Risk factors and prevention of pancreatic fistula after laparoscopic gastrectomy for gastric cancer

Following laparoscopic gastrectomy(LG),one of the critical complications that can arise is a pancreatic fistula(PF).The inability to promptly prevent,diagnose,and manage this condition can lead to severe complications and potentially be life-threatening for the patient.The incidence of PF post-LG in gastric cancer treatment is related to factors such as surgical approach,surgical instruments,characteristics of the pancreas itself,tumor stage,and the surgeon’s experience.Currently,the diagnosis of postoperative PF is mainly based on the definition and diagnostic criteria consensus established by the International Study Group of Pancreatic Surgery.Gastrointestinal surgeons should be aware of the risk factors for PF,perform LG for gastric cancer with great care and precision,avoid pan-creatic injury,and actively work to reduce the risk of postoperative PF.

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.

Identifying the risk factors for pancreatic fistula after laparoscopic pancreaticoduodenectomy in patients with pancreatic cancer

BACKGROUND Laparoscopic pancreaticoduodenectomy(LPD)is a surgical procedure for treating pancreatic cancer;however,the risk of complications remains high owing to the wide range of organs involved during the surgery and the difficulty of anastomosis.Pancreatic fistula(PF)is a major complication that not only increases the risk of postoperative infection and abdominal hemorrhage but may also cause multi-organ failure,which is a serious threat to the patient’s life.This study hypothesized the risk factors for PF after LPD.AIM To identify the risk factors for PF after laparoscopic pancreatoduodenectomy in patients with pancreatic cancer.METHODS We retrospectively analyzed the data of 201 patients admitted to the Fudan University Shanghai Cancer Center between August 2022 and August 2023 who underwent LPD for pancreatic cancer.On the basis of the PF’s incidence(grades B and C),patients were categorized into the PF(n=15)and non-PF groups(n=186).Differences in general data,preoperative laboratory indicators,and surgery-related factors between the two groups were compared and analyzed using multifactorial logistic regression and receiver-operating characteristic(ROC)curve analyses.RESULTS The proportions of males,combined hypertension,soft pancreatic texture,and pancreatic duct diameter≤3 mm;surgery time;body mass index(BMI);and amylase(Am)level in the drainage fluid on the first postoperative day(Am>1069 U/L)were greater in the PF group than in the non-PF group(P<0.05),whereas the preoperative monocyte count in the PF group was lower than that in the non-PF group(all P<0.05).The logistic regression analysis revealed that BMI>24.91 kg/m²[odds ratio(OR)=13.978,95%confidence interval(CI):1.886-103.581],hypertension(OR=8.484,95%CI:1.22-58.994),soft pancreatic texture(OR=42.015,95%CI:5.698-309.782),and operation time>414 min(OR=15.41,95%CI:1.63-145.674)were risk factors for the development of PF after LPD for pancreatic cancer(all P<0.05).The areas under the ROC curve for BMI,hypertension,soft pancreatic texture,and time prediction of PF surgery were 0.655,0.661,0.873,and 0.758,respectively.CONCLUSION BMI(>24.91 kg/m²),hypertension,soft pancreatic texture,and operation time(>414 min)are considered to be the risk factors for postoperative PF.

A comparison of laparoscopic to open pancreaticoduodenectomy for pancreatic adenocarcinoma by propensity score matching analysis

