Postoperative Outcomes Analysis After Pancreatic Duct Occlusion: A Safe Option to Treat the Pancreatic Stump After Pancreaticoduodenectomy in Low-Volume Centers

Background: Surgical resection is the only possible choice of treatment in several pancreatic disorders that included periampullar neoplasms. The development of a postoperative pancreatic fistula (POPF) is the main complication. Despite three different surgical strategies that have been proposed–pancreatojejunostomy (PJ), pancreatogastrostomy (PG), and pancreatic duct occlusion (DO)–none of them has been clearly validated to be superior. The aim of this study was to analyse the postoperative outcomes after DO.Methods: We retrospectively reviewed 56 consecutive patients who underwent Whipple's procedure from January 2007 to December 2014 in a tertiary Hepatobiliary Surgery and Liver Transplant Unit. After pancreatic resection in open surgery, we performed DO of the Wirsung duct with Cyanoacrylate glue independently from the stump characteristics. The mean follow-up was 24.5 months.Results: In total, 29 (60.4%) were men and 19 were (39.6%) women with a mean age of 62.79 (SD ± 10.02) years. Surgical indications were in 95% of cases malignant diseases. The incidence of POPF after DO was 31 (64.5%): 10 (20.8%) patients had a Grade A fistula, 18 (37.5%) Grade B fistula, and 3 (6.2%) Grade C fistula. No statistical differences were demonstrated in the development of POPF according to pancreatic duct diameter groups (p = 0.2145). Nevertheless, the POPF rate was significantly higher in the soft pancreatic group (p = 0.0164). The mean operative time was 358.12 min (SD ± 77.03, range: 221–480 min). Hospital stay was significantly longer in patients who developed POPF (p < 0.001). According to the Clavien-Dindo (CD) classification, seven of 48 (14.58%) patients were classified as CD III–IV. At the last follow-up, 27 of the 31 (87%) patients were alive.Conclusions: Duct occlusion could be proposed as a safe alternative to pancreatic anastomosis especially in low-/medium-volume centers in selected cases at higher risk of clinically relevant POPF.

O-P01 Potential Utility of Intraoperative Fluid Amylase Measurement During Pancreaticoduodenectomy

Background Postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) is a source of major morbidity and mortality. Early diagnosis and treatment of POPF is mandatory to improve patient outcomes, and clinical risk scores may be combined with postoperative drain fluid amylase (DFA) values to stratify patients. The aim of this study was to determine if intraoperative fluid amylase values (IFA) correlate with DFA1 and POPF. Methods In consecutive patients undergoing PD between February and November 2020, intraoperative samples of intra-abdominal fluid adjacent to the pancreatic anastomosis were taken and sent for fluid amylase measurement prior to abdominal closure. Data regarding patient demographics, postoperative DFA values, complications and mortality were prospectively collected. Results Patient Demographics: Data was obtained for 52 patients with a median alternative Fistula Risk Score (aFRS) of 9.4. Postoperative complications occurred in 20 patients (38%), including five Clavien grade 3+. There were eight POPFs and two patients died (pneumonia/sepsis). There was significant correlation between IFA and DFA1 (Pearson’s correlation: R2=0.713; p < 0.001) and DFA3 (p < 0.001), and median IFA was higher in patients with POPF than patients without (1232.5 vs. 122; p = 0.0003). IFA>260 U/l predicted POPF with sensitivity, specificity, PPV and NPV of 88%, 75%, 39% and 97%, respectively. The incidence of POPF was 43% in high risk (high aFRS/IFA) and 0% in low risk patients (low aFRS/IFA). Complications: Conclusions Intraoperative fluid amylase closely correlated with postoperative pancreatic fistula, and may be a useful adjunct to clinical risk scores to stratify patients during pancreatico-duodenectomy, allowing targeted intervention to reduce the clinical impact of pancreatic fistula.It is possible to detect fluid amylase adjacent to the completed pancreatic anastomosis in patients undergoing PD. Presence of IFA correlates with postoperative DFA and POPF. IFA increases the accuracy of the alternate Fistula Risk Score in predicting POPF. Low risk patients with a low IFA may be suitable for a ‘no drain’ strategy, whilst patients with a high IFA may benefit from intraoperative mitigation strategies to reduce the incidence and/or severity of a postoperative pancreatic fistula.

Postoperative pancreatic fistulas after pancreaticoduodenectomy using pair-watch suturing and duct-to-mucosa pancreaticojejunostomy anastomosis techniques

Background: Morbidity and mortality after pancreaticoduodenectomy (PD) have been associated with postoperative pancreatic fistula (POPF). Pancreatic anastomosis is challenging for most surgeons, and there is no universal or standardized technique. This study compared the incidence of POPF between the pair-watch suturing technique (PWST) and duct-to-mucosa pancreaticojejunostomy (PJ) anastomosis technique. Methods: This retrospective cohort analysis included 71 patients who underwent a PD between January 2009 and October 2018. The incidence and risk factors of complications after PWST and duct-to-mucosa PJ anastomoses were compared. Results: There was no significant difference in the incidence of POPF between the PWST (n = 7; 30.4%) and duct-to-mucosa PJ (n = 9; 18.7%) groups. The tumor site (p = 0.001) and pancreas density on computed tomography without contrast (p = 0.002) were significantly different between the groups. Age ≥ 60 years (odds ratio (OR): 11.07; 95% confidence interval (CI): 1.14–107.36; p = 0.038) and pancreatic body mass/duct size (B/W) ratio (OR: 1.41; 95% CI: 1.04–1.91; p = 0.029) were identified as significant risk factors for POPF. International Study Group for Pancreatic Fistula grade B POPF, wound infections, and pneumonia occurred more frequently in patients who underwent a duct-to-mucosa PJ anastomosis. However, the postoperative complications were not significantly different between the groups. Conclusions: The incidence of clinically relevant POPF was similar between patients who underwent the PWST and those who underwent a duct-to-mucosa PJ anastomosis. However, a preoperative risk factor assessment for the evaluation of tumor site, patient age, and B/W ratio could help determine which surgical technique should be used in individual patients.

