Initial suction drainage decreases severe postoperative complications after pancreatic trauma:A cohort study

BACKGROUND Few studies have addressed the question of which drain types are more beneficial for patients with pancreatic trauma(PT).AIM To investigate whether sustained low negative pressure irrigation(NPI)suction drainage is superior to closed passive gravity(PG)drainage in PT patients.METHODS PT patients who underwent pancreatic surgery were enrolled consecutively at a referral trauma center from January 2009 to October 2021.The primary outcome was defined as the occurrence of severe complications(Clavien-Dindo grade≥Ⅲb).Multivariable logistic regression was used to model the primary outcome,and propensity score matching(PSM)was included in the regression-based sensitivity analysis.RESULTS In this study,146 patients underwent initial PG drainage,and 50 underwent initial NPI suction drainage.In the entire cohort,a multivariable logistic regression model showed that the adjusted risk for severe complications was decreased with NPI suction drainage[14/50(28.0%)vs 66/146(45.2%);odds ratio(OR),0.437;95%confidence interval(CI):0.203-0.940].After 1:1 PSM,44 matched pairs were identified.The proportion of each operative procedure performed for pancreatic injury-related and other intra-abdominal organ injury-related cases was comparable in the matched cohort.NPI suction drainage still showed a lower risk for severe complications[11/44(25.0%)vs 21/44(47.7%);OR,0.365;95%CI:0.148-0.901].A forest plot revealed that NPI suction drainage was associated with a lower risk of Clavien-Dindo severity in most subgroups.CONCLUSION This study,based on one of the largest PT populations in a single high-volume center,revealed that initial NPI suction drainage could be recommended as a safe and effective alternative for managing complex PT patients.

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.

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.

Elderly patients had more severe postoperative complications after pancreatic resection:A retrospective analysis of 727 patients

AIM To examine the impact of aging on the short-term outcomes following pancreatic resection(PR) in elderly patients.METHODS A retrospective cohort study using prospectively collected data was conducted at the China National Cancer Center. Consecutive patients who underwent PR from January 2004 to December 2015 were identifiedand included. ‘Elderly patient' was defined as ones age 65 and above. Comorbidities, clinicopathology, perioperative variables, and postoperative morbidity and mortality were compared between the elderly and young patients. Univariate and multivariate analyses were performed using the Cox proportional hazard model for severe postoperative complications(grades Ⅲb-Ⅴ).RESULTS A total of 454(63.4%) patients were < 65-yearsold and 273(36.6%) patients were ≥ 65-yearsold, respectively. Compared to patients < 65-yearsold, elderly patients had worse American Society of Anesthesiologists scores(P = 0.007) and more comorbidities(62.6% vs 32.4%, P < 0.001). Elderly patients had more severe postoperative complications(16.8% vs 9.0%, P = 0.002) and higher postoperative mortality rates(5.5% vs 0.9%, P < 0.001). In the multivariate Cox proportional hazards model for severe postoperative complications, age ≥ 65 years [hazard ratio(HR) = 1.63; 95% confidence interval(CI): 1.18-6.30], body mass index ≥ 24 kg/m^2(HR = 1.20, 95%CI: 1.07-5.89), pancreaticoduodenectomy(HR = 4.86, 95%CI: 1.20-8.31) and length of operation ≥ 241 min(HR = 2.97; 95%CI: 1.04-6.14) were significant(P = 0.010, P = 0.041, P = 0.017 and P = 0.012, respectively).CONCLUSION We found that aging is an independent risk factor for severe postoperative complications after PR. Our results might contribute to more informed decision-making for elderly patients.

Impact of continuous local lavage on pancreatic juice-related postoperative complications: Three case reports

BACKGROUND Postoperative pancreatic leakage readily results in intractable pancreatic fistula and subsequent intraperitoneal abscess.This refractory complication can be fatal;therefore,intensive treatment is important.Continuous local lavage (CLL) has recently been reevaluated as effective treatment for severe infected pancreatitis,and we report three patients with postoperative intractable pancreatic fistula successfully treated by CLL.We also discuss our institutional protocol for CLL for postoperative pancreatic fistula.CASE SUMMARY The first patient underwent subtotal stomach-preserving pancreaticoduodenectomy,and pancreatic leakage was observed postoperatively.Intractable pancreatic fistula led to intraperitoneal abscess,and CLL near the pancreaticojejunostomy site was instituted from postoperative day (POD) 8.The abscess resolved after 7 d of CLL.The second patient underwent distal pancreatectomy.Pancreatic leakage was observed,and intractable pancreatic fistula led to intraperitoneal abscess near the pancreatic stump.CLL was instituted from POD 9,and the abscess resolved after 4 d of CLL.The third patient underwent aneurysmectomy and splenectomy with wide exposure of the pancreatic parenchyma.Endoscopic retrograde pancreatic drainage was performed on POD 15 to treat pancreatic fistula;however,intraperitoneal abscess was detected on POD 59.We performed CLL endoscopically via the transgastric route because the percutaneous approach was difficult.CLL was instituted from POD 63,and the abscess resolved after 1 wk of CLL.CONCLUSION CLL has therapeutic potential for postoperative pancreatic fistula.

Is it sufficient to evaluate only preoperative systemic inflammatory biomarkers to predict postoperative complications after pancreaticoduodenectomy?

