Early Drain Removal Regardless of Drain Fluid Amylase Level Might Reduce Risk of Postoperative Pancreatic Fistula

Postoperative pancreatic fistula (PF) is a relatively frequent and occasionally fatal complication of pancreatoduodenectomy (PD). Several risk factors for PF have been reported, including high drain amylase level (D-AMY). Among the 140 consecutive patients who underwent PD, we analyzed 110 cases with D-AMY measurements over time after PD. According to the D-AMY change, we divided patients into five patterns and defined delayed PF cases. We analyzed clinical characteristics, including serum amylase and D-AMY, and examined the correlation between the period of drain insertion and PF grade. In 15 delayed PF cases, 12 cases were grade B or C, pancreatic cancer was less frequent, pancreatic ducts were smaller, and soft pancreas texture was more commonly observed. The D-AMYon postoperative day (POD) 1 was higher in cases of delayed PF compared with non-PF cases ( P < 0.0001). In 28 cases with drain removal before POD 7, grade B or C PF was not observed afterward. The average D-AMYon POD 1 in cases with drain removal before POD 1 was significantly lower than in delayed PF cases. Although further studies are required to determine the most appropriate timing of drain removal, it is thought that intra-abdominal drains should be removed within seven days of PD in cases without signs of PF. On the other hand, delayed PF should be considered in cases of soft pancreas texture and/or high D-AMY on POD 1, even if D-AMY levels are low on POD 3 or decreasing on POD 5.

Download Full-text

Comparison of prognostic impact of anatomic location of the pancreas on postoperative pancreatic fistula in laparoscopic and open gastrectomy

BMC Gastroenterology ◽

10.1186/s12876-020-01476-9 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Jun Kinoshita ◽

Takahisa Yamaguchi ◽

Hiroto Saito ◽

Hideki Moriyama ◽

Mari Shimada ◽

...

Keyword(s):

Gastric Cancer ◽

Pancreatic Fistula ◽

Left Gastric Artery ◽

Postoperative Pancreatic Fistula ◽

Open Gastrectomy ◽

Amylase Level ◽

Prognostic Impact ◽

Anatomic Location ◽

Significant Difference ◽

Preoperative Ct

Abstract Background Postoperative pancreatic fistula (POPF) is a serious complication after gastric cancer surgery. The current study aimed to investigate the significance of the anatomic location of the pancreas as a predictor for POPF in both laparoscopic gastrectomy (LG) and open gastrectomy (OG). Methods In total, 233 patients with gastric cancer were assessed retrospectively. We measured the maximum vertical (P-L height; PLH) and horizontal length (P-L depth; PLD) between the upper border of pancreas and the root of left gastric artery on a preoperative CT in the sagittal direction. The maximum length of the vertical line between the surface of the pancreas and the aorta (P-A length), previously reported as prognostic factor of POPF, was also measured. We investigated the correlations between these parameters and the incidence of POPF in LG and OG groups. Results Among the patients in this study, 118 underwent OG and 115 underwent LG. In LG, the median PLH and P-A length in patients with POPF were significantly longer compared with those without POPF (p = 0.026, 0.034, respectively), but not in OG. There was no significant difference in the median PLD between the patients with or without POPF in both LG and OG. The multivariate analysis demonstrated that PLH (odds ratio [OR] 4.19, 95% confidence interval [CI] 1.57–11.3, P = 0.004) and P-A length (OR 4.06, 95%CI 1.05–15.7, P = 0.042] were independent factors for predicting POPF in LG. However, intraoperative blood loss (OR 2.55, 95%CI 1.05–6.18, P = 0.038) was extracted as an independent factor in OG. The median amylase level in the drained fluid (D-Amy) were significantly higher in patients with high PLH(≥12.4 mm) or high P-A length (≥45 mm) compared with those with low PLH or low P-A length in LG. However, there were no differences in the D-Amy levels by PLH or P-A length in OG patients. Conclusions The anatomic location of the pancreas is a specific and independent predictor of POPF in LG but not in OG. PLH is a simple parameter that can evaluate the anatomic position of the pancreas, and it may be useful for preventing POPF after LG.

Download Full-text

Comparison of prognostic impact of anatomic location of the pancreas on postoperative pancreatic fistula in laparoscopic and open gastrectomy

10.21203/rs.3.rs-53308/v3 ◽

2020 ◽

Author(s):

Jun Kinoshita ◽

Takahisa Yamaguchi ◽

Hiroto Saito ◽

Hideki Moriyama ◽

Mari Shimada ◽

...

