Fístula pancreática: una complicación temida. Experiencia en una unidad de cirugía hepatobiliopancreática de cuarto nivel / Pancreatic fistula: A feared complication. Experience in a fourth level hepatobiliopancreatic surgery unit

Introducción. La fístula pancreática postoperatoria es una de las complicaciones más importantes en la cirugía hepatobiliopancreática. Su diagnóstico se hace mediante la presencia de un nivel de amilasa en el líquido de drenaje al menos tres veces por encima del valor de la amilasa en suero a partir del tercer día postoperatorio. El objetivo de este estudio fue caracterizar los pacientes con fístula pancreática postoperatoria en nuestra institución, evaluando la importancia de la detección temprana y el establecimiento de un manejo oportuno. Métodos. Estudio descriptivo, retrospectivo, que incluyó los pacientes sometidos a pancreatoduodenectomía, con diagnóstico de fístula pancreática postoperatoria como complicación de cirugía hepatobiliopancreática, en el Hospital Internacional de Colombia, en Piedecuesta, entre enero del 2017 y diciembre de 2020. Se excluyeron los pacientes con otro tipo procedimiento quirúrgico y aquellos que decidieron no participar en el estudio. Resultados. Se evaluaron 69 pacientes, con un predominio del sexo femenino (n=38; 55,1 %) y mediana de la edad de 57 años. El 33,3 % (n=24) de los pacientes intervenidos desarrollaron fístula pancreática postoperatoria, siendo el 23,2 % fuga bioquímica, grado B 8,7 % y grado C 2,9 %, para quienes se indicaron manejo expectante, control ecográfico y reintervención, respectivamente. Fallecieron 5 pacientes (7,2 %). Conclusiones. La fístula pancreáticapostoperatoria es una complicación para tener en cuenta en todos los pacientes sometidos a pancreatoduodenectomía. Existen estrategias que pueden permitir disminuir la incidencia de esta complicación, con el fin de mejorar el desenlace, el pronóstico y la morbilidad posquirúrgica.

Introduction. Postoperative pancreatic fistula is one of the most important complications in hepatobiliopancreatic surgery. Its diagnosis is made by the presence of an amylase level in the drainage fluid at least three times above the serum amylase value from the third postoperative day. The objective of this study was to characterize patients with postoperative pancreatic fistula at our institution, evaluating the importance of early detection and to establish a timely management. Methods. Descriptive, retrospective study that included patients who underwent pancreatoduodenectomy with a diagnosis of postoperative pancreatic fistula as a complication of hepatobiliopancreatic surgery at the Hospital Internacional Colombia, between January 2017 and December 2020. Patients with another type of procedure performed by this specialty and those who did not decide to participate in the study were excluded. Results. A total of 69 patients were included, the median age was 57 years with a predominance of females (n=38; 55.1%). 33.3% (n=24) of the operated patients developed postoperative pancreatic fistula, with 23.2% having a biochemical leak, grade B in 8.7% and grade C in 2.9%, for whom expectant management, ultrasound control and reintervention were indicated, respectively. Five patients died (7.2%). Conclusions. Pancreatic fistula is a complication to take into account in all patients undergoing pancreatoduodenectomy. There are strategies that can reduce the incidence of this complication and thus improve not only the outcome but also the prognosis and postoperative morbidity.

Complicaciones de cirugía de Whipple en un paciente pediátrico con tumor pseudopapilar de páncreas / Complications of Whipple procedure in a pediatric patient with pseudopapillary tumor of the pancreas

Las neoplasias de páncreas son una entidad poco frecuente en pediatría; el tumor pseudopapilar de páncreas (TSP) es el más comúnmente diagnosticado. Habitualmente, se localizan en la cabeza del páncreas. La cirugía de Whipple o pancreatoduodenectomía es la técnica elegida para el tratamiento de los tumores benignos o malignos de páncreas. Si bien la mortalidad conocida ha descendido en los últimos años, debido a la mayor experiencia de los cirujanos y al mejor cuidado pre- y posoperatorio, la morbilidad se ha mantenido elevada secundaria a las complicaciones asociadas. Dentro de estas se destacan retardo en el vaciamiento gástrico, colecciones intraabdominales, fístula pancreática, reestenosis del sitio quirúrgico y hemorragia pospancreatectomía. Se presenta el caso clínico de una niña de 13 años con diagnóstico de TSP que recibió tratamiento quirúrgico efectivo desde el punto de vista oncológico, pero que requirió una internación prolongada secundaria a las complicaciones quirúrgicas.

