Determinants of complications in pancreaticoduodenectomy (original) (raw)
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Journal of hepato-biliary-pancreatic sciences, 2017
The morbidity rate after pancreaticoduodenectomy remains high. The objectives of this retrospective cohort study were to clarify the risk factors associated with serious morbidity (Clavien-Dindo classification grades IV-V), and create complication risk calculators using the Japanese National Clinical Database. Between 2011 and 2012, data from 17564 patients who underwent pancreaticoduodenectomy at 1311 institutions in Japan were recorded in this database. The morbidity rate and associated risk factors were analysed. The overall and serious morbidity rates were 41.6% and 4.5%, respectively. A pancreatic fistula (PF) with an International Study Group of Pancreatic Fistula (ISGPF) grade C was significantly associated with serious morbidity (P < 0.001). Twenty-one variables were considered statistically significant predictors of serious complications, and 15 of them overlapped with those of a PF with ISGPF grade C. The predictors included age, sex, obesity, functional status, smoking...
In order to ameliorate our results after pancreaticoduodenectomy, we elaborated a management protocol in 2009, including a diagnosis pathway and a preparation one. The present study is one necessary step in the evaluation process of this protocol. Material and methods In January 2009, we prepared a management protocol for patient with periampullary cancer, including two parallel pathways, a diagnosis one and a preparation one. As for diagnosis, the golden standard was, and still is, the computer-tomography exam (CECT), which offers information on the local development of the tumor, mostly the involvement of the portal vein (PV), superior mesenteric vessels (SMA, SMV), inferior cava vein (ICV) or common hepatic artery (CHA), and the presence of the metastases (hepatic, peritoneal or pulmonary). In cases of doubt regarding vascular invasion, we perform an endoscopic ultrasound (EUS) exam. We consider a periampullary tumor to be unresectable if it invades arteries, if there are signs of venous thrombosis or if there are metastases. In parallel, we prepare the patient for major surgery, correcting anemia (by blood transfusion until the hemoglobin levels exceeds 10 g/dl), hypoalbuminemia and liver status (if transaminases levels are more than five times normal, or bilirubin levels Abstract. Aim: The aim of this study is to identify the risk factors for the main complications (pancreatic fistula-POPF, delay gastric emptying-DGE, pancreatic stump bleeding) following pancreaticoduodenectomy (PD) in a specialized surgery department. Material and method: Between January 2009-December 2015, 298 pancreaticoduodenectomies (PD) were performed in our department. 168 (56.19%) of cases were males and 131 (43.81%) were females, ages between 22-84 (61±10.4). Their data were introduced in a prospective database, also including co-morbid conditions, clinical characteristics and intraoperative aspects. Results: There were 27 (9.06%) cases of POPF, 61 (20.47%) of DGE and 20 (6.71%) of pancreatic stump bleeding. Pancreatico-jejunostomy (p=0.02) and the soft texture of the pancreas (p=0.05) significantly have favored POPF. The pancreatico-gastrostomy (p=0.05), the classical Whipple resection (p=0.03) and the need for intraoperative transfusion (p=0.016) were identified as risk factors for DGE. For pancreatic stump bleeding, significant risk factors were the soft texture of the gland (p=0.0007) and the intraoperative blood loss (p=0.016). The average length of hospital stay was 13.9+/-8.86 days. Reoperation rate was 12.08%. We had a 6.04% mortality rate relating to surgical complication. Conclusion: We can improve our results following PD by correcting some intraoperative risk factors: pancreatico-gastroanastomosis should be the choice for pancreatic stump treatment and we must care more for intraoperative blood loss and consecutively need for transfusion. The soft texture of the pancreas should warn us about a possible incidental postoperative outcome.
