Preoperative systemic inflammatory response index as a prognostic marker for distal cholangiocarcinoma after pancreatoduodenectomy

BACKGROUND The relationship between preoperative inflammation status and tumorigenesis as well as tumor progression is widely acknowledged.AIM To assess the prognostic significance of preoperative inflammatory biomarkers in patients with distal cholangiocarcinoma(dCCA)who underwent pancreat-oduodenectomy(PD).METHODS This single-center study included 216 patients with dCCA after PD between January 1,2011,and December 31,2022.The individuals were categorized into two sets based on their systemic inflammatory response index(SIRI)levels:A low SIRI group(SIRI<1.5,n=123)and a high SIRI group(SIRI≥1.5,n=93).Inflam-matory biomarkers were evaluated for predictive accuracy using receiver operating characteristic curves.Both univariate and multivariate Cox proportional hazards analyses were performed to estimate SIRI for overall survival(OS)and recurrence-free survival(RFS).RESULTS The study included a total of 216 patients,with 58.3%being male and a mean age of 65.6±9.6 years.123 patients were in the low SIRI group and 93 were in the high SIRI group after PD for dCCA.SIRI had an area under the curve value of 0.674 for diagnosing dCCA,showing better performance than other inflammatory biomarkers.Multivariate analysis indicated that having a SIRI greater than 1.5 independently increased the risk of dCCA following PD,leading to lower OS[hazard ratios(HR)=1.868,P=0.006]and RFS(HR=0.949,P<0.001).Additionally,survival analysis indicated a significantly better prognosis for patients in the low SIRI group(P<0.001).CONCLUSION It is determined that a high SIRI before surgery is a significant risk factor for dCCA after PD.

Hepatopancreatoduodenectomy for the treatment of extrahepatic cholangiocarcinoma

To the Editor:Extrahepatic cholangiocarcinoma(ECC)is an uncommon neoplasm associated with a poor prognosis[1-3].Surgical resection represents the only curative approach,since systemic treatments have scarce efficacy in achieving disease control.However,only 10%-40%of patients with ECC are resectable at diagnosis[1].Ma-jor hepatectomy and portal lymphadenectomy are usually required for hilar ECC,while pancreatoduodenectomy is the standard operation for distal ECC[3-5].However,ECC may spread horizon-tally along the biliary tree,causing tumor involvement of the entire extrahepatic biliary system.In these circumstances,hep-atopancreatoduodenectomy(HPD)has been proposed as a pro-cedure with curative intent[2,6,7].

Predictive value of preoperative albumin-bilirubin score and other risk factors for short-term outcomes after open pancreatoduodenectomy

BACKGROUND Pancreatoduodenectomy represents a complex procedure involving extensive organ resection and multiple alimentary reconstructions.It is still associated with high morbidity,even in high-volume centres.Prediction tools including preoperative patient-related factors to preoperatively identify patients at high risk for postoperative complications could enable tailored perioperative management and improve patient outcomes.AIM To evaluate the clinical significance of preoperative albumin-bilirubin score and other risk factors in relation to short-term postoperative outcomes in patients after open pancreatoduodenectomy.METHODS This retrospective study included all patients who underwent open pancreatic head resection(pylorus-preserving pancreatoduodenectomy or Whipple resection)for various pathologies during a five-year period(2017-2021)in a tertiary care setting at University Medical Centre Ljubljana,Slovenia and Cattinara Hospital,Trieste,Italy.Short-term postoperative outcomes,namely,postoperative complications,postoperative pancreatic fistula,reoperation,and mortality,were evaluated in association with albumin-bilirubin score and other risk factors.Multiple logistic regression models were built to identify risk factors associated with these short-term postoperative outcomes.RESULTS Data from 347 patients were collected.Postoperative complications,major postoperative complications,postoperative pancreatic fistula,reoperation,and mortality were observed in 52.7%,22.2%,23.9%,21.3%,and 5.2%of patients,respectively.There was no statistically significant association between the albumin-bilirubin score and any of these short-term postoperative complications based on univariate analysis.When controlling for other predictor variables in a logistic regression model,soft pancreatic texture was statistically significantly associated with postoperative complications[odds ratio(OR):2.09;95%confidence interval(95%CI):1.19-3.67];male gender(OR:2.12;95%CI:1.15-3.93),soft pancreatic texture(OR:3.06;95%CI:1.56-5.97),and blood loss(OR:1.07;95%CI:1.00-1.14)were statistically significantly associated with major postoperative complications;soft pancreatic texture was statistically significantly associated with the development of postoperative pancreatic fistula(OR:5.11;95%CI:2.38-10.95);male gender(OR:1.97;95%CI:1.01-3.83),soft pancreatic texture(OR:2.95;95%CI:1.42-6.11),blood loss(OR:1.08;95%CI:1.01-1.16),and resection due to duodenal carcinoma(OR:6.58;95%CI:1.20-36.15)were statistically significantly associated with reoperation.CONCLUSION The albumin-bilirubin score failed to predict short-term postoperative outcomes in patients undergoing pancreatoduodenectomy.However,other risk factors seem to influence postoperative outcomes,including male sex,soft pancreatic texture,blood loss,and resection due to duodenal carcinoma.