Pancreatic neoplasms are rare in pediatrics; the pseudopapillary tumor (PPT) of the pancreas is the most common. PPTs of the pancreas are usually located in the head of the pancreas. A pancreaticoduodenectomy or Whipple procedure is the technique of choice for the treatment of benign or malignant pancreatic tumors. Although mortality for this cause has decreased in recent years, due to the greater experience of surgeons and improved pre- and postoperative care, morbidity has remained high secondary to associated complications. These include delayed gastric emptying, intra-abdominal collections, pancreatic fistula, surgical site restenosis, and post-pancreatectomy hemorrhage. Here we describe the clinical case of a 13-year-old girl diagnosed with PPT of the pancreas who underwent an effective surgery in terms of cancer treatment, but who required a prolonged hospitalization secondary to surgical complications.

Octreotide and postoperative pancreatic fistula after pancreaticoduodenectomy: What we know so far? A narrative review

Postoperative pancreatic fistula (POPF) is the most feared complication following pancreatic resection. Octreotide, a synthetic somatostatin analog, has been widely used by pancreatic surgeons worldwide after pancreatic resections, often as per surgeon抯 discretion, to prevent POPF especially in cases at high risk of developing POPF. We herein analyze the data available till date of the subject. A PubMed search with keywords 搒omatostatin OR octreotide OR somatostatin analogues AND postoperative pancreatic fistula� was made. Further filters were applied in the search 揅linical Trial, Meta?Analysis, Randomized Controlled Trial, Systematic Review, from 1990 � 2021,� and the 68 results thus obtained were analyzed and included in this narrative review. There is considerable heterogeneity among the studies assessing the role of octreotide in the prevention of POPF making data comparison difficult, and hence results remain inconclusive. Most of the earlier studies used different definitions of POPF and other complications; included patients with varied pancreatic pathologies such as cancer, chronic pancreatitis, and benign lesions; surgical techniques such as pancreaticoduodenectomy, distal pancreatectomy, and other procedures; use of somatostatin and its analogs such as octreotide, lanreotide, pasireotide, and vapreotide; varied surgeon and institutional volume; and so on. Besides, pancreatic surgery is per se a complex surgical procedure and has its own inherent biases related to patient and the pancreas itself affecting the overall outcome. Data indicate favorable role of newer somatostatin analogs, and further studies are urgently needed. The question about the efficacy of prophylactic octreotide to reduce POPF after pancreaticoduodenectomy remains open to debate

Síndrome de desconexión del conducto pancreático

El síndrome del ducto pancreático desconectado (SDPD) consiste en la disrupción del ducto pancreático principal con pérdida de continuidad entre el remanente pancreático distal viable y el tracto gastrointestinal, generalmente causado por necrosis ductal secundaria a pancreatitis aguda grave. Esto resulta en fuga de fluido pancreático, provocando un curso de enfermedad prolongado y complicaciones. La literatura sobre este tema es limitada, con algoritmos de tratamiento poco claros. Hemos realizado una revisión de la literatura sobre el tema. Revisión en Pubmed y Scielo (2011-2021) de artículos en inglés y español utilizando términos «síndrome del conducto pancreático desconectado», «DPDS» y «páncreas desconectado» encontrando 16 artículos relevantes. Dadas las pocas citas, se revisaron las referencias de estos artículos. Finalmente, revisamos un total de 21 artículos. Entre las referencias encontradas existe 1 metaanálisis, 4 estudios prospectivos y no existen ensayos aleatorizados.

Disconnected pancreatic duct syndrome (DPDS) is characterized by disruption of the main pancreatic duct with a loss of continuity between the viable upstream pancreatic parenchyma and the gastrointestinal tract, generally caused by ductal necrosis after severe acute necrotizing pancreatitis. This compromised ductal integrity leads to extraductal leakage of pancreatic secretions, causing a prolonged disease course and complications. The existing literature is limited, with unclear therapeutic algorithms. We have performed a review of the literature on DPDS. Review in Pubmed and Scielo (2011-2021) of articles in English and Spanish using the terms "disconnected pancreatic duct syndrome", "DPDS" and "disconnected pancreas" finding 16 relevant articles. Given the few citations, the references of these articles was reviewed. Finally, we found 21 articles. Among them, there is one meta-analysis, 4 prospective studies and no randomized trials.