Assessment of Complications After Pancreatic Surgery
Annals of Surgery, 2006
Objective: To define a simple and reproducible classification of complications following pancreaticoduodenectomy (PD) based on a therapy-oriented severity grading system. Background: While mortality is rare after PD, morbidity rates remain high. The lack of standardization in evaluating morbidity after PD has severely hampered meaningful comparisons over time and among centers. We adapted a novel classification of complication to stratify morbidity by severity after PD, to test whether the incidence of pancreatic fistula has changed over time, and to identify risk factors in a single North American center. Methods: The classification was applied to a consecutive series of 633 patients undergoing PD between February 2003 and August 2005. Another series of 141 patients treated between 1987 and 1990 was also analyzed to identify changes in the incidence and severity of fistula. Univariate and multivariate analyses were performed to link respective complications with preoperative and intraoperative parameters, length of hospital stay, and long-term survival. Results: A total of 263 (41.5%) patients did not develop any complication, while 370 (58.5%) had at least one complication; 62 (10.0%) patients had only grade I complications (no need for specific intervention), 192 patients (30.0%) had grade II (need for drug therapy such as antibiotics), 85 patients (13.5%) had grade III (need for invasive therapy), and 19 patients (3.0%) had grade IV complications (organ dysfunction with ICU stay). Grade V (death) occurred in 12 patients (2.0%). A total of 57 patients (9.0%) developed pancreatic fistula, of which 33 (58.0%) were classified as grade II, 17 (30.0%) as grade III, 5 (9.0%) as grade IV, and 2 (3.5%) as grade V. Delayed gastric emptying was documented in 80 patients (12.7%); half of them were scored as grade II and the other half as From the *Swiss HPB (Hepato-Pancreato-
The American Journal of Surgery, 2009
BACKGROUND: Pancreatic fistula (PF) is one of the most common postoperative complications of pancreatoduodenectomy (PD). A recent International Study Group on Pancreatic Fistula (ISGPF) definition grades the severity of PF according to the clinical impact on the patient's hospital course. Although PF is generally treated conservatively (grade A), some cases may require interventional procedures (grade B) or may be life-threatening and necessitate emergency reoperation (grade C). The aim of the present study was to evaluate the incidence of postoperative grade C PF after PD and to assess the prognosis and risk factors for this life-threatening condition. STUDY DESIGN: Between January 2000 and December 2006, 680 consecutive patients underwent PD in 5 digestive surgery departments in the northwest region of France (Lille, Amiens, Rouen, and Caen). PF was defined as drain output of any measurable volume of fluid on or after postoperative day 3 with amylase content greater than 3 times the serum amylase activity (ISGPF guidelines). To identify possible risk factors for grade C PF, we reviewed the records of 111 (16.3%) patients with postoperative PF and compared grade C cases with grade AϩB cases. RESULTS: The median age was 59 years (range 22-87). The male-to-female ratio was 1.6:1. Fifty-six (50.4%) PDs were performed via pancreaticogastrostomy and 55 via pancreaticojejunostomy. Overall mortality was 2% (n ϭ 14). Grade C PF was observed in 36 (32%) patients, of whom 17 (47%)
Indian Journal of Surgical Oncology, 2020
Fistula following leaked pancreatico-enteric anastomosis is a common, potentially lethal complication of pancreaticoduodenectomy (PD). Early assessment and prediction of its occurrence can improve postoperative outcomes. Various perioperative factors were analyzed for its contribution to clinically relevant postoperative pancreatic fistula (crPOPF). Also, the difference in clinical outcomes of patients with and without fistula was studied. Sixty-seven patients undergoing PD for malignancies were analyzed during 3-year period in a dual-institutional study. Various preoperative, intraoperative, and postoperative factors were assessed. The incidence and severity of POPF and its association with the development of other post-PD complications were observed. Patients with and without POPF were divided into groups and compared with univariate and multivariate analyses, to identify significant contributing factors. Clinically relevant POPF was present in 20.9% cases. crPOPF contributed to delayed gastric emptying, albeit insignificant (p = 0.403), but was significantly associated with increased incidence of post-pancreatectomy hemorrhagic (p = 0.005) and infectious complications (p = 0.013). Soft pancreas (p = 0.024), intraoperative blood loss (p = 0.045), blood transfusion (p = 0.024), and fistula risk score (p = 0.001) were significant predictors of crPOPF. First postoperative day (POD1) drain fluid amylase (DFA) values at cutoff of 1336 U/L (AUC = 0.871; p < 0.001) significantly predicted crPOPF with good sensitivity and specificity. POD1 DFA was only factor significant on multivariate analysis (p = 0.014). There was no significant difference in overall survival between groups. crPOPF results in significant post-pancreatectomy hemorrhagic and septic complications, along with increased mortality. It can be accurately predicted by several preoperative and intraoperative factors. POD1 DFA can independently predict crPOPF development.
Digestive Surgery, 2001
Pancreaticoduodenectomy (PD) is still a difficult procedure with significant morbidity. We report 150 consecutive PDs performed during a 3-year period. All the cases have been prospectively evaluated with regard to the surgical outcome. Mortality in this series was 3/150 (2%) with a re-operation rate of 5/150 (3.3%); surgical complications were experienced in 57/150 (38%). The most frequent complications were collections in 25/150 (16.6%) and pancreatic fistulas in 16/150 (10.7%). The majority of these complications were conservatively managed: only one abscess and one fistula due to an anastomotic dehiscence required re-operation. The complication most responsible for mortality was haemorrhage secondary to arterial pseudoaneurysms in patients with severe postoperative pancreatitis. The continued high morbidity of PDs is compensated by the ability to treat complications non-operatively, resulting in a surgical risk that should now be considered medium to low in high volume centres.
Risk Score for Prediction of Severe Postoperative Complications After Pancreaticoduodenectomy
Journal of Institute of Medicine, 2021
Methods This was a retrospective observational study. Patients undergoing pancreaticoduodenectomy at Tribhuvan University Teaching Hospital (TUTH) between January 2017 to December 2017 were included in the study. Variables were recorded from case sheets of the patients. The “Risk Score” was calculated using the pancreatic duct diameter and body mass index (BMI). Association of risk score and severe postoperative complications were analyzed.