Safety and feasibility of modified duct-to-mucosa pancreaticojejunostomy during pancreatoduodenectomy: A retrospective cohort study

BACKGROUND Pancreatoduodenectomy(PD)is the most effective surgical procedure to remove a pancreatic tumor,but the prevalent postoperative complications,including postoperative pancreatic fistula(POPF),can be life-threatening.Thus far,there is no consensus about the prevention of POPF.AIM To determine possible prognostic factors and investigate the clinical effects of modified duct-to-mucosa pancreaticojejunostomy(PJ)on POPF development.METHODS We retrospectively collected and analyzed the data of 215 patients who under-went PD between January 2017 and February 2022 in our surgery center.The risk factors for POPF were analyzed by univariate analysis and multivariate logistic regression analysis.Then,we stratified patients by anastomotic technique(end-to-side invagination PJ vs modified duct-to-mucosa PJ)to conduct a comparative study.RESULTS A total of 108 patients received traditional end-to-side invagination PJ,and 107 received modified duct-to-mucosa PJ.Overall,58.6%of patients had various complications,and 0.9%of patients died after PD.Univariate and multivariate logistic regression analyses showed that anastomotic approaches,main pancreatic duct(MPD)diameter and pancreatic texture were significantly associated with the incidence of POPF.Additionally,the POPF incidence and operation time in patients receiving modified duct-to-mucosa PJ were 11.2%and 283.4 min,respectively,which were significantly lower than those in patients receiving traditional end-to-side invagination PJ(27.8%and 333.2 minutes).CONCLUSION Anastomotic approach,MPD diameter and pancreatic texture are major risk factors for POPF development.Compared with traditional end-to-side invagination PJ,modified duct-to-mucosa PJ is a simpler and more efficient technique that results in a lower incidence of POPF.Further studies are needed to validate our findings and explore the clinical applicability of our technique for laparoscopic and robotic PD.

Pancreatic surgery and tertiary pancreatitis services warrant provision for support from a specialist diabetes team