Application of a novel modified Blumgart anastomosis in laparoscopic pancreaticoduodenectomy / 中国医师进修杂志

Objective:To investigate the efficacy and safety of a novel modified Blumgart pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy (LPD).Methods:Between May 2021 and January 2022, 13 successive cases from Lihuili Hospital Affiliated to Ningbo University who underwent LPD were enrolled in this retrospective study. The study retrospectively analyzed the demographic characteristics, perioperative outcomes, and pathological results of these cases.Results:Twenty patients underwent LPD success-fully and one required conversion to open surgery. The operative time was (308.6 ± 61.7) min. The duration for PJ was (26.7 ± 4.3) min. The estimated blood loss was (188.1 ± 94.2) ml. The postoperative hospital stay was (14.2 ± 3.5) d. There was one case of biochemical leakage and no case of grade B or grade C pancreatic fistula.Conclusions:The new method is safe, simple and feasible. The novel method could reduce the incidence of pancreatic fistula and other complications after LPD.

Prevention and management of pancreatic fistula after pancreatoduodenectomy with precise and comprehensive opinion / 中华消化外科杂志

Pancreaticoduodenectomy (PD) is a major operation of abdominal surgery, with high risk, complex operation, more complications and high mortality. Pancreatic fistula is the main cause of death after PD. Due to its complexity and obstinacy, pancreatic fistula has become the top challenge of pancreatic surgery. The authors review the relevant literature and summarize the prevention and management of pancreatic fistula after PD, such as the optimization strategies for pancreatic anastomosis, the use of external stents, prophylactic drains in surgical field, the applica-tion of somatostatin and its analogues, and whole-course nutrition management, based on the precise and comprehensive opinion, in order to provide reference for improving the prevention and treatment of pancreatic fistula after PD.

Research progress in the selection of pancreaticojejunostomy suture in pancreaticoduodenec-tomy / 中华消化外科杂志

Pancreaticoduodenectomy (PD) is the mainstay of treatment for periampullary space-occupying disease. The occurrence of pancreatic fistula after PD is still an unsolved clinical problem, which seriously affects the safety of surgery. Various methods have been reported in clinical practice to reduce the incidence of pancreatic fistula, such as improving pancreaticoenteric anastomosis, using biological sealants, applying somatostatin analogs, and continuous peritoneal irrigation, etc., but the incidence of pancreatic fistula remains at 5%-30%. There are many risk factors related to pancreatic fistula after PD, in which reasonable selection of suture materials is an important factor and also an important factor affecting the curative effect of surgery. The authors analyze the characteristics and shortcomings of various sutures used in PD, in order to provide help to improve the safety of surgery and reduce the incidence of pancreatic fistula after PD.

Application value of laparoscopic pancreatic tumor enucleation / 中华消化外科杂志

Objective:To investigate the application value of laparoscopic pancreatic tumor enucleation (LapEN).Methods:The retrospective and descriptive study was conducted. The clinical data of 47 patients who underwent LapEN in Second Hospital of Hebei Medical University from September 2016 to June 2022 were collected. There were 18 males and 29 females, aged (49±12)years. Observa-tion indicators: (1) surgical situations; (2) postoperative complications; (3) postoperative recovery; (4) follow-up. Measurement data with normal distribution were represented as Mean± SD, and measurement data with skewed distribution were represented as M( Q1, Q3) or M(range). Count data were described as absolute numbers. Results:(1) Surgical situations. All 47 patients underwent LapEN successfully, with the operation time as (135±19)minutes and the volume of intraoperative blood loss as 100(50,100)mL. (2) Postoperative complications. Of the 47 patients, there were 12 patients with postoperative pancreatic fistula, 3 patients with postoperative abdominal infection, 1 case with postoperative hemorrhage, 1 case with postoperative gastric emptying disorder. (3) Postoperative recovery. Of the 47 patients, there were 13 cases with pancreatic solid pseudopapillary neoplasm, 12 cases with insulinoma, 11 cases with pancreatic serous cystadenoma, 7 cases with pancreatic intraductal papillary mucinous neoplasm (branched type), 4 cases with pancreatic mucinous cyst-adenoma. The tumor diameter of 47 patients was 1.9(1.6,2.3)cm and all patients with R 0 resection. There was no patient with perioperative death in the 47 patients. The postoperative duration of hospital stay and total hospital expenses of 47 patients was (13±4)days and (6.8±1.2) ten thousand yuan, respectively. (4) Follow-up. All 47 patients were followed up for 14(range, 8?18)months. None of the 47 patients had new onset diabetes or situations required postoperative exocrine replacement therapy, and no patient died. Conclusion:LapEN is safe and feasible for patients with pancreatic benign tumor or low potential malignancy.

