The Severity of Postoperative Pancreatic Fistula Predicts 30-Day Unplanned Hospital Visit and Readmission after Pancreaticoduodenectomy: A Single-Center Retrospective Cohort Study

Background: Unplanned hospital visits (UHV) and readmissions after pancreaticoduodenectomy (PD) impact patients’ postoperative recovery and are associated with increased financial burden and morbidity. The aim of this study is to identify predictive factors related to these events and target the potentially preventable UHV and readmissions. Methods: We enrolled 518 patients in this study. Characteristics were compared between patients with or without UHV and readmissions. Results: The unplanned visit and readmission rate was 23.4% and 15.8%, respectively. Postoperative pancreatic fistula (POPF) grade B or C, the presence of postoperative biliary drainage, and reoperation were found to be predictive factors for UHV, whereas POPF grade B or C and the presence of postoperative biliary drainage were independently associated with hospital readmission. The most common reason for readmission was an infection, followed by failure to thrive. The overall mortality rate in the readmission group was 4.9%. Conclusions: UHV and readmissions remain common among patients undergoing PD. Patients with grade B or C POPF assessed during index hospitalization harbor an approximately two-fold increased risk of subsequent unplanned visits or readmissions compared to those with no POPF or biochemical leak. Proper preventive strategies should be adopted for high-risk patients in this population to maintain the continuum of healthcare and improve quality.

Application Analysis of Omental Flap Isolation and Modified Pancreaticojejunostomy in Pancreaticoduodenectomy (175 Cases)

Background: To explore the application value of free omentum wrapping and modified pancreaticojejunostomy in pancreaticoduodenectomy (PD).Methods: The clinical data of 175 patients who underwent pancreaticoduodenectomy from January 2015 to December 2020 were retrospectively analyzed. All patients were divided into 86 cases in group A (omental wrapping and modified pancreaticojejunostomy) and 89 cases in group B (control group). The incidence of pancreatic fistula and other related complications, inflammatory factors and survival rate were compared between the two groups.Results: The incidences of B/C pancreatic fistula, bile leakage, delayed bleeding, and reoperation in group A were lower than those in group B, and the difference was statistically significant (P <0.05). The free omentum wrapping isolation and the modified pancreaticojejunostomy group drainage tube extubation time, open diet time and postoperative hospital stay were earlier than the control group (P <0.05). There were also statistically significant differences in CRP, IL-6, PCT inflammatory factors 1, 3, and 7 days after surgery as well as in postoperative survival rate.Univariate analysis showed that BMI, pancreatic duct diameter, greater omental flap isolation and modified pancreaticojejunostomy were related to the occurrence of pancreatic fistula after PD. Multivariate analysis showed that BMI≥24, pancreatic duct diameter less than 3mm, no greater omental flap isolation method and modified pancreaticojejunostomy were independent risk factors for pancreatic fistula (P<0.05).Conclusions: Wrapping and isolating with free greater omentum plus modified pancreaticojejunostomy can significantly reduce the incidence of postoperative pancreatic fistula and related complications, inhibit the development of inflammation, and is conducive to the prognosis.

Cavitojejunostomy for post-traumatic disconnected pancreatic duct syndrome presenting as persistent external pancreatic fistula: A case report

Post-traumatic disconnected pancreatic duct syndrome (DPDS) can present as persistent external pancreatic fistula following percutaneous drainage (PCD) of pancreatic collection. Management of these cases can be difficult and involves a multidisciplinary approach. Here, we present a case of a 16-year-old boy who presented with persisted pancreatic fistula following initial management including PCD of peripancreatic collection following polytrauma 3 months prior. Magnetic resonance imaging showed a disconnected pancreatic duct. Intraoperatively, there was a disconnected and viable distal pancreas with a defect cavity measuring 2 × 2 cm at the neck of the pancreas. The wall of the cavity was anastomosed with a Roux limb of the jejunum (cavitojejunostomy). Post-operative recovery was uneventful and the patient remains asymptomatic at 2 months of follow-up. Cavitojejunostomy is a feasible and safe surgical option in DPDS with a well-formed cavity. This avoids dissection in difficult anatomical planes and preserves pancreatic parenchyma.

Comparison of an Inside Stent and a Fully Covered Self-Expandable Metallic Stent as Preoperative Biliary Drainage for Patients with Resectable Perihilar Cholangiocarcinoma Retrospectively.

BackgroundThere is a need for a more tolerable preoperative biliary drainage (PBD) method for perihilar cholangiocarcinoma (PHCC). In recent years, inside stents (ISs) have attracted attention as a less suffering PBD method. Few studies have compared IS with a fully covered self-expandable metallic stent (FCSEMS) as PBD for resectable PHCC. The aim of this study is to compare them.MethodsThis study involved 87 consecutive patients (IS: 51, FCSEMS: 36). The recurrent biliary obstruction (RBO) rate until undergoing surgery or being diagnosed as unresectable, time to RBO, factors related to RBO, incidence of adverse events related to endoscopic retrograde cholangiography and postoperative complications associated with each stent were evaluated retrospectively.ResultsThere was no significant difference between the two groups in the incidence of adverse events after stent insertion. The mean (s.d.) time to RBO was 40.0 (28.1) days in the IS group and 52.0 (45.5) days in the FCSEMS group, with no significant difference (P=0.384). A total of 7/51 patients in the IS group and 3/36 patients in the FCSEMS group developed RBO. The only risk factor for RBO was bile duct obstruction of the future excisional liver lobe(s) due to stenting (HR 0.033, P=0.006) in the FCSEMS group, but risk factors could not be indicated in the IS group. Regarding postoperative complications, there was no significant difference in the incidence of bile leakage or liver failure. In contrast, pancreatic fistula was significantly more common in the FCSEMS group (13/24 patients) than in the IS group (3/28 patients) (P=0.001), especially in patients who did not undergo pancreatectomy (P=0.001).ConclusionsAs PBD for PHCC, both IS and FCSEMS achieved low RBO rates. In contrast, the incidence of postoperative pancreatic fistula was higher with FCSEMS. Thus, IS, which can be inserted easily, is considered an optimal approach as PBD for resectable PHCC.clinical trial registration number: UMIN000025631

P-P37 Robot assisted pancreaticojejunostomy may be associated with lower risk of post-operative pancreatic fistula in high-risk cases: Initial experience

Background Robot assisted pancreaticoduodenectomy has increased in popularity over recent years. There is evidence from high volume centers which suggests that it is associated with lower risk of post-operative pancreatic fistula than open surgery. The aims of this study were to evaluate our initial experience after robotic assisted pancreaticoduodenectomy and compare if a low volume center can produce similar positive outcomes. Methods The initial 12 patients who were listed for a robot assisted pancreaticoduodenectomy were included in the study in a consecutive manner. A standardised method of anastomosis was used in all surgeries, this being a duct-to-mucosa two-layer modified Blumgart pancreato-jejunostomy. Data was collected prospectively and stored in an encrypted database. Surgical outcomes were then analysed. Results The study included first 12 consecutive patients who underwent robotic pancreaticoduodenectomy between August 2019 and January 2020. None of the patients had clinically relevant postoperative pancreatic fistula despite 75% of the patients falling into moderate to high-risk group for fistula development. Median operative time and length of stay was 547 minutes and 8 days respectively with three Clavien Dindo grade III complications and three Clavien-Dindo grade II complications. Conclusions Robotic assisted pancreaticoduodenectomy maybe associated with lower risk of post-operative pancreatic fistula in high-risk cases.