Pancreatic surgery units undertake several complex operations,albeit with consi-derable morbidity and mortality,as is the case for the management of complicated acute pancreatitis or chronic pancreatitis.The centralisation of pancreatic surgery services,with the development of designated large-volume centres,has contribu-ted to significantly improved outcomes.In this editorial,we discuss the complex associations between diabetes mellitus(DM)and pancreatic/periampullary disease in the context of pancreatic surgery and overall management of complex pancreatitis,highlighting the consequential needs and the indispensable role of specialist diabetes teams in support of tertiary pancreatic services.Type 3c pan-creatogenic DM,refers to DM developing in the setting of exocrine pancreatic disease,and its identification and management can be challenging,while the glycaemic control of such patients may affect their course of treatment and outcome.Adequate preoperative diabetes assessment is warranted to aid identification of patients who are likely to need commencement or escalation of glucose lowering therapy in the postoperative period.The incidence of new onset diabetes after pancreatic resection is widely variable in the literature,and depends on the type and extent of pancreatic resection,as is the case with pancreatic parenchymal loss in the context of severe pancreatitis.Early involvement of a specialist diabetes team is essential to ensure a holistic management.In the current era,large volume pancreatic surgery services commonly abide by the principles of enhanced recovery after surgery,with inclusion of provisions for optimisation of the perioperative glycaemic control,to improve outcomes.While various guidelines are available to aid perioperative management of DM,auditing and quality improvement platforms have highlighted deficiencies in the perioperative management of diabetic patients and areas of required improvement.The need for perioperative support of diabetic patients by specialist diabetes teams is uniformly underlined,a fact that becomes clearly more prominent at all different stages in the setting of pancreatic surgery and the management of complex pancreatitis.Therefore,pancreatic surgery and tertiary pancreatitis services must be designed with a provision for support from specialist diabetes teams.With the ongoing accumulation of evidence,it would be reasonable to consider the design of specific guidelines for the glycaemic management of these patients.

保留十二指肠胰头全切除术11例临床分析

目的 探讨保留十二指肠胰头全切除术(DPPHRt)对胰头良性及低度恶性疾病的治疗经验,包括手术适应证、手术并发症尤其是胆管并发症的防治。方法 回顾性分析2021年7月至2023年5月苏州大学附属第一医院11例施行DPPHRt患者的病例资料。结果 本组共11例,其中男7例,女4例,平均年龄55.6岁,平均手术时间249(165~390)min,平均术中出血量187(50~500)mL,平均术后住院时间27.6(12~55)d。疾病类型:慢性肿块型胰腺炎2例(1例伴胰管结石),慢性胰腺炎1例(车祸外伤所致),胰腺神经内分泌肿瘤1例,胰头导管内乳头状瘤(IPMN)5例,胰腺浆液性囊腺瘤1例,胰头黏液性囊肿1例。手术方式均为开腹手术,无手术死亡。术后发生胰瘘3例(均为B级胰瘘),胆瘘3例,胆总管狭窄3例,腹腔出血1例,腹腔感染1例,胃排空延迟2例,经非手术治疗均治愈出院。术后获得随访11例,随访时间为2个月至2年,无复发、内外分泌功能减退、胃排空延迟等远期并发症发生,无死亡病例。结论 DPPHRt对胰头良性与低度恶性疾病是一种有效的手术方式。

胰十二指肠切除术后胰瘘及胰瘘合并出血的预防及治疗策略

目的探讨胰十二指肠切除术后胰瘘及胰瘘合并出血的预防及治疗策略。方法选取广东省人民医院自2019年8月至2022年12月收治的90例拟行胰十二指肠切除术的患者为研究对象。根据是否发生术后胰瘘将患者分为术后胰瘘组(n=35)与术后无胰瘘组(n=55);根据是否合并出血将35例术后胰瘘患者分为胰瘘合并出血组(n=10)与胰瘘无出血组(n=25)。采用χ^(2)检验或Fisher精确检验进行单因素分析,有统计学差异的变量进一步行逐步回归变量筛选,多因素logistic回归分析确定发生胰瘘和术后胰瘘合并出血的独立危险因素。结果90例患者均顺利完成胰十二指肠切除术,术后胰瘘发生率为38.9%(35/90)。两组患者胰管直径(P=0.013)、术中失血量(P=0.045)、吻合方式(P=0.045)、残余胰腺质地(P=0.010)比较,差异均有统计学意义(P<0.05)。多因素logistic回归分析结果显示,胰腺质地软、胰腺导管直径<3 mm、术中出血量≥300 mL以及胰肠吻合方式为胰十二指肠切除术后胰瘘的独立危险因素。在发生术后胰瘘的患者中,多因素logistic回归分析结果显示,胰瘘量>100 mL/d、术后胰瘘持续时间>7 d是胰十二指肠切除术后胰瘘合并出血的独立危险因素。结论胰十二指肠切除术后胰瘘的发生风险较高,重视关注术前胰管直径及规范化判断胰腺质地,有助于预防术后胰瘘。术中仔细止血,尽量避免术后早期出血,可以降低术后B、C级胰瘘的发生率。胰瘘患者当胰瘘量>100 mL/d、术后胰瘘持续时间>7 d时要警惕出血的发生。