Construction and validation of a risk prediction model for pancreatic fistula after pancreaticoduodenectomy / 中华内分泌外科杂志

Objective:To investigate the risk factors of pancreatic fistula after pancreaticoduodenectomy and establish the risk graph model of pancreatic fistula.Methods:The clinical data of 147 patients undergoing pancreaticoduodenectomy from Jan. 2018 to Jan. 2021 in Department of Hepatobiliary Surgery of Northern Theater Command General Hospital were retrospectively analyzed. The independent risk factors for postoperative pancreatic fistula were determined by univariate and multivariate analysis, and the linear graph model for predicting individual pancreatic fistula was drawn. The area under the subject operating characteristic curve was used to evaluate the model differentiation, the calibration curve was used to evaluate the model calibration, and finally the clinical application value of the model was evaluated by the clinical decision curve (DCA) .Results:The incidence of pancreatic fistula was 38.1%, including grade B pancreatic fistula in 49 cases and Grade C pancreatic fistula in 7 cases. Univariate analysis showed that operation method, body mass index (BMI), pancreatic texture, pancreatic duct diameter and lesion location were the related factors for postoperative pancreatic fistula. Multivariate analysis showed that BMI>25 kg/m 2, pancreatic soft texture, pancreatic duct diameter ≤3 mm and non-pancreatic diseases were independent risk factors for postoperative pancreatic fistula. According to the results of multiple factors, a prediction model of the nomogram was drawn, and the area under the subject operating characteristic curve of the model was calculated as AUC=0.792 (95% CI: 0.718-0.867). The calibration curve was drawn through internal verification of re-sampling, and the fitting curve swung around the 45° reference line, showing a high calibration degree; Clinical decision curve (DCA) analysis showed that the threshold probability was between 15% and 75% for maximum net benefit. It had good clinical application value. Conclusions:BMI>25 kg/m 2, soft pancreas, pancreatic duct diameter ≤3 mm and non-pancreatic diseases are independent risk factors for pancreatic fistula after pancreaticoduodenectomy. The established line graph model has good predictive efficiency and can effectively predict the occurrence of postoperative pancreatic fistula.

Historical evolution of pancreatic fistula definition and current grading limitations and potential improvements / 国际外科学杂志

Pancreatic fistula is one of the most important complications after pancreatic surgery. The International Study Group on Pancreatic Fistula proposed the definition and classification of postoperative pancreatic fistula (POPF) in 2005 firstly, which has promoted the development of pancreatic surgery research. And the International Study Group on Pancreatic Surgery modified the POPF standard in 2016 and paid more attention to clinical relevance. The POPF is often used to evaluate anastomotic methods. However, this grading version is based on clinical outcomes, which more represents the comprehensive treatment effect than reflects the quality of pancreaticojejunostomy. Using the current POPF grading criteria for the purpose of improving anastomosis methods is not very accurate, so an indicator that only reflects anastomosis′ quality is needed for the comparison of various surgical methods. To avoid the influence of non-reconstruction elements on the incidence and degree of POPF, this research team prefer the total drainage fluid amylase(DFA)or the duration of high DFA. And in this way, the comparation among different anastomotic operations could be specific and objective, which further helps to find out an ideal method for pancreatic digestive tract reconstruction.

Alternative fistula risk score and first postoperative day drain fluid amylase as predictors of pancreatic fistula after pancreaticoduodenectomy / Escore alternativo de risco de fístula e níveis de amilase do fluido de drenagem no primeiro dia de pós-operatório como preditores de fístula pancreática após pancreaticoduodenectomia

ABSTRACT BACKGROUND: The high morbidity and mortality rates of pancreaticoduodenectomy are mainly associated with pancreaticojejunal anastomosis, the most fragile and susceptible to complications such as clinically relevant postoperative pancreatic fistula. AIMS: The alternative fistula risk score and the first postoperative day drain fluid amylase are predictors of the occurrence of clinically relevant postoperative pancreatic fistula. No consensus has been reached on which of the scores is a better predictor; moreover, their combined predictive power remains unclear. To the best of our knowledge, this association had not yet been studied. METHODS: This study assessed the predictive effect of alternative fistula risk score and/or drain fluid amylase on clinically relevant postoperative pancreatic fistula in a retrospective cohort of 58 patients following pancreaticoduodenectomy. The Shapiro-Wilk and Mann-Whitney tests were applied for assessing the distribution of the samples and for comparing the medians, respectively. The receiver operating characteristics curve and the confusion matrix were used to analyze the predictive models. RESULTS: The alternative fistula risk score values were not statistically different between patients in the clinically relevant postoperative pancreatic fistula and non- clinically relevant postoperative pancreatic fistula groups (Mann-Whitney U test 59.5, p=0.12). The drain fluid amylase values were statistically different between clinically relevant postoperative pancreatic fistula and non- clinically relevant postoperative pancreatic fistula groups (Mann-Whitney U test 27, p=0.004). The alternative fistula risk score and drain fluid amylase were independently less predictive for clinically relevant postoperative pancreatic fistula, compared to combined alternative fistula risk score + drain fluid amylase. CONCLUSION: The combined model involving alternative fistula risk score >20% + drain fluid amylase=5,000 U/L was the most effective predictor of clinically relevant postoperative pancreatic fistula occurrence following pancreaticoduodenectomy.