Objective:In previous studies,laparoscopic pancreaticoduodenectomy(LPD)has demonstrated safety and potential benefits over open pancreaticoduodenectomy(OPD)for pancreatic adenocarcinoma(PDAC).After performing both LPD and OPD procedures interchangeably in routine practice for a decade,the outcomes of LPD versus OPD for PDAC were analyzed and compared at a single institution.Our primary aim was to compare features of LPD and OPD in PDAC patients so that the suitable surgical approach may be chosen for each individual.Methods:From January 2010 through December 2020,all patients undergoing pancreaticoduodenectomy(PD)were identified,and information was collected prospectively.At a single institution,PD was performed on 589 patients,of whom 347 were OPD patients and 242 were LPD patients.After excluding those who underwent pancreatectomy for indications other than PDAC,total pancreatectomy,major vascular or concomitant organ resection,there were 237 patients(OPD¼157,LPD¼80).Then propensity score matching was completed to analyze 77 OPD patients versus 77 LPD patients to create a similar group of patients who underwent either LPD or OPD for PDAC.A comparison of perioperative data and 90-day outcomes with subsequent statistical analysis was performed.Results:Operative time(491 min vs.281 min,p<0.001)was longer for LPD than OPD.The rates of pancreatic fistula(11.7%vs.0.0%,p<0.001)and delayed gastric emptying(15.6%vs.3.9%,p¼0.027)were higher for LPD than OPD respectively but overall morbidity was similar.Blood loss,mortality and postpancreatectomy hemorrhage were also similar for both groups,but total costs($60,245 vs.$50,900,p¼0.002)were significantly higher for LPD than OPD.Recurrence and overall survival were similar for the two groups.Conclusion:In our experience,LPD does not offer any advantages over OPD for PDAC and is associated with a higher rate of complications and costs.

Gradient inflammation in the pancreatic stump after pancreaticoduodenectomy:Two case reports and review of literature

BACKGROUND Postoperative pancreatic fistula(POPF)contributes significantly to morbidity and mortality after pancreaticoduodenectomy(PD).However,the underlying mechanisms remain unclear.This study explored this pathology in the pancreatic stumps and elucidated the mechanisms of POPF following PD.CASE SUMMARY Pathological analysis and 16S rRNA gene sequencing were performed on specimens obtained from two patients who underwent complete pancreatectomy for grade C POPF after PD.Gradient inflammation is present in the pancreatic stump.The apoptosis was lower than that in the normal pancreas.Moreover,neu-trophildominated inflammatory cells are concentrated in the ductal system.No-tably,neutrophils migrated through the ductal wall in acinar duct metaplasia-formed ducts.Additionally,evidence indicates that gut microbes migrate from the digestive tract.Gradient inflammation occurs in pancreatic stumps after PD.CONCLUSION The mechanisms underlying POPF include high biochemical activity in the pancreas,mechanical injury,and digestive reflux.To prevent POPF and address pancreatic inflammation and reflux,breaking the link with anastomotic dehi-scence is practical.

Stent A pancreaticojejunostomy after pancreatoduodenectomy:Is it always necessary?

The establishment of a postoperative pancreatic fistula(POPF)is considered the most common and,concomitantly,the most serious complication associated with pancreaticoduodenectomy(PD).The search for either technical modifications of the operative technique or pharmaceutical interventions that could possibly aid in decreasing the incidence of this often-devastating complication appears justified.The stenting of the pancreatic duct,with the use of either internal or external stents,has been evaluated in this direction.In theory,it is an approach that could eliminate many pathophysiological factors responsible for the occurrence of a POPF.The purpose of the present study was to review the current data regarding the role of pancreatic duct stenting on the incidence of POPF,after PD,by using PubMed and Reference Citation Analysis.In general,previous studies seem to highlight the superiority of external stents over their internal counterparts in regard to the incidence of POPF;this is at the cost,however,of increased morbidity associated mainly with the stent removal.Certainly,the use of an internal stent is a less invasive approach with acceptable results and is definitely deprived of the drawbacks arising through the complete diversion of pancreatic juice from the gastrointestinal tract.Bearing in mind the scarcity of high-quality data on the subject,an approach of reserving stent placement for the high-risk for POPF patients and individualizing the selection between the use of an internal or an external stent according to the distinct characteristics of each individual case scenario appears appropriate.