手术台次对胰十二指肠切除术后早期转归的影响

目的分析手术台次对胰十二指肠切除术(Whipple手术)术中出血量和早期转归的影响。方法收集2017至2021年接受Whipple手术的胰腺癌患者519例,男306例,女213例,年龄32~86岁,BMI 15~35 kg/m^(2),ASAⅠ—Ⅲ级。依据手术台次分为两组:台次≤2组和台次>2组。将患者术中出血量作为主要观察指标,晶体输液量、胶体输液量,术后胰瘘、胆瘘、乳糜瘘、腹部出血、肺部感染、腹腔感染、胃排空障碍、发热等并发症发生率,术后住院时间为次要观察指标。采用Logistic回归分析手术台次与术中大出血和早期转归指标的相关性。结果共纳入患者519例,其中台次≤2组有415例(800%)。与台次≤2组比较,台次>2组术中大出血发生率明显增加(RR=1669,95%CI 1146~2430,P=0011)。两组晶体输液量、胶体输液量、住院期间胰瘘、胆瘘、乳糜瘘、腹部出血、肺部感染、腹腔感染、胃排空障碍、发热等术后并发症发生率和术后住院时间差异无统计学意义。多因素Logistic回归分析示术中大出血的危险因素为手术台次>2(OR=2269,95%CI 1318~3907,P=0003)和手术时间延长(OR=1012,95%CI 1009~1016,P<0001)。结论手术台次>2及手术时间延长会增加胰腺癌患者Whipple手术中发生大出血的风险,但对术后住院时间和住院期间术后并发症无明显影响。

胰十二指肠切除术后迟发性出血行DSA介入栓塞治疗的临床效果

目的 探讨胰十二指肠切除术(PD)后患者迟发性出血行数字减影血管造影(DSA)介入栓塞治疗的疗效和临床意义。方法 回顾性分析湖北省中西医结合医院2016年1月至2023年1月31例因PD术后迟发性出血行DSA介入栓塞治疗的临床资料,评估介入治疗的临床效果。结果 本研究PD术后迟发性出血发生率为6.37%(31/487),31例迟发性出血患者中首次DSA阳性22例(71%),14例伴有假性动脉瘤形成。出血部位包括胃十二指肠动脉9例,肝总动脉7例,肠系膜上动脉分支6例,肝固有动脉5例,脾动脉起始3例,胃左动脉1例。行微弹簧圈栓塞12例,微弹簧圈加明胶海绵栓塞8例,覆膜支架9例,明胶海绵栓塞2例。29例(94%)行DSA介入治疗达到彻底止血效果;2例再发出血,行手术止血处理。结论 DSA及栓塞止血创伤小,可精准发现PD术后出血血管,及时进行栓塞,止血效果安全有效,可作为PD术后迟发性出血首选治疗方法。

The International Study Group of Pancreatic Surgery definition of delayed gastric emptying and the effects of various surgical modifications on the occurrence of delayed gastric emptying after pancreatoduodenectomy