RESUMO RACIONAL: A alta morbimortalidade da pancreaticoduodenectomia está associada, principalmente, à anastomose pancreatojejunal, a mais frágil e suscetível a complicações como a fístula pancreática pós-operatória clinicamente relevante (clinically relevant postoperative pancreatic fistula - CR-POPF). OBJETIVOS: O escore alternativo de risco de fístula (alternative fistula risk score) e os níveis de amilase do fluido de drenagem no primeiro dia pós-operatório (first postoperative day drain fluid) são preditores da ocorrência de fístula pancreática pós-operatória clinicamente relevante. Nenhum consenso foi alcançado sobre qual das pontuações é um melhor preditor; além disso, seu poder preditivo combinado permanece obscuro. Até onde sabemos, essa associação ainda não havia sido estudada. MÉTODOS: Este estudo avaliou o efeito preditivo do escore alternativo de risco de fístula e/ou do fluido de drenagem no primeiro dia pós-operatório em uma coorte retrospectiva de 58 pacientes após pancreaticoduodenectomia. Os testes de Shapiro-Wilk e Mann-Whitney foram aplicados para avaliar a distribuição das amostras e para comparar as medianas, respectivamente. A curva de características operacionais do receptor e a matriz de confusão foram utilizadas para analisar os modelos preditivos. RESULTADOS: Os valores do escore alternativo de risco de fístula não foram estatisticamente diferentes entre os pacientes dos grupos fístula pancreática pós-operatória clinicamente relevante e não- fístula pancreática pós-operatória clinicamente relevante (teste U de Mann-Whitney 59,5, p=0,12). Os valores de fluido de drenagem no primeiro dia pós-operatório foram estatisticamente diferentes entre os grupos fístula pancreática pós-operatória clinicamente relevante e não- fístula pancreática pós-operatória clinicamente relevante (teste U de Mann-Whitney 27, p=0,004). O escore alternativo de risco de fístula e fluido de drenagem no primeiro dia pós-operatório foram independentemente menos preditivos para fístula pancreática pós-operatória clinicamente relevante, em comparação com escore alternativo de risco de fístula + fluido de drenagem no primeiro dia pós-operatório combinados. CONCLUSÕES: O modelo combinado envolvendo escore alternativo de risco de fístula>20% + fluido de drenagem no primeiro dia pós-operatório=5.000 U/L foi o preditor mais eficaz da ocorrência de fístula pancreática pós-operatória clinicamente relevante após pancreaticoduodenectomia.

The effect of abdominal visceral fat area on perioperative complications and pancreatic fistula in primary gastric carcinoma patients after laparoscopic assisted radical gastrectomy / 中华普通外科杂志

Objective:To study the effect of visceral fat area (VFA) on postoperative complications and pancreatic fistula in patients undergoing laparoscopic assisted radical gastrectomy for gastric careinoma.Methods:Clnical data of 214 primary gastric cancer patients undergoing laparoscopic assisted radical gastrectomy between Jan 2017 and Jan 2022 at the Department of General Surgery, Shouguang People's Hospital were retrospectively reviewed.Results:There were 85 patients in high VFA group and 129 patients in the low VFA group. The body mass index (25.1±3.4) kg/m 2 and visceral fat area (143.4±41.1) cm 2 in the high VFA group were higher than those in the low VFA group (21.2±2.9) kg/m 2 and visceral fat area (58.7±31.9) cm 2. The operative time was (228.3±53.1) min vs. (206.3±62.9) min ( t=5.538, P=0.017). The intraoperative blood loss was (264.6±173.6) ml vs. (213.9±156.2) ml ( t=3.373, P=0.035). The postoperative hospital stay was (12.5±4.0) d vs. (10.3±3.7) d ( t=7.781, P=0.013). Twenty-three cases developed postoperative complications in the high VFA group vs. 20 cases in the low VFA group ( χ2=4.261, P=0.039). Patients in the high VFA group had an incidence of clinically relevant pancreatic fistula of 10.6% vs. 3.1% in patients in the low VFA group ( χ2=5.034, P=0.038). Univariate and multivariate analysis of clinically relevant pancreatic fistulas in patients with different VFA groups showed that men ≥134.6 cm 2 and women ≥91.1 cm 2 with VFA and operative time ≥250 min were independent risk factors for the occurence of clinically relevant pancreatic fistulas after laparoscopic assisted radical gastrectomy. Conclusions:VFA increases the difficulty of laparoscopic-assisted radical gastrectomy, resulting in increased postoperative complications. VFA and operation time are independent risk factors for clinically relevant pancreatic fistula after radical gastrectomy for gastric cancer.