Surgical techniques and postoperative management to prevent postoperative pancreatic fistula after pancreatic surgery

Postoperative pancreatic fistula (POPF) is one of the most severe complications after pancreatic surgeries. POPF develops as a consequence of pancreatic juice leakage from a surgically exfoliated surface and/or anastomotic stump, which sometimes cause intraperitoneal abscesses and subsequent lethal hemorrhage. In recent years, various surgical and perioperative attempts have been examined to reduce the incidence of POPF. We reviewed several well-designed studies addressing POPF-related factors, such as reconstruction methods, anastomotic techniques, stent usage, prophylactic intra-abdominal drainage, and somatostatin analogs, after pancreaticoduodenectomy and distal pancreatectomy, and we assessed the current status of POPF. In addition, we also discussed the current status of POPF in minimally invasive surgeries, laparoscopic surgeries, and robotic surgeries.

Pancreatic fistula after pancreatectomy:Evolving definitions,preventive strategies and modern management

Pancreatic resection is the treatment of choice for pancreatic malignancy and certain benign pancreatic disorders. However, pancreatic resection is technically a demanding procedure and whereas mortality after a pancreaticoduodenectomy is currently < 3%-5% in experienced high-volume centers, post-operative morbidity is considerable, about 30%-50%. At present, the single most significant cause of morbidity and mortality after pancreatectomy is the development of pancreatic leakage and fistula (PF). The occurrence of a PF increases the length of hospital stay and the cost of treatment, requires additional investigations and procedures, and can result in life-threatening complications. There is no universally accepted definition of PF that would allow standardized reporting and proper comparison of outcomes between different centers. However, early recognition of a PF and prompt institution of appropriate treatment is critical to the prevention of potentially devastating consequences. The present article, reviews the evolution of post resection pancreatic fistula as a concept, and discusses evolving definitions, the current preventive strategies and the management of this problem.

Application of air insufflation to prevent clinical pancreatic fistula after pancreaticoduodenectomy

AIM:To introduce an air insufflation procedure and to investigate the effectiveness of air insufflation in preventing pancreatic fistula(PF).of 185 patients underwent pancreaticoduodenectomy(PD)at our institution,and 74 patients were not involved in this study for various reasons.The clinical outcomes of 111 patients were retrospectively analyzed.The air insufflation test was performed in 46 patients to investigate the efficacy of the pancreaticojejunal anastomosis during surgery,and 65 patients who did not receive the air insufflation test served as controls.Preoperative assessments and intraoperative outcomes were compared between the 2 groups.Univariate and multivariate analyses were performed to identify the risk factors for PF.RESULTS:The two patient groups had similar baseline demographics,preoperative assessments,operative factors,pancreatic factors and pathological results.The overall mortality,morbidity,and PF rates were1.8%,48.6%,and 26.1%,respectively.No significant differences were observed in either morbidity or mortality between the two groups.The rate of clinical PF(grade B and grade C PF)was significantly lower in the air insufflation test group,compared with the nonair insufflation test group(6.5%vs 23.1%,P=0.02).Univariate analysis identified the following parameters as risk factors related to clinical PF:estimated blood loss;pancreatic duct diameter≤3 mm;invagination anastomosis technique;and not undergoing air insufflation test.By further analyzing these variables with multivariate logistic regression,estimated blood loss,pancreatic duct diameter≤3 mm and not undergoing air insufflation test were demonstrated to be independent risk factors.CONCLUSION:Performing an air insufflation test could significantly reduce the occurrence of clinical PF after PD.Not performing an air insufflation test was an independent risk factor for clinical PF.

Preventing pancreatic fistula after distal pancreatectomy: An invagination method

Following an increase in the use of the GIA stapler for treating a pancreatic stump, more techniques to prevent postoperative pancreatic juice leakage have been required. We describe one successful case using our new technique of invaginating the cut end of the pancreas into the stomach to prevent a pancrea-tic fistula(PF) from occurring. A 50-year-old woman with pancreatic cancer in the tail of the pancreas underwent distal pancreatectomy, causing a grade A PF. We resected the distal pancreas without additional reinforcement to invaginate the stump into the gastric posterior wall with single layer anastomosis using a 3-0 absorbable suture. The drain tubes were removed on the third postoperative day. Although a grade A PF was noted, the patient was discharged on foot on the eleventh postoperative day. Our technique may be a suitable method for patients with a pancreatic body and tail tumor.