BACKGROUND:A number of definitions have been used for delayed gastric emptying(DGE) after pancreatoduodenectomy and the reported rates varied widely.The International Study Group of Pancreatic Surgery(ISGPS) definition is the current standard but it is not used universally.In this comprehensive review,we aimed to determine the acceptance rate of ISGPS definition of DGE,the incidence of DGE after pancreatoduodenectomy and the effect of various technical modifications on its incidence.DATA SOURCE:We searched PubM ed for studies regarding DGE after pancreatoduodenectomy that were published from 1 January 1980 to 1 July 2015 and extracted data on DGE definition,DGE rates and comparison of DGE rates among different technical modifications from all of the relevant articles.RESULTS:Out of 435 search results,178 were selected for data extraction.The ISGPS definition was used in 80% of the studies published since 2010 and the average rates of DGE and clinically relevant DGE were 27.7%(range:0-100%;median:18.7%) and 14.3%(range:1.8%-58.2%;median:13.6%),respectively.Pylorus preservation or retrocolic reconstruction were not associated with increased DGE rates.Although pyloric dilatation,Braun’s entero-enterostomy and Billroth Ⅱ reconstruction were associated with significantly lower DGE rates,pyloric ring resection appears to be most promising with favorable results in 7 out of 10 studies.CONCLUSIONS:ISGPS definition of DGE has been used in majority of studies published after 2010.Clinically relevant DGE rates remain high at 14.3% despite a number of proposed surgical modifications.Pyloric ring resection seems to offer the most promising solution to reduce the occurrence of DGE.

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.

Treatment of massive pancreaticojejunal anastomotic hemorrhage after pancreatoduodenectomy

AIM： To compare the treatment modalities for patients with massive pancreaticojejunal anastomotic hemorrhage after pancreatoduodenectomy （PDT）.METHODS： A retrospective study was undertaken to compare the outcomes of two major treatment modalities： transcatheter arterial embolization （TAE） and open surgical hemostasis. Seventeen patients with acute massive hemorrhage after PDT were recruited in this study. A comparison of two treatment modalities was based upon the clinicopathological characteristics and hospitalization stay, complications, and patient prognosis of the patients after surgery.RESULTS： Of the 11 patients with massive hemorrhage after PDT treated with TAE, 1 died after discontinuing treatment, the other 10 stopped bleeding completely without recurrence of hemorrhage. AIJ the 10 patients recovered well and were discharged, with a mean hospital stay of 10.45 d after hemostasis. The patients who underwent TAE twice had a re-operation rate of 18.2% and a mortality rate of 0.9%. Among the six patients who received open surgical hemostasis, two underwent another round of open surgical hemostasis. The mortality was 50%, and the recurrence of hemorrhage was 16.67%, with a mean hospital stay of 39.5 d.CONCLUSION： TAE is a safe and effective treatment modality for patients with acute hemorrhage after PDT. Vasography should be performed to locate the bleeding site.

Effect of Blumgart anastomosis in reducing the incidence rate of pancreatic fistula after pancreatoduodenectomy

BACKGROUND Pancreatic fistula is one of the most serious complications after pancreatoduodenectomy for treating any lesions at the pancreatic head. For years, surgeons have tried various methods to reduce its incidence. AIM To investigate and emphasize the clinical outcomes of Blumgart anastomosis compared with traditional anastomosis in reducing postoperative pancreatic fistula. METHODS In this observational study, a retrospective analysis of 291 patients who underwent pancreatoduodenectomy, including Blumgart anastomosis (201 patients) and traditional embedded pancreaticojejunostomy (90 patients), was performed in our hospital. The preoperative and perioperative courses and longterm follow-up status were analyzed to compare the advantages and disadvantages of the two methods. Moreover, 291 patients were then separated by the severity of postoperative pancreatic fistula, and two methods of pancreaticojejunostomy were compared to detect the features of different anastomosis. Six experienced surgeons were involved and all of them were proficient in both surgical techniques.RESULTS The characteristics of the patients in the two groups showed no significant differences, nor the preoperative information and pathological diagnoses. The operative time was significantly shorter in the Blumgart group (343.5 ± 23.0 vs 450.0 ± 40.1 min, P = 0.028), as well as the duration of pancreaticojejunostomy drainage tube placement and postoperative hospital stay (12.7 ± 0.9 d vs 17.4 ± 1.8 d, P = 0.031;and 21.9 ± 1.3 d vs 28.9 ± 1.3 d, P = 0.020, respectively). The overall complications after surgery were much less in the Blumgart group than in the embedded group (11.9% vs 26.7%, P = 0.002). Patients who underwent Blumgart anastomosis would suffer less from severe pancreatic fistula (71.9% vs 50.0%, P = 0.006), and this pancreaticojejunostomy procedure did not have worse influences on long-term complications and life quality. Thus, Blumgart anastomosis is a feasible pancreaticojejunostomy procedure in pancreatoduodenectomy surgery. It is safe in causing less postoperative complications, especially pancreatic fistula, and thus shortens the hospitalization duration. CONCLUSION Surgical method should be a key factor in reducing pancreatic fistula, and Blumgart anastomosis needs further promotion.