A modified Blumgart procedure in laparoscopic pancreaticoduodenectomy / 中华普通外科杂志

Objective:To evaluate A modified Blumgart pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy.Methods:The clinical data of 81 patients undergoing laparoscopic pancreaticoduodenectomy in Zhengzhou University Affiliated Cancer Hospital from Jan 2019 to Jan 2022 were retrospectively analyzed. Among them, 26 patients underwent modified Blumgart anastomosis and 55 underwent conventional Blumgart anastomosis.The data of demographics, liver function, pancreatic texture, operational result and complications were compared between the two groups.Results:The preoperative data (body mass index, preoperative albumin, prealbumin, transaminase, total bilirubin) between two groups were comparable ( P>0.05). There was no significant difference in pancreatic texture, pancreatic duct diameter and intraoperative blood loss between the two groups ( P>0.05). The modified group had shorter total operation time ( P<0.05), shorter pancreaticojejunostomy time ( P<0.05), shorter postoperative hospital stay ( P<0.05). The incidence of total pancreatic fistula and biochemical fistula in the modified group were lower than those in the conventional group ( P<0.05). There was no significant difference in the incidence of B/C grade pancreatic fistula and bile leakage, postoperative bleeding, infection and delayed gastric emptying between the two groups ( P>0.05). Conlusions:The modified Blumgart pancreaticojejunostomy during laparoscopic pancreaticoduodenectomy is safe, easy to do and time saving. While the incidence of postoperative pancreatic fistula with clinical significance　and other major complications were similar to traditional Blumgart procedure.

Risk factors of pancreatic fistula after pancreaticoduodenectomy and pancreaticojejunostomy / 中华肝胆外科杂志

Objective:To analyze the risk factors of clinically-relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD) and penetrating pancreaticojejunostomy (PPJ).Methods:The clinical data of 108 patients who underwent PD and PPJ in the Department of Hepatobiliary Surgery of the First Affiliated Hospital of Wannan Medical College from January 2017 to October 2022 were analyzed retrospectively, including 65 males and 43 females, aged 65.5 (54.2, 72.0) years. The incidences of POPF, biliary fistula, abdominal bleeding and other related complications were reviewed. The related factors of CR-POPF were analyzed by univariate analysis, and the statistically significant factors were included in multivariate logistic regression analysis.Results:A total of 108 patients were successfully treated with PD, including laparoscopic PD in 76 cases (70.4%) and open PD in 32 cases (29.6%). PPJ was performed in PD, including the continuous fashion in 39 cases (36.1%), intermittent fashion in 49 cases (45.4%) and modified continuous fashion in 20 cases (18.5%). The operation time was 390.0 (314.0, 480.0) min, the intraoperative blood loss was 200.0 (100.0, 384.0) ml, the postoperative hospital stay was 12.0 (10.0, 15.0) d, and the incidence of POPF (grade B + C) was 11.1% (12/108). Body mass index, pancreatic CT value and pancreatic duct size were the significant factors of CR-POPF (all P<0.05). Multivariate logistic regression analysis showed that age ( OR=0.895, 95% CI: 0.822-0.975), pancreatic CT value ( OR=0.812, 95% CI: 0.698-0.946) and pancreatic duct size ( OR=0.457, 95% CI: 0.220-0.952) were risk factors of CR-POPF after PPJ (all P<0.05). Conclusion:PPJ is a safe method of pancreaticoenterostomy, and CR-POPF may be related to younger patients, lower pancreatic CT value and the smaller pancreatic duct size.

Analysis of pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy / 中华肝胆外科杂志

Laparoscopic pancreaticoduodenectomy is an important surgical undertaking, mostly used for benign and malignant tumors in the pancreatic head and periampullary region. The postoperative pancreatic fistula is the main factor to cause death after pancreaticoduodenectomy, and pancreaticojejunostomy is an independent risk factor for pancreatic fistula. In order to reduce the incidence of pancreatic fistula, surgeons have proposed dozens of pancreaticojejunostomy, but so far there are no randomized trials proved which method of pancreaticojejunostomy is better than the others. This article reviews the methods and characteristics of different pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy.

