Clinically Relevant Postoperative Pancreatic Fistula rates in two methods of pancreatico-jejunal anastomosis compared: Evolution of surgical technique in a single centre over time

Background:Pancreaticoduodenectomy remains the gold standard for management of patients with pancreatic head and periampullary neoplasms. Despite the low mortality, overall morbidity remains high, principally due to the development of a clinically relevant postoperative pancreatic fistula (CR-POPF).The aim of the present study is to compare rates of CR-POPF in two groups of patients treated with two different pancreaticojejunostomy techniques. Methods:Among 264 consecutive patients submitted to surgery for pancreatic neoplasm, 142 pancreaticoduodenectomies with end-to-side pancreaticojejunostomy were analysed. The first group of patients underwent a direct mucosa-to-mucosa anastomosis as described by Longmire and Traverso. In the second group, a duct-to-mucosa anastomosis with an outer seromuscolar and inner full thickness layer as described by Z’graggen, Shrikhande and Buchler was performed. Results:Mortality was 2,8% in the first group (2/71) and zero in the second. In group 1°, 48.5% of patients suffered one or more grade II-V Clavien-Dindo complications; in group 2°, complications were observed in 26,7% of patients. Clinically relevant POPF occurred in 12 patients in group 1° (17%) and in 4 patients in group 2° (5,6%). Conclusions:Changing pancreaticojejunostomy techniques may produce different outcomes. In our experience, a standardized duct-to-mucosa anastomosis, as performed in group 2, significantly reduced the rate of CR-POPF.

Impact of Age on Short- and Long-Term Outcomes after Pancreatoduodenectomy for Periampullary Neoplasms

Background. Although mortality and morbidity of pancreatoduodenectomy (PD) have improved significantly over the past years, the impact of age for patients undergoing PD is still debated. This study is aimed at analyzing short- and long-term outcomes of PD in elderly patients. Methods. 124 consecutive patients who have undergone PD for pancreas neoplasms in our center between 2012 and 2017 were analyzed. Patients were divided into two groups: group I (<75 years) and group II (≥75 years). Demographic features and intraoperative and clinical-pathological data were collected. Primary endpoints were perioperative morbidity and mortality; complications were classified according to the Clavien-Dindo Score. Secondary endpoints included feasibility of adjuvant treatment and overall survival rates. Results. A total of 106 patients were included in this study. There were 73 (68.9%) patients in group I and 33 (31.1%) in group II. Perioperative deceases were 4 (3.6%), and postoperative pancreatic fistulas were 34 (32.1%). Significant difference between two groups was demonstrated for the ASA Score (p=0.004), Karnofsky Score (p=0.025), preoperative jaundice (p=0.004), and pulmonary complications (p=0.034). No significance was shown for diabetes, radicality of resection, stage of disease, operative time, length of stay, postoperative complications according to the Clavien-Dindo Score, postoperative mortality, pancreatic fistula, and reoperation rates. 69.9% of the patients in group I underwent adjuvant treatment vs. 39.4% of the older ones (p=0.012). Mean overall survival was 28.5 months in group I vs. 22 months in group II (p=0.909). Conclusion. PD can be performed safely in elderly patients. Advanced age should not be an absolute contraindication for PD, even if greater frailty should be considered. The outcome of elderly patients who have undergone PD is similar to that of younger patients, even though adjuvant treatment administration is significantly lower, demonstrating that surgery remains the main therapeutic option.

Outcomes of pancreaticoduodenectomy in patients with obstructive jaundice with and without preoperative biliary drainage: a retrospective observational study

Background Preoperative biliary drainage (PBD) in patients with obstructive jaundice from periampullary neoplasms may reduce the untoward effects of biliary obstruction and subsequent postoperative complications. However, PBD is associated with bile contamination and increases infectious complications after pancreaticoduodenectomy (PD). Objectives To determine whether PBD is associated with more complications after PD. Methods Patients with obstructive jaundice from periampullary lesions who underwent PD from 2000 to 2015 at our institution were retrospectively enrolled. The cohort was divided into a group with PBD and a group without. PBD was performed using one of the following methods: endoprosthesis, percutaneous transhepatic biliary drainage, surgical biliary-enteric bypass, or T-tube choledochostomy. PDs were performed by the first author using uniform surgical techniques. Postoperative complications were recorded. Statistical analyses were conducted using an unpaired t, Fisher exact, or chi-squared tests as appropriate. Results There were 26 with PBD and 28 patients without. Patients in the 2 groups were similar in age, presenting serum bilirubin level, operative time, operative blood transfusion, and hospital stay. The group with PBD had longer duration of jaundice, more patients presenting with cholangitis, and more patients with carcinoma of the ampulla of Vater. The overall complications were higher in patients in the group with PBD than in the group without. Conclusions PBD was associated with more complications overall after PD. However, PBD was necessary and lifesaving in certain clinical situations and improved the condition of patients before they underwent PD. Routine PBD in patients with obstructive jaundice without definite indications is not recommended.

Regional oncology network between pancreatic centers safeguards waiting times for pancreatoduodenectomy

Pancreatoduodenectomy (PD) is increasingly performed in high-volume centers, which may compromise waiting times. The aim of this study was to evaluate patient flow and outcome of PD within a regional oncology network of two high-volume centers. A post hoc analysis of a partially retrospective and prospective database was performed of all patients who underwent PD for pancreatic or periampullary neoplasms in both centers of the Gastrointestinal Oncology Center Amsterdam, a collaboration between an academic center and affiliated general teaching hospital, from 2010 to 2014. Outcomes included waiting time to surgery and postoperative morbidity and mortality. A total of 525 PDs were performed, 329 in the academic center (annual volume 66) and 196 in the teaching hospital (annual volume 39). Neoadjuvant treatment was more often used in the academic center, other baseline characteristics were similar. Overall time to surgery was 26 days, which was significantly less in the teaching hospital. The major postoperative morbidity rate was 38.3% (n = 201), and the 30- and 90-day mortality was 2.3% and 3.6%. A regional oncology network between an academic center and a general teaching hospital for PD can be an attractive option to safeguard waiting times in selected patients, without compromising outcome.