Comparison of Wirsung-jejunal duct-tomucosa and dunking technique for pancreatojejunostomy after pancreatoduodenectomy

Pancreato-enteric reconstruction after pancreatoduodenectomy (PD) is still a source of debate because of the high incidence of complications. Among the various types of pancreato-jejunostomies we don't know yet which is the best in terms of anastomotic failure and related complications rates. Wirsung-jejunal duct-to-mucosa anastomosis (WJ) and 'dunking' pancreato-jejunal anastomosis (DPJ) are the two most used ones worldwide but conflicting results are reported. To determine which is the safer anastomosis and to define when an anastomosis should be preferred, we retrospectively reviewed two groups of patients who underwent WJ or DPJ. METHODS:Twenty-three patients underwent PD with WJ (n=17) with dilated (WJD) (n=9) or not-dilated Wirsung's duct (WJND) (n=8) or with a DPJ (n=6) over a 3-year period at a single institution. RESULTS: The complications rate was high in all groups of patients (33.3% in WJD, 37.5% in WJND and 66.7% in DPJ). A pancreatic fistula developed in one patient in each group (11. 1% in WJD, 12. 5% in WJND and 16. 7% in DPJ). All these patients were managed conservatively. Anastomotic disruption took place in the WJ patients especially in the WJND group (n=2) compared to the WJD (n=1) (25% vs 11.1%) or DPJ groups (0%) : these three patients required a re-operation. Overall, the anastomotic defects were higher in patients who underwent WJND (37.5%), compared to WJD (22.2%) and to DPJ (16.7%). However, no statistical differences were found among the groups. Delayed gastric emptying (DGE) and total parenteral nutrition (TPN) along with anastomotic defects were responsible for a prolonged hospital stay. CONCLUSIONS:Our results were not able to demonstrate any statistical difference between the two different techniques in preventing anastomotic failure. WJ can represent a valid choice in case of a dilated duct and a firm, fibrotic enlarged gland that could not be properly invaginated in a small jejunal loop. DGE may occur in those patients who experienced an anastomotic failure and required a TPN regimen with a prolonged hospital stay.

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.

Does antecolic reconstruction decrease delayed gastric emptying after pancreatoduodenectomy?

Delayed gastric emptying(DGE) is a frequent complication after pylorus-preserving pancreatoduodenectomy(PpPD).Kawai and colleagues proposed pylorus-resecting pancreatoduodenectomy(PrPD) with antecolic gastrojejunal anastomosis to obviate DGE occurring after PpPD.Here we debate the reported differences in the prevalence of DGE in antecolic and retrocolic gastro/duodeno-jejunostomies after PrPD and PpPD,respectively.We concluded that the route of the gastro/duodeno-jejunal anastomosis with respect to the transverse colon;i.e.,antecolic route or retrocolic route,is not responsible for the differences in prevalence of DGE after pancreatoduodenectomy(PD) and that the impact of the reconstructive method on DGE is related mostly to the angulation or torsion of the gastro/duodeno-jejunostomy.We report a prevalence of 8.9% grade A DGE and 1.1% grade C DGE in a series of 89 subtotal stomach-preserving PDs with Roux-en Y retrocolic reconstruction with anastomosis of the isolated Roux limb to the stomach and single Roux limb to both the pancreatic stump and hepatic duct.Retrocolic anastomosis of the isolated first jejunal loop to the gastric remnant allows outflow of the gastric contents by gravity through a "straight route".