Radiological parameters to predict pancreatic texture:Current evidence and future perspectives

Preoperative prediction of the postoperative pancreatic fistula risk is critical in the current era of minimally invasive pancreatic surgeries to tailor perioperative management,thereby minimizing postoperative morbidity.Pancreatic duct diameter can be readily measured by any routine imaging used to diagnose pancreatic disease.However,radiological evaluation of pancreatic texture,an important determinant of pancreatic fistula,has not been widely used to predict the risk of postoperative pancreatic fistula.Qualitative and quantitative assessment of pancreatic fibrosis and fat fraction provides the basis for predicting pancreatic texture.Traditionally computed tomography has been utilized in identifying and characterizing pancreatic lesions and background parenchymal pathologies.With the increasing utilisation of endoscopic ultrasound and magnetic resonance imaging for evaluating pancreatic pathologies,elastography is emerging as a promising tool for predicting pancreatic texture.Also,recent studies have shown that early surgery for chronic pancreatitis is associated with better pain relief and preservation of pancreatic function.Pancreatic texture assessment can allow early diagnosis of chronic pancreatitis,facilitating early intervention.The present review outlines the current evidence in utilizing various imaging modalities for determining the pancreatic texture based on different parameters and image sequences.However,multidisciplinary investigations using strong radiologic-pathologic correlation are needed to standardize and establish the role of these non-invasive diagnostic tools in predicting pancreatic texture.

Novel invagination procedure for pancreaticojejunostomy using double purse string sutures:A technical note

BACKGROUND Postoperative pancreatic fistula(POPF)is one of the most serious complications after pancreaticoduodenectomy(PD),and the choice of pancreaticojejunostomy(PJ)is considered a key factor affecting the occurrence of POPF.Numerous anastomotic methods and their modifications have been proposed,and there is no method that can completely avoid the occurrence of POPF.Based on our team’s experience in pancreatic surgery and a review of relevant literature,we describe a novel invagination procedure for PJ using double purse string sutures,which has resulted in favourable outcomes.AIM To describe the precise procedural steps,technical details and clinical efficacy of the novel invagination procedure for PJ.METHODS This study adopted a single-arm retrospective cohort study methodology,involving a total of 65 consecutive patients who underwent PD with the novel invagination procedure for PJ,including the placement of a pancreatic stent,closure of the residual pancreatic end,and two layers of purse-string suturing.Baseline data included age,sex,body mass index(BMI),pancreatic texture,pancreatic duct diameter,operation time,and blood loss.Clinical outcomes included the operation time,blood loss,and incidence of POPF,postoperative haemorrhage,delayed gastric emptying,postoperative pulmonary infection,postoperative abdominal infection,and postoperative pulmonary infection.RESULTS The mean age of the patients was 59.12(±8.08)years.Forty males and 25 females were included,and the mean BMI was 21.61 kg/m^(2)(±2.74).A total of 41.53% of patients had a pancreatic duct diameter of 3 mm or less.The mean operation time was 263.83 min(±59.46),and the mean blood loss volume was 318.4 mL(±163.50).Following the surgical intervention,only three patients showed grade B POPF(4.62%),while no patients showed grade C POPF.Five patients(5/65,7.69%)were diagnosed with postoperative haemorrhage.Six patients(6/65,9.23%)experienced delayed gastric emptying.Four patients(4/65,6.15%)developed postoperative pulmonary infection,while an equivalent number(4/65,6.15%)exhibited postoperative abdominal infection.Additionally,two patients(2/65,3.08%)experienced postoperative pulmonary infection.CONCLUSION The novel invagination technique for PJ is straightforward,yields significant outcomes,and has proven to be safe and feasible for clinical application.