Y-en-Roux reconstruction in abdominal surgery: historical retrospective of operative method’s evolution. Part II

This historical review is more focused on the analysis of highly relevant, unique method proposed by A. Wölfl er, E. Doyen and C. Roux more than 140 years ago. We also try to present main facts and the chronology of Y-reconstruction of the digestive tube concept’s development. Hereby we present historical retrospective of theoretic concept creation, experimental confi rmation and initial clinical experience of Y-shaped reconstruction of the digestive tube on Roux-en-Y-loop, stages of concept evolution and development from the end of the 19th century and continuing into current times. Scientifi c research of surgical gastroenterology, oncology, pancreatology and hepatobiliary surgery founders, expand application of Roux-en-Y-reconstruction from distal resection of the stomach and gastroenterostomy to gastrectomy, repeated operations on the upper part of the digestive tube, the formation of biliary-enteric and pancreatic anastomosis, and the use in the routine practice of bariatric surgery.

Total pancreatectomy and pancreatic fistula: friend or foe?

Postoperative pancreatic fistula (POPF) still represents the major driver of surgical morbidity after pancreaticoduodenectomy. The purpose of this narrative review was to critically analyze current evidence supporting the use of total pancreatectomy (TP) to prevent the development of POPF in patients with high-risk pancreas, and to explore the role of completion total pancreatectomy (CP) in the management of severe POPF. Considering the encouraging perioperative outcomes, TP may represent a promising tool to avoid the morbidity related to an extremely high-risk pancreatic anastomosis in selected patients. Surgical management of severe POPF is only required in few critical scenarios. In this context, even if anecdotal, CP might play a role as last resort in expert hands.

Preoperative and intraoperative risk factors of postoperative pancreatic fistula after pancreaticoduodenectomy – systematic review and meta-analysis

Introduction: Postoperative pancreatic fistula (POPF) is a potentially life-threatening complication after pancreaticoduodenectomy (PD). It is observed when the amylase activity in the drain fluid exceeds three times the normal upper value. Grades B and C of POPF are considered as clinically relevant. Fistula might originate due to failure of healing of a pancreatic anastomosis or from raw pancreatic surface. Materials and methods: 18 retrospective and prospective studies published between 2015 and 2020 were included in this meta-analysis. Total number of patients was 5836. To investigate potential risk factors associated with the occurrence of POPF, odds ratios (OR) with 95% confidence intervals (CI) were calculated. To compare discontinuous data, mean differences (MD) were calculated. Results: 13 factors were divided into preoperative and intraoperative groups. Male sex, higher BMI, soft pancreatic texture and small pancreatic duct were considered as significant risk factors while vascular resection lowered the risk of development pancreatic fistula. Discussion: It is considered that the development of POPF is associated with intrapancreatic fat. More severe infiltration with fat tissue is responsible for soft texture of the gland, while higher BMI is one of the risk factors of increased pancreatic fat. On the contrary, diabetes is associated with fibrotic pancreas which could lower the risk of developing POPF.

More is More? Total Pancreatectomy for Periampullary Cancer as an Alternative in Patients with High-Risk Pancreatic Anastomosis: A Propensity Score-Matched Analysis

Background Postpancreatectomy morbidity remains significant even in high-volume centers and frequently results in delay or suspension of indicated adjuvant oncological treatment. This study investigated the short-term and long-term outcome after primary total pancreatectomy (PTP) and pylorus-preserving pancreaticoduodenectomy (PPPD) or Whipple procedure, with a special focus on administration of adjuvant therapy and oncological survival. Methods Patients who underwent PTP or PPPD/Whipple for periampullary cancer between January 2008 and December 2017 were retrospectively analyzed. Propensity score-matched analysis was performed to compare perioperative and oncological outcomes. Correspondingly, cases of rescue completion pancreatectomy (RCP) were analyzed. Results In total, 41 PTP and 343 PPPD/Whipple procedures were performed for periampullary cancer. After propensity score matching, morbidity (Clavien-Dindo classification (CDC) ≥ IIIa, 31.7% vs. 24.4%; p = 0.62) and mortality rates (7.3% vs. 2.4%, p = 0.36) were similar in PTP and PPPD/Whipple. Frequency of adjuvant treatment administration (76.5% vs. 78.4%; p = 0.87), overall survival (513 vs. 652 days; p = 0.47), and progression-free survival (456 vs. 454 days; p = 0.95) did not significantly differ. In turn, after RCP, morbidity (CDC ≥ IIIa, 85%) and mortality (40%) were high, and overall survival was poor (median 104 days). Indicated adjuvant therapy was not administered in 77%. Conclusions In periampullary cancers, PTP may provide surgical and oncological treatment outcomes comparable with pancreatic head resections and might save patients from RCP. Especially in selected cases with high-risk pancreatic anastomosis or preoperatively impaired glucose tolerance, PTP may provide a safe treatment alternative to pancreatic head resection.