ligated main pancreatic duct method)and group B(n=38,patients underwent a coverage procedure).Patients in group A had a longer recovery from postoperative pancreatic fistula than those in group B(16.4±3.5 vs 10.8±1.6 days,P【0.05).The coverage procedure with ligamentum teres hepatis is a safe,effective and convenient method for patients with a soft pancreas remnant during distal pancreatectomy.

Personal predictive model based on systemic inflammation markers for estimation of postoperative pancreatic fistula following pancreaticoduodenectomy

BACKGROUND Postoperative pancreatic fistula(PF)is a serious life-threatening complication after pancreaticoduodenectomy(PD).Our research aimed to develop a machine learning(ML)-aided model for PF risk stratification.AIM To develop an ML-aided model for PF risk stratification.METHODS We retrospectively collected 618 patients who underwent PD from two tertiary medical centers between January 2012 and August 2021.We used an ML algorithm to build predictive models,and subject prediction index,that is,decision curve analysis,area under operating characteristic curve(AUC)and clinical impact curve to assess the predictive efficiency of each model.RESULTS A total of 29 variables were used to build the ML predictive model.Among them,the best predictive model was random forest classifier(RFC),the AUC was[0.897,95%confidence interval(CI):0.370–1.424],while the AUC of the artificial neural network,eXtreme gradient boosting,support vector machine,and decision tree were between 0.726(95%CI:0.191–1.261)and 0.882(95%CI:0.321–1.443).CONCLUSION Fluctuating serological inflammatory markers and prognostic nutritional index can be used to predict postoperative PF.

Risk Factors And Outcome of Pancreatic Fistula after Consecutive Pancreaticoduodenectomy with Pancreaticojejunostomy for Patients with Malignant Tumor

Objective： Pancreatic fistula （PF） is a common complication after pancreaticoduodenectomy （PD） and there is no consensus regarding the criteria to define PF. The study was undertaken to determine the risk factors for PF according to the definition of the International Study Group on Pancreatic Fistula （ISGPF） and to delineate its impact on patient outcome. Methods： Between March 1994 and May 2009, data from 153 consecutive patients with malignant tumors underwent a PD with pancreaticojejunostomy in the Peking University People＇s Hospital were recorded prospectively A total of 24 factors were examined with univariate analysis and multivariate logistic regression analysis was used to estimate relative risks, and their 95% confidence intervals （95% CI） and odds ratio （OR）. Results： Our institution belonged to medium-volume center and PF occurred in 30 patients （19.6%）. Pancreatic texture, early postoperative hemorrhage and pancreatic pathologies correlated with PF rates significantly in univariate analyses. But in multivariate regression, soft gland （OR, 4.934; 95% CI, 1.132-7.312） and early postoperative hemorrhage with conservative therapy （OR, 4.130; 95% CI, 1.057-21.112） were predictive. The mean postoperative length of stay in patients with PF was longer （32.7±23.9 versus 60.5±56.2 days） than patients without PF （P=0.001）. Overall 30-day mortality was not affected by the development of PF （P=0.657）. There was no difference in reoperation rates between patients with and without PF （10.0% versus 6.5%, P=0.787）. Concerning the sum of postoperative complications, there were 36 complications for 30 patients with PF, while 64 for 123 patients without PF. When patients with distal cholangiocarcinoma, ampullary and duodenal cancer were considered as a whole for survival analysis, the median survival for patients with PF was 20 months, whereas the median survival for patients without PF was 26 months. Kaplan-Meier survival curves for patients with and without PF were not statistically different （P=0.903）. Conclusion： Soft texture and early postoperative hemorrhage with conservative therapy are independent correlates of increased rate of PF. Anastomotic technique for pancreaticojejunostomy does not have impact on the development of PF in our experience. PF contributes to early postoperative morbidity and the length of hospital stay, but it dose not affect postoperative 30-day mortality, reoperation rate and overall survival.

Pancreatic parenchymal injection of ethanol and octreotide to induce focal pancreatic fibrosis in rats: Strategies to eliminate postoperative pancreatic fistula

Background: Postoperative pancreatic fistula(POPF) is more likely to occur in a soft pancreas compared to a hard pancreas in which fibrosis has progressed. There is almost no leakage at the anastomosis site or cut surface of a hard pancreas. The aim of this study was to induce localized fibrosis at the cut surface of the pancreas in a rat model.Methods: Thirty-six rats were divided into three groups(group S: normal saline group; group E: ethanol group; and group O: octreotide group). Each rat was directly injected with a particular compound at the duodenal lobe of the pancreatic parenchyma. Each group was divided into three subgroups according to the time of post-injection sacrifice(1, 2, or 4 weeks). The hardness, suture holding capacity(SHC), and histological fibrosis grade of each pancreas were measured.Results: The hardness, SHC, and fibrosis grade of groups E and O were increased at week 1, with greater increases in group E(all P < 0.001). In a subgroup comparison, the hardness, SHC, and fibrosis grade of group E tended to decrease gradually over time, with no regular pattern evident in group O. A comparison between the injected site(duodenal lobe) and non-injected site(splenic lobe) of the pancreas revealed increases in the three parameters of group E only in the duodenal lobe, with increases in group O at both the duodenal and splenic lobes.Conclusions: Parenchymal injection of ethanol and octreotide increased pancreatic fibrosis. Unlike octreotide, ethanol provoked localized fibrosis that was maintained over time. It is expected that ethanol injection could eliminate POPF during pancreatic surgery.