Risk factors for postoperative pancreatic fistula: Analysis of 539 successive cases of pancreaticoduodenectomy

AIM To analyze the risk factors for pancreatic fistula after pancreaticoduodenectomy.METHODS We conducted a retrospective analysis of 539 successive cases of pancreaticoduodenectomy performed at our hospital from March 2012 to October 2015. Pancreatic fistula was diagnosed in strict accordance with the definition of pancreatic fistula from the International Study Group on Pancreatic Fistula. The risk factors for pancreatic fistula were analyzed by univariate analysis and multivariate logistic regression analysis.RESULTS A total of 269(49.9%) cases of pancreatic fistula occurred after pancreaticoduodenectomy,including 71(13.17%) cases of grade A pancreatic fistula,178(33.02%) cases of grade B,and 20(3.71%) cases of grade C. Univariate analysis showed no significant correlation between postoperative pancreatic fistula(POPF) and the following factors: age,hypertension,alcohol consumption,smoking,history of upper abdominal surgery,preoperative jaundice management,preoperative bilirubin,preoperative albumin,pancreatic duct drainage,intraoperative blood loss,operative time,intraoperative blood transfusion,Braun anastomosis,and pancreaticoduodenectomy(with or without pylorus preservation). Conversely,a significant correlation was observed between POPF and the following factors: gender(male vs female: 54.23% vs 42.35%,P = 0.008),diabetes(non-diabetic vs diabetic: 51.61% vs 39.19%,P = 0.047),body mass index(BMI)(≤ 25 vs > 25: 46.94% vs 57.82%,P = 0.024),blood glucose level(≤ 6.0 mmol/L vs > 6.0 mmol/L: 54.75% vs 41.14%,P = 0.002),pancreaticojejunal anastomosis technique(pancreatic duct-jejunum double-layer mucosa-to-mucosa pancreaticojejunal anastomosis vs pancreatic-jejunum single-layer mucosa-tomucosa anastomosis: 57.54% vs 35.46%,P = 0.000),diameter of the pancreatic duct(≤ 3 mm vs > 3 mm: 57.81% vs 38.36%,P = 0.000),and pancreatic texture(soft vs hard: 56.72% vs 29.93%,P = 0.000). Multivariate logistic regression analysis showed that gender(male),BMI > 25,pancreatic duct-jejunum double-layer mucosa-to-mucosa pancreaticojejunal anastomosis,pancreatic duct diameter ≤ 3 mm,and soft pancreas were risk factors for pancreatic fistula after pancreaticoduodenectomy.CONCLUSION Gender(male),BMI > 25,pancreatic duct-jejunum double-layer mucosa-to-mucosa pancreaticojejunal anastomosis,pancreatic duct diameter ≤ 3 mm,and soft pancreas were risk factors for pancreatic fistula after pancreaticoduodenectomy.

Analysis of risk factors for postoperative pancreatic fistula following pancreaticoduodenectomy

AIM: To explore the morbidity and risk factors of postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy.

Risk factors to predict severe postoperative pancreatic fistula following gastrectomy for gastric cancer