Hepatopancreatoduodenectomy for advanced hepatobiliary malignancies: a single-center experience

BACKGROUND: Hepatopancreatoduodenectomy is a complicated and challenging procedure but necessary for curative resection for advanced hepatobiliary malignancies. This retrospective study was to examine the safety and survival outcomes of hepatopancreatoduodenectomy in our center. METHODS: Prospectively collected data of 12 patients who underwent hepatopancreatoduodenectomy for advanced hepatobiliary malignancies in our hospital from January 1998 to December 2014 were analyzed. The primary endpoints are treatment-related morbidity and mortality and the secondary endpoints are overall survival and disease-free survival. RESULTS: Curative resection was achieved in 11 (91.7%) patients. Complications developed in 10 (83.3%) patients. Three hospital deaths resulted from multiorgan failure secondary to postoperative pancreatic fistula or hepaticojejunostomy leakage. Six of the nine remaining patients had disease recurrence. The nine patients had a median survival of 39.8 (5.3-151.8) months. The 1-, 3- and 5-year overall survival rates were 66.7%, 55.6% and 27.8%, respectively. The corresponding disease-free survival rates were 55.6%, 44.4% and 29.6%, respectively. CONCLUSIONS: Morbidity and mortality after hepatopancreatoduodenectomy were significant. With RO resection, the 5-year overall survival and disease-free survival rates were 27.8% and 29.6%, respectively.

CD14 upregulation as a distinct feature of non-alcoholic fatty liver disease after pancreatoduodenectomy

AIM:To investigate the pathogenesis of non-alcoholic fatty liver disease(NAFLD)after pancreatoduodenectomy(PD).METHODS:A cohort of 82 patients who underwent PD at Okayama University Hospital between 2003 and 2009 was enrolled and the clinicopathological features were compared between patients with and without NAFLD after PD.Computed tomography(CT)images were evaluated every 6 mo after PD for follow-up.Hepatic steatosis was diagnosed on CT when hepatic attenuation values were 40 Hounsfield units.Liver biopsy was performed for 4 of 30 patients with NAFLD after PD who consented to undergo biopsies.To compare NAFLD after PD with NAFLD associated with metabolic syndrome,liver samples were obtained from 10 patients with NAFLD associated with metabolic syndrome [fatty liver,n = 5;non-alcoholic steatohepatitis(NASH),n = 5] by percutaneous ultrasonography-guided liver biopsy.Double-fluorescence immunohistochemistry was applied to examine CD14 expression as a marker of lipopolysaccharide(LPS)-sensitized macrophage cells(Kupffer cells)in liver biopsy specimens.RESULTS:The incidence of postoperative NAFLD was 36.6%(30/82).Univariate analysis identified cancer of the pancreatic head,sex,diameter of the main pancreatic duct,and dissection of the nerve plexus as factors associated with the development of NAFLD after PD.Those patients who developed NAFLD after PD demonstrated significantly decreased levels of serum albumin,total protein,cholesterol and triglycerides compared to patients without NAFLD after PD,but no glucose intolerance or insulin resistance.Liver biopsy was performed in four patients with NAFLD after PD.All four patients showed moderate-to-severe steatosis and NASH was diagnosed in two.Numbers of cells positive for CD68(a marker of Kupffer cells)and CD14(a marker of LPSsensitized Kupffer cells)were counted in all biopsy specimens.The number of CD68+ cells in specimens of NAFLD after PD was significantly increased from that in specimens of NAFLD associated with metabolic syndrome specimens,which indicated the presence of significantly more Kupffer cells in NAFLD after PD than in NAFLD associated with metabolic syndrome.Similarly,more CD14+ cells,namely,LPS-sensitized Kupffer cells,were observed in NAFLD after PD than in NAFLD associated with metabolic syndrome.Regarding NASH,more CD68+ cells and CD14+ cells were observed in NASH after PD specimens than in NASH associated with metabolic syndrome.This showed that more Kupffer cells and more LPS-sensitized Kupffer cells were present in NASH after PD than in NASH associated with metabolic syndrome.These observations suggest that after PD,Kupffer cells and LPS-sensitized Kupffer cells were significantly upregulated,not only in NASH,but also in simple fatty liver.CONCLUSION:NAFLD after PD is characterized by both malnutrition and the up-regulation of CD14 on Kupffer cells.Gut-derived endotoxin appears central to the development of NAFLD after PD.