Brachiocephalic to left brachial vein thrombotic vasculitis accompanying mediastinal pancreatic fistula:A case report

BACKGROUND Pancreatitis is a severe inflammatory pancreatic disease commonly due to bile duct stones or excessive alcohol usage,with clinical manifestations of abdominal pain,nausea,fever,and fluid collections.Healthy persons with less symptomatic pancreatitis are quite rare.Herein,we report a case of a patient with an undetermined onset of pancreatitis mimicking left arm cellulitis due to thrombotic vasculitis of the brachiocephalic vein.CASE SUMMARY A 50-year-old woman visited our hospital for tenderness in the left arm over several recent days.She was diagnosed with cellulitis on the left arm due to left elbow tenderness.Intravenous antibiotics administration did not improve symptoms and laboratory data worsened;thus,chest and abdominal computed tomography(CT)was performed.CT demonstrated pancreatitis with pseudocyst around the pancreas extending to the mediastinum.Thrombotic vasculitis of the brachiocephalic to left brachial vein was observed,which could be the cause of left elbow pain.A pancreatic fistula was found in the head of the pancreas by endoscopic retrograde cholangiopancreatography,so a pancreatic cyst drainage tube via the duodenum was placed in the pseudocyst.Cyst content culture was positive for Escherichia coli infection.Clinical symptoms,imaging findings,and inflammatory reactions resolved gradually after starting therapeutic intervention.The mediastinal pancreatic pseudocysts shrunk,and the venous thrombi remained but shrunk.CONCLUSION The case of a patient with pancreatitis with an undetermined onset that mimics left arm cellulitis is reported.Deep vein thrombosis should be kept in mind when treating patients with severe inflammatory disease.

Drain fluid biomarkers for prediction and diagnosis of clinically relevant postoperative pancreatic fistula:A narrative review

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 POPFrelated 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.

Do preoperative pancreatic computed tomography attenuation index and enhancement ratio predict pancreatic fistula after pancreaticoduodenectomy?

BACKGROUND The commonly used predictors of clinically relevant postoperative pancreatic fistula(CR-POPF)following pancreaticoduodenectomy(PD)have subjective assessment components and can be used only in the postoperative setting.Also,the available objective predictors based on preoperative cross-sectional imaging were not prospectively studied.AIM To evaluate the accuracy of the pancreatic attenuation index(PAI)and pancreatic enhancement ratio(PER)for predicting CR-POPF following PD and its correlation with pancreatic fat fraction and fibrosis.METHODS A prospective observational study included patients who underwent PD for benign and malignant pathology of the periampullary region or pancreatic head between February 2019 and February 2021.Patients undergoing extended or total pancreatectomy and those with severe atrophy of pancreatic tissue or extensive parenchymal calcifications in the pancreatic head and neck precluding calculation of PAI and PER were excluded from the study.Preoperatively PAI was measured in the neck of the pancreas by marking regions of interest(ROI)in the non-contrast computed tomography(CT),and PER was measured during the contrast phase of the CT abdomen.Also,the fibrosis score and fat fraction of the pancreatic neck were assessed during the histopathological examination.Demographic,clinical and preoperative radiological indices(PAI,PER)were evaluated to predict CR-POPF.Preoperative pancreatic neck CT indices were correlated with the histopathological assessment of fat fraction and fibrosis.RESULTS Of the 70 patients who underwent PD,61 patients fulfilling the inclusion criteria were included in the analysis.The incidence of CR-POPF was 29.5%(18/61).PAI had no association with the development of CR-POPF.Of the preoperative parameters,PER(mean±standard deviation[SD])was significantly lower in patients developing CR-POPF(0.58±0.20 vs 0.81±0.44,P=0.006).The area under the curve for the PER was 0.661(95%CI:0.517-0.804),which was significant(P=0.049).PER cut-off of 0.673 predicts CR-POPF with 77.8%sensitivity and 55.8%specificity.PAI and PER had a weak negative correlation(Strength-0.26,P=0.037).Also,PER showed a moderately positive correlation with fibrosis(Strength 0.50,P<0.001).Patients with CR-POPF had a significantly higher incidence of the intraabdominal abscess(50%vs 2.3%,P<0.001),delayed gastric emptying(83.3%vs 30.2,P<0.001),and prolonged mean(±SD)postoperative hospital stay(26.8±13.9 vs 9.6±3.6,P=0.001).CONCLUSION PER exhibited good accuracy in predicting the development of CR-POPF.PER additionally showed a good correlation with PAI and fibrosis scores and may be used as an objective preoperative surrogate for assessing pancreatic texture.However,ROI-based PAI did not show any association with CR-POPF and pancreatic fat fraction.