Digestive Surgery
Pancreaticoduodenectomy (PD) is still a difficult procedure with significant morbidity. We report 150 consecutive PDs performed during a 3-year period. All the cases have been prospectively evaluated with regard to the surgical outcome. Mortality in this series was 3/150 (2%) with a re-operation rate of 5/150 (3.3%); surgical complications were experienced in 57/150 (38%). The most frequent complications were collections in 25/150 (16.6%) and pancreatic fistulas in 16/150 (10.7%). The majority of these complications were conservatively managed: only one abscess and one fistula due to an anastomotic dehiscence required re-operation. The complication most responsible for mortality was haemorrhage secondary to arterial pseudoaneurysms in patients with severe post-operative pancreatitis. The continued high morbidity of PDs is compensated by the ability to treat complications non-operatively, resulting in a surgical risk that should now be considered medium to low in high volume centres.
Evaluation of risk factors for postoperative pancreatic fistula following pancreaticoduodenectomy
INTRODUCTION Pa n c r e a t i c f i s t u l a (P F) r e m a i n s t h e m o s t common and challenging complication following pancreaticoduodenectomy (PD), with an incidence of 2%-28%. [1] A soft pancreas is the most consistent risk factor for postoperative pancreatic fistula (POPF) following PD. In addition to organ consistency, other potential risk factors include pancreatic duct size, body mass index (BMI), diabetes mellitus (DM), and preoperative elevated serum bilirubin. The mortality rate following PD is <5%, while Background: Pancreatic fistula (PF) remains the most common and challenging complication following pancreaticoduodenectomy (PD), with an incidence of 2%-28%. The primary objective of this study was to assess the correlation of fatty infiltration and fibrosis of the pancreas with postoperative pancreatic fistula (POPF). Secondary objectives were to investigate the correlations of POPF with the main pancreatic duct size and subjective intraoperative assessment of pancreatic texture and to determine if diabetes mellitus (DM), body mass index, or increased serum bilirubin correlate with POPF. Materials and Methods: This prospective study was performed at Sudhamayi Hospital, Kochi, India. Forty-six patients were included and divided into either the fatty infiltration group (n = 20) or fibrosis group (n = 17); nine patients had neither fatty nor fibrotic glands. Data were analyzed using analysis of variance and Chi-square test, utilizing SPSS software version 20 (IBM Inc., Armonk, NY, USA). Results: Patients with fatty pancreas had a ten times higher incidence of PF than those with fibrotic pancreas (odds ratio, 10.8; 95% confidence interval [CI], 2.2-52.4; P = 0.003). POPF was 7.9 times higher in patients with a nondilated duct compared to patients with a dilated duct (95% CI, 2.118-29.5; P = 0.003). Preoperative elevated serum bilirubin, body mass index, and DM were not found to be significant risk factors for POPF. Conclusion: We demonstrated that fatty pancreas and small pancreatic duct size (≤3 mm) are risk factors for POPF. Preoperative elevated serum bilirubin, body mass index, and DM were not found to be significant risk factors.
Journal of Gastrointestinal Surgery, 2009
Background The mortality associated with pancreaticoduodenectomy (PD) has decreased substantially in recent times, but high morbidity continues to be a significant problem. With reductions in mortality, there is increasing willingness to combine organ resections with PD when indicated. There is, however, a paucity of information regarding the morbidity and mortality of multivisceral resection (MVR) that involves pancreaticoduodenectomy (MVR-PD). Methods Patients undergoing PD between January 2002 and November 2007 by a single surgeon were reviewed and perioperative outcomes determined. Those treated by PD alone were compared to those undergoing MVR-PD. Results There were 105 patients overall who underwent PD during the study period, with MVR-PD performed in 19 patients. Twelve (63%) patients required PD combined with right colectomy, two (11%) underwent PD combined with right nephrectomy, two (11%) required liver resection with PD, and the remaining three (16%) had various combinations of kidney, colon, adrenal and small bowel resection in addition to PD. In both groups, the main indication for surgery was pancreatic cancer; however, there were proportionally more patients in the MVR-PD group with gastrointestinal stromal tumors (two (11%) patients), sarcomas (two (11%) patients) and metastases to the periampullary region (three (16%) patients). The overall complication rate in this study was 60%. Delayed gastric emptying (39%) and pancreatic fistula (16%) were the most common complications. There was no significant difference in complications between the two groups. A non pylorus-preserving PD was more commonly performed in cases of MVR-PD (53% vs 28%; p = 0.007), operating times were longer (9.5 vs 8 h; p = 0.002), and surgical intensive care unit stay was greater (2 vs 1 days; p < 0.001). The overall median length of hospital stay (7 days) and readmission rate were similar between the groups. Conclusion MVR-PD can be performed without significant added morbidity compared to PD alone. The main indication for MVR-PD is locally advanced pancreatic cancer requiring PD combined with right hemicolectomy.