Keyword(s):

Gastric Cancer ◽

Pancreatic Fistula ◽

Left Gastric Artery ◽

Postoperative Pancreatic Fistula ◽

Open Gastrectomy ◽

Amylase Level ◽

Prognostic Impact ◽

Anatomic Location ◽

Significant Difference ◽

Preoperative Ct

Abstract Background: Postoperative pancreatic fistula (POPF) is a serious complication after gastric cancer surgery. The current study aimed to investigate the significance of the anatomic location of the pancreas as a predictor for POPF in both laparoscopic gastrectomy (LG) and open gastrectomy (OG). Methods: In total, 233 patients with gastric cancer were assessed retrospectively. We measured the maximum vertical (P-L height; PLH) and horizontal length (P-L depth; PLD) between the upper border of pancreas and the root of left gastric artery on a preoperative CT in the sagittal direction. The maximum length of the vertical line between the surface of the pancreas and the aorta (P-A length), previously reported as prognostic factor of POPF, was also measured. We investigated the correlations between these parameters and the incidence of POPF in LG and OG groups. Results: Among the patients in this study, 118 underwent OG and 115 underwent LG. In LG, the median PLH and P-A length in patients with POPF were significantly longer compared with those without POPF (p=0.026, 0.034, respectively), but not in OG. There was no significant difference in the median PLD between the patients with or without POPF in both LG and OG. The multivariate analysis demonstrated that PLH (odds ratio [OR] 4.19, 95% confidence interval [CI] 1.57–11.3, P=0.004) and P-A length (OR 4.06, 95%CI 1.05–15.7, P=0.042] were independent factors for predicting POPF in LG. However, intraoperative blood loss (OR 2.55, 95%CI 1.05–6.18, P=0.038) was extracted as an independent factor in OG. The median amylase level in the drained fluid (D-Amy) were significantly higher in patients with high PLH(≥12.4 mm) or high P-A length (≥45 mm) compared with those with low PLH or low P-A length in LG. However, there were no differences in the D-Amy levels by PLH or P-A length in OG patients. Conclusions: The anatomic location of the pancreas is a specific and independent predictor of POPF in LG but not in OG. PLH is a simple parameter that can evaluate the anatomic position of the pancreas, and it may be useful for preventing POPF after LG.

Download Full-text

Systematic review and meta-analysis of surgical drain management after the diagnosis of postoperative pancreatic fistula after pancreaticoduodenectomy: draining-tract-targeted works better than standard management

Langenbeck s Archives of Surgery ◽

10.1007/s00423-020-02005-8 ◽

2020 ◽

Vol 405 (8) ◽

pp. 1219-1231

Author(s):

Sergio Pedrazzoli ◽

Alessandra R. Brazzale

Keyword(s):

Pancreatic Fistula ◽

English Literature ◽

Meta Analysis ◽

Pool Analysis ◽

Incidence Rates ◽

Postoperative Pancreatic Fistula ◽

Standard Management ◽

Drain Removal ◽

Number Of Patients ◽

Related Mortality

Abstract Purpose Drains’ role after pancreaticoduodenectomy (PD) is debated by proponents of no drain, draining selected cases, and early drain removal. The aim of the study was to assess the effect of “standard” and “draining-tract-targeted” management of abdominal drains still in situ after diagnosing a postoperative pancreatic fistula (POPF). Methods PubMed and Scopus were searched for “pancreaticoduodenectomy or pancreatoduodenectomy or duodenopancreatectomy,” “Whipple,” “proximal pancreatectomy,” “pylorus-preserving pancreatectomy,” and “postoperative pancreatic fistula or POPF.”. Main outcomes included clinically relevant (CR) POPF, grade-C POPF, overall mortality, POPF-related mortality, and CR-POPF-related mortality. Secondary outcomes were incidence of radiological and/or endoscopic interventions, reoperations, and completion pancreatectomies. Results Overall, 12,089 studies were retrieved by the search of the English literature (01/01/1990–31/12/2018). Three hundred and twenty-six studies (90,321 patients) reporting ≥ 100 PDs and ≥ 10 PD/year were finally included into the study. Average incidences were obtained by averaging the incidence rates reported in the single articles. Pooled incidences were calculated by combining the number of events and the total number of patients considered in the various studies. These were then meta-analyzed using DerSimonian and Laird’s (1986) method. Pearson’s chi-squared test was used to compare pooled incidences between groups. Post hoc testing was used to see which groups differed. The meta-analyzed incidences were compared using a fixed effect for moderators. “Draining-tract-targeted” management showed a significant advantage over “standard” management in four clinically relevant outcomes out of eight according to pool analysis and in one of them according to meta-analysis. Conclusion Clinically, “draining-targeted” management of POPF should be preferred to “standard” management.