Modified Blumgart anastomosis without pancreatic duct-to-jejunum mucosa anastomosis for pancreatoduodenectomy：a feasible and safe novel technique

Objective：This study proposed a modified Blumgart anastomosis（m-BA）that uses a firm ligation of the main pancreatic duct with a supporting tube to replace the pancreatic duct-to-jejunum mucosa anastomosis,with the aim of simplifying the complicated steps of the conventional BA（c-BA）.Thus,we observe if a difference in the risk of postoperative pancreatic fistula（POPF）exists between the two methods.Methods：The m-BA anastomosis method has been used since 2010.From October 2011 to October 2015,147 patients who underwent pancreatoduodenectomy（PD）using BA in Tianjin Medical University Cancer Institute and Hospital were enrolled in this study.According to the type of pancreatojejunostomy（PJ）,50 patients underwent m-BA and 97 received c-BA.The two patient cohorts were compared prospectively to some extent but not randomized,and the evaluated variables were operation time,the incidence rate of POPF,and other perioperative complications.Results：The operation time showed no significant difference（P〉0.05）between the two groups,but the time of duct-to-mucosa anastomosis in the m-BA group was much shorter than that in the c-BA group（P〈0.001）.The incidence rate of clinically relevant POPF was 12.0%（6/50）in the modified group and 10.3%（10/97）in the conventional group（P〉0.05）,which means that the modified anastomosis method did not cause additional pancreatic leakage.The mean length of postoperative hospital stay of the m-BA group was 23 days,and that of the c-BA group was 22 days（P〉0.05）.Conclusions：Compared with the conventional BA,we suggest that the modified BA is a feasible,safe,and effective operation method for P J of PD with no sacrifice of surgical quality.In the multivariate analysis,we also found that body mass index（≥25

Reconstruction after pancreatoduodenectomy:Pancreatojejunostomy vs pancreatogastrostomy

Pancreatic surgeons try to find the best technique for reconstruction after pancreatoduodenectomy(PD) in order to decrease postoperative complications,mainly pancreatic fistulas(PF).In this work,we compare the two most frequent techniques of reconstruction after PD,pancreatojejunostomy(PJ) and pancreatogastrostomy(PG),in order to determine which of the two is better.A systematic review of the literature was performed,including major meta-analysis articles,clinical randomized trials,systematic reviews,and retrospective studies.A total of 64 articles were finally included.PJ and PG are usually responsible for most of the postoperative morbidity,mainly due to the onset of PF,being considered a major trigger of life-threatening complications such as intra-abdominal abscess and hemorrhagia.The included systematic reviews reported a significant difference only in the incidence of intraabdominal collections favouring PG.PF,delayed gastric emptying and mortality were not different.Although there was heterogeneity between these studies,all were conducted in specialized centers by highly experienced surgeons,and the surgical care was likely to be similar for all the studies.The disadvantages of PG include an increased incidence of delayed gastric emptying and of main pancreatic duct obstruction due to overgrowth by the gastric mucosa.Exocrine function appears to be worse after PG than after PJ,resulting in severe atrophic changes in the remnant pancreas.Depending on the type of PJ or PG used,the PF rate and other complications can also be different.The best method to deal with the pancreatic stump after PD remains questionable.The choice of method of pancreatic anastomosis could be based on individual experience and on the surgeon's preference and adherence to basic principles such as good exposure and visualization.In conclusion,up to now none of the techniques can be considered superior or be recommended as standard for reconstruction after PD.