AIM:To allow the identification of high-risk postoperative pancreatic fistula(POPF)patients with special reference to the International Study Group on Pancreatic Fistula(ISGPF)classification.METHODS:Between 1997 and 2010,1341 consecutive patients underwent gastrectomy for gastric cancer at the Department of Digestive Surgery,Kyoto Prefectural University of Medicine,Japan.Based on the preoperative diagnosis,total or distal gastrectomy and sufficient lymphadenectomy was performed,mainly according to the Japanese guidelines for the treatment of gastric cancer.Of these,35 patients(2.6%)were diagnosed with Grade B or C POPF according to the ISGPF classification and were treated intensively.The hospital records of these patients were reviewed retrospectively.RESULTS:Of 35 patients with severe POPF,17(49%)and 18(51%)patients were classified as Grade B and C POPF,respectively.From several clinical factors,the severity of POPF according to the ISGPF classification was significantly correlated with the duration of intensive POPF treatments(P=0.035).Regarding the clinical factors to distinguish extremely severe POPF,older patients(P=0.035,65 years≤vs<65 years old)and those with lower lymphocyte counts at the diagnosis of POPF(P=0.007,<1400/mm3vs 1400/mm3≤)were significantly correlated with Grade C POPF,and a low lymphocyte count was an independent risk factor by multivariate analysis[P=0.045,OR=10.45(95%CI:1.050-104.1)].CONCLUSION:Caution and intensive care are required for older POPF patients and those with lower lymphocyte counts at the diagnosis of POPF.

Risk scoring system and predictor for clinically relevant pancreatic fistula after pancreaticoduodenectomy

AIM: To establish a scoring system to predict clinicallyrelevant postoperative pancreatic fistula(CR-POPF)after pancreaticoduodenectomy(PD).METHODS: The clinical records of 921 consecutive patients who underwent PD between 2008 and 2013 were reviewed retrospectively. Postoperative pancreatic fistula(POPF) was defined and classified by the international study group of pancreatic fistula(ISGPF).We used a logistic regression model to determine the independent risk factors of CR-POPF and developed a scoring system based on the regression coefficient of the logistic regression model. The optimal cut-off value to divide the risk strata was determined by the Youden index. The patients were divided into two groups(low risk and high risk). The independent sample t test was used to detect differences in the means of drain amylase on postoperative day(POD) 1, 2 and 3. The optimal cut-off level of the drain amylase to distinguish CR-POPF from non-clinical POPF in the two risk strata groups was determined using the receiver operating characteristic(ROC) curves.RESULTS: Grade A POPF occurred in 106(11.5%)patients, grade B occurred in 57(6.2%) patients,and grade C occurred in 32(3.5%) patients. A predictive scoring system for CR-POPF(0-6 points) was constructed using the following four factors: 1 point for each body mass index ≥ 28 [odds ratio(OR) = 3.86;95% confidence interval(CI): 1.92-7.75, P = 0.00],soft gland texture(OR = 4.50; 95%CI, 2.53-7.98, P =0.00), and the difference between the blood loss and transfusion in operation ≥ 800 mL(OR = 3.45; 95%CI,1.92-7.75, P = 0.00); and from 0 points for a 5 mm or greater duct diameter to 3 points for a less than 2 mm duct(OR = 8.97; 95%CI: 3.70-21.77, P = 0.00). The ROC curve showed that the area under the curve of this score was 0.812. A score of 3 points was suggested to be the best cut-off value(Youden index = 0.485). In the low risk group, a drain amylase level ≥ 3600 U/L on POD3 could distinguish CR-POPF from non-clinicalPOPF(the sensitivity and specificity were 75% and85%, respectively). In the high risk group, the best cutoff was a drain amylase level of 1600(the sensitivity and specificity were 77 and 63%, respectively).CONCLUSION: A 6-point scoring system accurately predicted the occurrence of CR-POPF. In addition, a drain amylase level on POD3 might be a predictor of this complication.

A new pancreaticojejunostomy technique: A battle against postoperative pancreatic fistula