Postoperative morbidity and mortality rates are still very high among patients undergoing pancreaticoduodenectomy(PD).However,mortality rates secondary to morbidities that are detected early and well-managed postoperatively are lower among patients undergoing PD.Since early detection of complications plays a very important role in the management of these patients,many ongoing studies are being conducted on this subject.Recent endoscopic retrograde cholangiopancreatography and biliary drainage history of the patient study group is important for comparison of C-reactive protein(CRP),an inflammatory parameter evaluated in the retrospective study by Coppola et al published in the World Journal of Gastrointestinal Surgery and titled“Utility of preoperative systemic inflammatory biomarkers in predicting postoperative complications after pancreaticoduodenectomy:Literature review and single center experience”.Therefore,it may be more appropriate to compare CRP values in randomized patients.

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.

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.

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.

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.

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 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.

Efficacy of octreotide in the prevention of complications after pancreaticoduodenectomy in patients with soft pancreas and non-dilated pancreatic duct: A prospective randomized trial

Background: The efficacy of octreotide to prevent postoperative pancreatic fistula(POPF) of pancreaticoduodenectomy(PD) is still controversial. This study aimed to evaluate the effect of postoperative use of octreotide on the outcomes after PD.Methods: This is a prospective randomized controlled trial for postoperative use of octreotide in patients undergoing PD. Patients with soft pancreas and pancreatic duct < 3 mm were randomized to 2 groups.Group I did not receive postoperative octreotide. Group II received postoperative octreotide. The primary end of the study is to compare the rate of POPF.Results: A total of 104 patients were included in the study and were divided into two randomized groups.There were no significant difference in overall complications and its severity. POPF occurred in 11 patients(21.2%) in group I and 10(19.2%) in group II, without statistical significance(P = 0.807). Also, there was no significant differences between both groups regarding the incidence of biliary leakage(P = 0.083), delayed gastric emptying(P = 0.472), and early postoperative mortality(P = 0.727).Conclusions: Octreotide did not reduce postoperative morbidities, reoperation and mortality rate. Also, it did not affect the incidence of POPF and its clinically relevant variants.

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.

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.

Postoperative mortality and morbidity after D2 lymphadenectomy for gastric cancer:A retrospective cohort study

BACKGROUND Surgery for gastric cancer is a complex procedure and lymphadenectomy is often mandatory.Postoperative mortality and morbidity after curative gastric cancer surgery is not insignificant.AIM To evaluate the factors determining mortality and morbidity in a population of patients undergoing R0 resection and D2 lymphadenectomy for gastric cancer.METHODS A retrospective analysis of clinical data and pathological characteristics(age,sex,primary site of the tumor,Lauren histotype,number of positive lymph nodes resected,number of negative lymph nodes resected,and depth of invasion as defined by the standard nomenclature)was conducted in patients with gastric cancer.For each patient we calculated the Kattan’s score.We arbitrarily divided the study population of patients into two groups based on the nomogram score(<100 points or≥100 points).Prespecified subgroups in these analyses were defined according to age(≤65 years or>65 years),and number of lymph nodes retrieved(≤35 lymph nodes or>35 lymph nodes).Uni-and multivariate analysis of clinical and pathological findings were performed to identify the factors affecting postoperative mortality and morbidity.RESULTS One-hundred and eighty-six patients underwent a curative R0 resection with D2 lymphadenectomy.Perioperative mortality rate was 3.8%(7 patients);a higher mortality rate was observed in patients aged>65 years(P=0.002)and in N+patients(P=0.04).Following univariate analysis,mortality was related to a Kattan’s score≥100 points(P=0.04)and the presence of advanced gastric cancer(P=0.03).Morbidity rate was 21.0%(40 patients).Surgical complications were observed in 17 patients(9.1%).A higher incidence of morbidity was observed in patients where more than 35 lymph nodes were harvested(P=0.0005).CONCLUSION Mortality and morbidity rate are higher in N+and advanced gastric cancer patients.The removal of more than 35 lymph nodes does not lead to an increase in mortality.

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

Strategies for pancreatic anastomosis after pancreaticoduodenectomy:What really matters?

Background: The postoperative pancreatic fistula rate remains approximately 10–20% even in institutions treating a high-volume of pancreatic cases. The best strategy to restore the continuity between the pancreatic remnant and the digestive tract is still in debate.Data sources: Studies were identified by searching Pub Med for studies published between January 1934 (when pancreaticogastrostomy was technically feasible) and December 2016. The following search terms were used: "duct-to-mucosa", "invagination", "pancreaticojejunostomy", "pancreaticogastrostomy," and"pancreaticoduodenectomy". The search was limited to English publications.Results: Many technical methods have been developed and optimized to restore pancreaticoenteric continuity, including pancreaticojejunostomy, pancreaticogastrostomy, and stented drainage of the pancreatic duct, among other modifications. Researchers have also attempted to decrease the postoperative pancreatic fistula after pancreaticoduodenectomy by using fibrin glue and somatostatin analogues. However, no significant decrease in postoperative pancreatic fistula has been observed in most of these studies, and only an external pancreatic duct stent has been found to decrease the leakage rate of pancreatic anastomosis after pancreaticojejunostomy.Conclusion: Pancreatic surgeons should choose a suitable technique according to the characteristics of individual cases.

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.

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.