Application of single-layer with full thickness of duct-to-mucosa pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy / 中华胰腺病杂志

Objective:To explore the clinical efficacy and safety of single-layer with full thickness of duct-to-mucosa pancreaticojejunostomy in laparoscopic pancreaticoduodenectomy.Methods:The clinical data of 45 patients who underwent laparoscopic pancreaticoduodenectomy with the procedures of single-layer with full thickness in Second Hospital of Hebei Medical University from Jan 2020 to Jan 2022 were retrospectively collected and compared with 45 matched patients with traditional two-layer pancreaticojejunostomy.Results:The laparoscopic pancreaticoduodenectomy procedures were successfully performed in all the 90 cases. The mean operation time (285.6±92.4 minutes) and the media pancreaticojejunostomy time 20(15, 35) minutes) of the single-layer with full thickness pancreaticojejunostomy group were shorter than those of the two-layer pancreaticojejunostomy group [the mean operation time: 317.0±85.5 minutes, the media pancreaticojejunostomy time: 46(30, 58) minutes] with significantly statistical differences (all P value<0.05). There were no significantly statistical differences on intraoperative blood loss, the postoperative complications or hospital stay between the two groups. Conclusions:Compared with traditional pancreaticojejunostomy, the single-layer with full thickness of duct-to-mucosa pancreaticojejunostomy is simple and safe, which has the advantage of easy manipulation and less time-consuming and can be recommended for laparoscopic procedures.

Use of primary continuous single-layer pancreaticojejunostomy after linear stapler closure of pancreatic remnants in pancreaticoduodenectomy / 中华肝胆外科杂志

Objective:To study the use of primary continuous single-layer pancreaticojejunostomy after linear stapler closure of pancreatic neck in pancreaticoduodenectomy (PD).Methods:The clinical data of 21 patients who were treated with primary continuous single-layer pancreaticojejunostomy after linear stapler closure of pancreatic neck in PD at Beijing Chaoyang Hospital Affiliated, West Campus, Capital Medical University, Rizhao Hepatobiliary-pancreatic-splenic Surgery Research Institute, Binzhou Second People’s Hospital, Chaoyang Central Hospital from February 2022 to May 2022 were retrospectively analyzed. There were 12 males and 9 females, with ages ranging from 31.0 to 82.0 years (median age 63.0 years). The success rates of linear stapling at pancreatic neck, time of pancreaticojejunostomy, postoperative complications, pancreatic fistula risk score, and length of hospital stay were studied.Results:Among the 21 patients, there were 3 patients who underwent open PD and 18 patients who underwent laparoscopic PD. Primary continuous single-layer pancreaticojejunostomy after linear stapler closure of pancreatic neck was successfully carried out in all these patients. The success rate was 100.0%. The success rate of finding pancreatic ducts at the pancreatic stumps and inserting an drainage tube was 100.0%(21/21). In the 3 patients who underwent open PD, the operation time were 230.0, 245.0 and 250.0 minutes respectively. The time for completing pancreaticojejunostomy were 12.0, 13.0 and 12.0 minutes respectively. The estimated blood loss were 300.0, 450.0 and 600.0 ml respectively. The length of hospital stay were 14.0, 15.0 and 21.0 days. In the 18 patients who underwent laparoscopic PD, the operation time was (295.9±14.5) min, the time for constructing pancreaticojejunostomy was (22.3±1.5) min, the blood loss was (180.0±40.0) ml, the length of hospital stay ranging from 8.0 to 16.0 days (median 10.5 days). Among all the 21 patients, the pancreatic fistula risk score was (4.7±1.5). Postoperative acute pancreatitis occurred in 3 patients (14.3%), delayed gastric emptying occurred in 4 patients (19.0%), and all of them recovered after conservative treatment. There was no postoperative bleeding, nosocomial infection, grade B and C postoperative pancreatic fistula or perioperative death.Conclusion:The continuous single-layer pancreaticojejunostomy after linear stapler closure of the pancreatic neck was safe, reliable, simple and technically easy. It has the potential to prevent clinical postoperative pancreatic fistula and pancreaticojejunostomy bleeding. It is worth to popularize this surgical procedure.

Post-operative pancreatic fistula and acute pancreatitis following pancreaticoduodenectomy / 中华肝胆外科杂志

Postoperative pancreatic fistula (POPF) is a common complication and the main leading cause of death after pancreaticoduodenectomy (PD). In recent years, with the deepening of people's understanding of acute pancreatitis (AP) after pancreatic surgery, more and more evidence shows that AP is another common complication which is different from POPF after PD. AP is an independent risk factor for the occurrence and development of POPF, and is closely related to serious complications such as infection and death. The establishment of the concept of AP after PD makes people have a more comprehensive understanding of the pathophysiological changes of residual pancreatic tissue in the early stage after PD, and further understanding of the occurrence and development mechanism of POPF, and have more thoughts on the prevention and treatment measures of AP and POPF after PD, which will further enhance clinical management level and safety after PD.