AIM:To present a new technique of end-to-side, ductto-mucosa pancreaticojejunostomy with seromuscular jejunal flap formation, and insertion of a silicone stent. METHODS:We present an end-to-side, duct-to-mucosa pancreaticojejunostomy with seromuscular jejunal flap formation, and the insertion of a silicone stent. This technique was performed in thirty-two consecutive patients who underwent a pancreaticoduodenectomy procedure by the same surgical team, from January 2005 to March 2011. The surgical procedure performed in all cases was classic pancreaticoduodenectomy, without preservation of the pylorus. The diagnosis of pancreatic leakage was defined as a drain output of any measurable volume of fluid on or after postoperative day 3 with an amylase concentration greater than three times the serum amylase activity. RESULTS:There were 32 patients who underwent end-to-side, duct-to-mucosa pancreaticojejunostomy with seromuscular jejunal flap formation. Thirteen of them were women and 19 were men. These data correspond to 40.6% and 59.4%, respectively. The mean age was 64.2 years, ranging from 55 to 82 years. The mean operative time was 310.2 ± 40.0 min, and was defined as the time period from the intubation up to the extubation of the patient. Also, the mean time needed to perform the pancreaticojejunostomy was 22.7 min, ranging from 18 to 25 min. Postoperatively, one patient developed a low output pancreatic fistula, three patients developed surgical site infection, and one patient developed pneumonia. The rate of overall morbidity was 15.6%. There was no 30-d postoperative mortality. CONCLUSION:This modification appears to be a significantly safe approach to the pancreaticojejunostomy without adversely affecting operative time.

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.

Novel risk scoring system for prediction of pancreatic fistula after pancreaticoduodenectomy

BACKGROUND The available prediction models for clinically relevant postoperative pancreatic fistula (CR-POPF) do not incorporate both preoperative and intraoperative variables. AIM To construct a new risk scoring system for CR-POPF that includes both preoperative and intraoperative factors. METHODS This was a retrospective study of patients who underwent pancreaticoduodenectomy (PD) or pylorus-preserving PD (PPPD) between January 2011 and December 2016 at the First Affiliated Hospital of Soochow University. Patients were divided into a study (01/2011 to 12/2014) or validation (01/2015 to 12/2016) group according to the time of admission. POPF severity was classified into three grades: Biochemical leak (grade A) and CR-POPF (grades B and C). Logistic regression was used to create a predictive scoring system. RESULTS Preoperative serum albumin ≥ 35 g/L [P = 0.032, odds ratio (OR)= 0.92, 95% confidence interval (CI): 0.85-0.99], hard pancreatic texture (P = 0.004, OR = 0.25, 95%CI: 0.10-0.64), pancreatic duct diameter ≥ 3 mm (P = 0.029, OR = 0.50, 95%CI: 0.27-0.93), and intraoperative blood loss ≥ 500 mL (P = 0.006, OR = 1.002, 95%CI:1.001-1.003) were independently associated with CR-POPF. We established a 10-point risk scoring system to predict CR-POPF. The area under the curve was 0.821 (95%CI: 0.736-0.905) and the cut-off value was 3.5. Including drain amylase levels improved the predictive power of the model. CONCLUSION This study established a 10-point scoring system to predict CR-POPF after PD/PPPD using preoperative and intraoperative parameters. Ultimately, this system could be used to distinguish between high- and low-risk populations in order to facilitate timely interventions after PD.

Risk factors affecting pancreatic fistulas after pancreaticoduodenectomy

AIM: To analyze the risk factors of pancreatic leakage after pancreaticoduodenectomy.METHODS: We retrospectively reviewed 172 consecutive patients who had undergone pancreatico-duodenectomy at Inha University Hospital between April 1996 and March 2006. We analyzed the pancreatic fistula rate according to the clinical characteristics, the pathologic and laboratory findings, and the anastomotic methods.RESULTS: The incidence of developing pancreatic fistulas in patients older than 60 years of age was 21.7% (25/115), while the incidence was 8.8% (5/57) for younger patients; the difference was significant (P = 0.03). Patients with a dilated pancreatic duct had a lower rate of post-operative pancreatic fistulas than patients with a non-dilated duct (P = 0.001). Other factors, including clinical features, anastomotic methods, and pathologic diagnosis, did not show any statistical difference. CONCLUSION: Our study demonstrated that pancreatic fistulas are related to age and a dilated pancreatic duct. The surgeon must take these risk factors into consideration when performing a pancre-aticoduodenectomy.