A Novel Radiological Predictor for Postoperative Pancreatic Fistula After Stapled Distal Pancreatectomy

Background Distal pancreatectomy (DP) is the main surgical treatment of benign and malignant lesions located in pancreatic body and tail. Postoperative pancreatic fistula (POPF) following DP is still a considerable cause of morbidity. Identification of risk factors for POPF after DP might provide some preventive applications. We aimed to evaluate the factors affecting POPF after DP and to present a new and easy radiological predictive factor. Materials and Methods Thirty-four patients underwent DP with stapler closure were included. Several risk factors for clinically relevant POPF (CR-POPF) were analyzed. Additionally, computed tomography findings of pancreatic thickness (PT), main pancreatic duct diameter (MPDD), and PT/MPDD ratio were evaluated for POPF. Results CR-POPF was observed in 10 patients (29.4%). Univariate and multivariate analyses showed that previous abdominal surgery and PT/MPDD ratio were predictive factors for CR-POPF after DP ( P = 0.040, P = 0.034, respectively). The cutoff value for the PT/MPDD ratio was 8. Conclusion A PT/MPDD ratio greater than 8 (a wide pancreas with a narrow duct) is a significant predictive factor for CR-POPF following DP.

Prediction of pancreatic fistula after distal pancreatectomy: Is it necessary to place prophylactic drain?

The aim of this study was to determine the predictive factors for pancreatic fistula (PF) after distal pancreatectomy (DP) among preoperative and intraoperative parameters, and to clarify the patients who did not require drain placement. Between July 2009 and April 2017, 102 consecutive patients underwent DP at Hyogo College of Medicine. Preoperative and intraoperative data were collected, and the predictors of PF after DP were identified. PF was identified in 35 (34%) patients. In the multivariate analysis, 3 factors (body mass index [BMI] ≥22.4, contiguous organ resection, and pancreatic thickness ≥11 mm) were found to be independent predictors of PF (odds ratio, 5.7; 95% confidence interval, 1.9-17, p=0.002, odds ratio, 6.7; 95% confidence interval, 1.6-28, p=0.009, odds ratio, 11.6; 95% confidence interval, 3.7-36, p<0.001, respectively). A scoring scale for the prediction of PF was developed. BMI ≥22.4 (score: 1), contiguous organ resection (score: 1), and pancreatic thickness ≥11 mm (score: 2) were included in the scoring scale. Patients with a score of 0 never developed PF, while PF occurred in all patients with a score of 4. BMI ≥22.4, contiguous organ resection, and pancreatic thickness ≥11 mm were predictive factors for PF after DP. No patients with BMI <22.4, no contiguous organ resection, and a pancreatic thickness of <11 mm developed PF after DP, indicating that such patients may not require drain placement.

The Impact of Stump Closure Techniques on Pancreatic Fistula Stratified by the Thickness of the Pancreas in Distal Pancreatectomy

Background: The purpose of this retrospective study was to evaluate the impact of stump closure techniques on pancreatic fistula (PF) focusing on pancreatic thickness after distal pancreatectomy (DP). Methods: A total of 213 patients who underwent DP between 2007 and 2017 were retrospectively reviewed. The risk factors of PF were investigated. Results: In all patients, age ≥65 years (odds ratio [OR]: 3.60, p = 0.012), operation time ≥300 min (OR: 3.05, p = 0.013) and thickness of transected pancreas (OR: 1.37, p < 0.001) were identified as independent risk factors for clinically relevant PF. A receiver operating curve analysis revealed the optimum cut-off values of thickness to be 14 mm with stapler closure and 17 mm with the clamp-crushing method. There were no significant differences regarding PF between the stapler closure and clamp-crushing methods in the thin (<14 mm) and very thick pancreas (≥17 mm) groups (p = 0.822, p = 0.072). In contrast, stapler closure was the only independent risk factor for developing PF in the moderately thick (≥14, <17 mm) pancreas group (OR: 6.75 and p = 0.004, respectively). Conclusion: The clamp-crushing method was superior to stapler closure for pancreatic transection, especially in patients with moderately thick pancreas.

Postoperative Pancreatic Swelling Predicts Pancreatic Fistula after Pancreaticoduodenectomy

Postoperative pancreatic fistula (POPF) is a serious complication of pancreaticoduodenectomy. However, the criteria for prompting drainage have not been clarified yet. We evaluated 80 patients who underwent pancreaticoduodenectomy between 2011 and 2016. Clinically relevant POPF (International Study Group of Postoperative Pancreatic Fistula grade B or C) was evaluated on the basis of the following parameters: changes in pancreatic thickness between preoperation and postoperative day (POD) 4 identified via enhanced CT, drain amylase level, laboratory data, and operative factors. POPF occurred in 21 patients (26.3%). The median change in pancreatic thickness before and after operation was 8.33 mm in the POPF-positive group, which was significantly larger than that in the POPF-negative group (3.79 mm, P <0.001). In addition, operation time, pancreatic texture, main pancreatic duct diameter, WBC count, C-reactive protein level, and drain amylase level demonstrated significant differences between the groups. In the multivariate analysis, operation time, C-reactive protein level on POD 3, drain amylase level on POD 1, and the change in pancreatic thickness before and after operation were independent risk factors of POPF. The drastic change in pancreatic thickness before and after operation predicted POPF in this study. This might be one of the factors that determine the requirement for drainage.