Related factors affecting the occurrence of severe pancreatic fistula after radical gastrectomy / 中国基层医药

Objective:To investigate the related factors that affect the occurrence of severe pancreatic fistula after radical gastrectomy.Methods:The clinical data of 460 patients undergoing radical gastrectomy in The People's Hospital of Shouguang from January 2015 to January 2021 were retrospectively analyzed. These patients were divided into severe pancreatic fistula group ( n = 24) and non-severe pancreatic fistula group ( n = 436) according to whether they developed severe pancreatic fistula after surgery. Preoperative clinical data, surgical data, and abdominal drainage fluid amylase level in the first postoperative days were compared. The receiver operating characteristics (ROC) curve was used to calculate the cutoff value of abdominal drainage fluid amylase level on the 1 st and 3 rd days of developing severe pancreatic fistula after radical gastrectomy. The incidence of pancreatic fistula was compared between different amylase level groups. Multivariate logistic regression was performed to analyze the independent risk factors of severe pancreatic fistula after surgery. Results:There were significant differences in body mass index, operative time, intraoperative blood loss, peritoneal drainage fluid amylase level on the 1 st and 3 rd days after surgery, and the number of cases undergoing splenectomy between the two groups (all P < 0.05). The cutoff values of amylase level in peritoneal drainage fluid (D-AMY) on the 1 st and 3 rd days after surgery were 2 156 IU/L and 596 IU/L respectively, which had high sensitivity and specificity. On the 1 st and 3 rd days after surgery, the incidence of pancreatic fistula in the high-level amylase group was significantly higher than that in the low-level amylase group [26.2% (16/61) vs. 0.8% (3/334), χ2 = 62.82, P < 0.05). Multivariate logistic analysis showed that obesity, splenectomy, and abdominal drainage fluid amylase level higher than the cut-off value on the 1 st and 3 rd days after surgery were independent risk factors for severe pancreatic fistula, and the differences were statistically significant (all P < 0.05). Conclusion:Obesity, splenectomy, and abdominal drainage fluid amylase level higher than the cut-off value on the 1 st and 3 rd days after surgery are independent risk factors affecting the occurrence of severe pancreatic fistula. D-AMY (> 2 156 IU/L) on the 1 st day and D-AMY (> 596 IU/L) on the 3 rd day in the early postoperative days can be used as cutoff values to predict the occurrence of severe pancreatic fistula after radical gastrectomy.

Application of Hong′s single-stitch duct to mucosa pancreaticoenterostomy in laparoscopic pancreaticoduodenectomy / 中华胰腺病杂志

Objective:To explore the value of Hong′s single-stitch duct to mucosa pancreaticoenterostomy(HSDMP) in laparoscopic pancreaticoduodenectomy(LPD).Methods:The perioperative clinical data of 300 patients undergoing LPD admitted to the Second Department of Hepatobiliary Surgery in the First Hospital of Jilin University from April 2015 to March 2019 were retrospectively analyzed. The patients were categorized into pancreatic fistula group( n=43) and non pancreatic fistula group( n=257). according to the presence or absence of postoperative pancreatic fistula. Among them, pancreaticojejunostomy was performed with HSDMP in 210 patients, and 90 patients underwent traditional pancreaticoenterostomy. Univariate and multivariate logistic regression were used to analyze the risk factors for the development of pancreatic fistula after LPD, and the difference on the time of pancreaticojejunostomy and the incidence of postoperative pancreatic fistula were compared between HSDMP and traditional pancreaticojejunostomy. Results:Univariate analysis showed that the differences on BMI, abdominal operation history, pancreatic texture, and pancreatic duct diameter were statistically significant compared with non-pancreatic fistula group (all P value <0.05). Multivariate logistic regression showed that BMI ( OR1.180, 95% CI1.047-1.338, P=0.008) and pancreatic texture( OR=0.375, 95% CI 0.135-0.861, P=0.036) were independent risk factors for pancreatic fistula after LPD. Compared with traditional pancreaticojejunostomy, HSDMP was associated with shorter anastomosis time and low incidence of postoperative pancreatic fistula, but there was no statistical significance between the two groups. Conclusions:The independent risk factors for pancreatic fistula are high BMI and soft pancreatic texture. Compared with traditional pancreaticojejunostomy, HSDMP does not prolong LPD time and increase the incidence of postoperative pancreatic fistula.