Download Full-text

Postoperative pancreatic fistula affects recurrence-free survival of pancreatic cancer patients

PLoS ONE ◽

10.1371/journal.pone.0252727 ◽

2021 ◽

Vol 16 (6) ◽

pp. e0252727

Author(s):

Sameer A. Dhayat ◽

Ahmad N. J. Tamim ◽

Marius Jacob ◽

Georg Ebeling ◽

Laura Kerschke ◽

...

Keyword(s):

Risk Factors ◽

Regression Analysis ◽

Pancreatic Fistula ◽

Tumor Recurrence ◽

Postoperative Pancreatic Fistula ◽

Recurrence Free Survival ◽

Free Survival ◽

Staining Score ◽

Drain Fluid ◽

Picrosirius Red

Purpose Postoperative pancreatic fistula (POPF) with reported incidence rates up to 45% contributes substantially to overall morbidity. In this study, we conducted a retrospective evaluation of POPF along with its potential perioperative clinical risk factors and its effect on tumor recurrence. Methods Clinical data on patients who had received pancreatoduodenectomy (PD), distal pancreatectomy (DP), or duodenum-preserving pancreatic head resection (DPPHR) were prospectively collected between 2007 and 2016. A Picrosirius red staining score was developed to enable morphological classification of the resection margin of the pancreatic stump. The primary end point was the development of major complications. The secondary end points were overall and recurrence-free survival. Results 340 patients underwent pancreatic resection including 222 (65.3%) PD, 87 (25.6%) DP, and 31 (9.1%) DPPHR. Postoperative major complications were observed in 74 patients (21.8%). In multivariable logistic regression analysis, POPF correlated with body mass index (BMI) (p = 0.025), prolonged stay in hospital (p<0.001), high Picrosirius red staining score (p = 0.049), and elevated postoperative levels of amylase or lipase in drain fluid (p≤0.001). Multivariable Cox regression analysis identified UICC stage (p<0.001), tumor differentiation (p<0.001), depth of invasion (p = 0.001), nodal invasion (p = 0.001), and the incidence of POPF grades B and C (p = 0.006) as independent prognostic markers of recurrence-free survival. Conclusion Besides the known clinicopathological risk factors BMI and amylase in the drain fluid, the incidence of POPF correlates with high Picrosirius red staining score in the resection margins of the pancreatic stumps of curatively resected pancreatic ductal adenocarcinoma (PDAC). Furthermore, clinically relevant POPF seems to be a prognostic factor for tumor recurrence in PDAC.

Download Full-text

Innovations in pancreatic anastomosis technique during pancreatoduodenectomies

Langenbeck s Archives of Surgery ◽

10.1007/s00423-020-01942-8 ◽

2020 ◽

Vol 405 (7) ◽

pp. 1039-1044

Author(s):

S. Ferencz ◽

Zs. Bíró ◽

A. Vereczkei ◽

D. Kelemen

Keyword(s):

Pancreatic Fistula ◽

Reoperation Rate ◽

Whipple Procedure ◽

Morbidity Rate ◽

Amylase Level ◽

Pancreatic Anastomosis ◽

Drain Removal ◽

Pancreatic Resections ◽

Drain Amylase

Abstract Purpose Pancreatic fistula following pancreatic resections is still a relevant complication. The present work shows the efforts of a single institute to decrease this problem. Methods A total of 130 patients (63 men, 67 women) with a mean age of 60 (range: 23–81) years were operated on between January 2013 and March 2020. The most frequent type of pancreatic resection was a Whipple procedure with partial antrectomy. During all operations, an innovative method was used, namely a modification of the purse-string suture pancreatojejunostomy. Moreover, an early drain removal policy was applied, based on the drain amylase level on the first and subsequent postoperative days. Results Mean postoperative hospital stay was 13 days (range: 7–75). The overall morbidity rate was 43.8%; the clinically relevant (grade B/C) pancreatic fistula (CR-POPF) rate was 6.9%. Delayed gastric emptying (DGE) was observed in 4% of the patients. The ratio of operative mortality was 0.7%; the reoperation rate was 5.3%. Based on the drain amylase level on the first postoperative day, two groups could be established. In the first one, the drain was removed early, on the fourth day in average (range: 2–6). In the other group, the drain was left in situ protractedly or reinserted later on. Conclusion A single center’s experience proves that the refinement of the technique can improve the results of pancreatic surgery.

Download Full-text