Postoperative bleeding(POB)is a major complication following pancreaticoduodenectomy(PD),leading to significant morbidity and potential mortality.This minireview focuses on the prevention and management strategies for...Postoperative bleeding(POB)is a major complication following pancreaticoduodenectomy(PD),leading to significant morbidity and potential mortality.This minireview focuses on the prevention and management strategies for POB,synthesizing current evidence on surgical techniques,perioperative management,and postoperative interventions.Effective prevention strategies include the use of regional vessel wrapping,optimal pancreatic anastomosis,and meticulous intraoperative hemostasis.Postoperative management strategies,such as early detection using predictive models and advanced imaging,along with endovascular interventions like angiographic embolization and stent graft placement,are essential for timely intervention.Risk factors,including pancreatic texture,anticoagulation therapy,and patient comorbidities,further influence bleeding outcomes.The minireview also identifies gaps in current research and emphasizes the need for prospective randomized controlled trials to establish standardized protocols.Overall,a multidisciplinary approach combining surgical expertise,predictive analytics,and personalized care is essential to improving patient out comes and minimizing the risk of POB following PD.展开更多
BACKGROUND Acute pancreatitis(AP)is a potentially life-threatening complication of pancreaticoduodenectomy that increases morbidity and mortality in patients.Interleukin-17A(IL-17a)the potential preoperative marker fo...BACKGROUND Acute pancreatitis(AP)is a potentially life-threatening complication of pancreaticoduodenectomy that increases morbidity and mortality in patients.Interleukin-17A(IL-17a)the potential preoperative marker for predicting postoperative outcomes.The purpose of this study is to retrospectively assess the prognostic value of preoperative IL-17a level in prediction of AP and related postoperative pancreatic fistula(POPF)following pancreaticoduodenectomy.AIM To retrospectively assess the prognostic value of preoperative IL-17a levels in predicting AP and related POPF following pancreaticoduodenectomy.METHODS Retrospective analysis of pancreaticoduodenectomies performed on patients 150 patients between 2017 and 2023.Clinical data including pre-operative IL-17a levels were collected.The primary composite outcomes were postoperative AP and postoperative pancreatic(PP),and the predictive performances of IL-17a levels and fluid load status for postoperative complications were evaluated by statistical analysis.RESULTS A total of 150 patients were included,and 26 patients(17.3%)developed postoperative AP and 34 patients(22.7%)developed PP.Preoperative IL-17a was a risk factor for postoperative AP(P=0.03).Furthermore,excessive intraoperative fluid load was a significantly associated(P=0.01)with PP.The model(IL-17a levels+fluid load status)was highly accurate.CONCLUSION Preoperative IL-17a levels and intravascular volume status may serve as useful predictors of AP and subsequent PP following PD.These parameters provide means to evaluate preoperative risk and may guide clinical decision making to enhance postoperative recovery.展开更多
BACKGROUND Postoperative pancreatic fistula(POPF)is the most frequent cause of morbimortality after pancreaticoduodenectomy,but the best technique to use to prevent its development is unclear.The choice of drainage me...BACKGROUND Postoperative pancreatic fistula(POPF)is the most frequent cause of morbimortality after pancreaticoduodenectomy,but the best technique to use to prevent its development is unclear.The choice of drainage method external duct stent(EDS),internal duct stent(IDS),or non-ductal stent(NDS)is also controversial.AIM To compare the three groups(EDS,IDS and NDS),analyzing the patient characteristics,perioperative examinations and survival.METHODS Patients who underwent pancreaticoduodenectomy and pancreaticojejunostomy between 2012 and 2020,were divided into the EDS,IDS and NDS groups.RESULTS Of the 244 patients included,129 were in the EDS group,71 in the IDS group,and 44 in the NDS group.Except for preoperative pancreatitis in the NDS patients,comorbidities were similar among the groups.Patients in the NDS group had a high caliber of the Wirsung duct and frequently presented with a hard pancreas(P<0.001).A lower rate of grade C POPF was observed in the EDS(1.6%)compared to the NDS(9.1%)and IDS group(14.1%)(P=0.009).The groups showed similar findings for delayed gastric emptying,postoperative hemorrhage,reoperation,and 5-year survivals.Ninety-day mortality rate was significantly higher in the IDS group(5.6%)compared to the EDS(1.6%)and NDS(4.5%)groups(P=0.046).Multivariate analysis showed that the use of EDS was a protective factor for grade B/C POPF(P=0.034),and 90-day mortality(P=0.018).Additionally,a Wirsung duct diameter<3 mm was the only risk factor for grade B/C POPF(P=0.001),and 90-day mortality(P=0.031).CONCLUSION The use of the EDS was a protective factor for grade B/C POPF and 90-day mortality,and the Wirsung duct<3 mm was a risk factor for grade B/C POPF and 90-day mortality.展开更多
Background:Laparoscopic pancreaticoduodenectomy(LPD)has gained growing acceptance for the resection of periampullary carcinoma.However,postoperative ascites(POA)frequently occurs after LPD,yet little is known about th...Background:Laparoscopic pancreaticoduodenectomy(LPD)has gained growing acceptance for the resection of periampullary carcinoma.However,postoperative ascites(POA)frequently occurs after LPD,yet little is known about the underlying factors that promote POA under this laparoscopic approach.This study aimed to explore the clinical influence of POA after LPD and its potential predictors.Methods:Patients diagnosed with periampullary carcinoma who subsequently underwent LPD from December 2015 to February 2023 were reviewed.Patients were assigned to the two groups by whether daily abdominal drainage>500 mL for at least three consecutive days,followed by subgroup analysis of pancreatic fistula(PF)-POA and non-PF-POA.Variables,including preoperative laboratory tests,past history,surgery-related factors,and incidence of complications,were compared.In addition,logistic regression analysis was applied to reveal the potential independent risk factors for PF-POA and non-PF-POA.Results:A total of 38 patients(17.4%)developed POA,with 17 having PF-POA and 21 having non-PF-POA.Patients with grade B PF-POA experienced a higher incidence of intra-abdominal infection,and a longer hospital stay compared with other groups.Multivariate analysis demonstrated that prothrombin time>14 s and main pancreatic duct diameter<3 mm were independent risk factors for PF-POA.Moreover,male sex,total bilirubin>34.2μmol/L and platelet count<100×10^(9)/L were independent risk factors for non-PF-POA.The areas under the receiver operating characteristic curve were 0.682 and 0.786 for predicting PF-POA and non-PF-POA,respectively.Conclusions:LPD recovery and postoperative complications are impacted by POA,where PF-POA is the most clinically relevant POA.Prolonged prothrombin time and narrowed main pancreatic duct were independent risk factors for PF-POA;male sex,elevated total bilirubin level,and decreased platelet count were independent risk factors for non-PF-POA.展开更多
BACKGROUND This study aimed to compare and analyze risk factors for pancreatic fistula following pancreaticoduodenectomy(PD)using different definition criteria,and to develop a predictive model for standardized pancre...BACKGROUND This study aimed to compare and analyze risk factors for pancreatic fistula following pancreaticoduodenectomy(PD)using different definition criteria,and to develop a predictive model for standardized pancreatic fistula risk assessment.AIM To identify and compare risk factors for postoperative pancreatic fistula(POPF)following PD using both the 2005 International Study Group of Pancreatic Fistula and updated 2016 International Study Group on Pancreatic Surgery diagnostic criteria,and to develop a clinically applicable predictive model based on objective preoperative parameters for standardized pancreatic fistula risk assessment and perioperative management optimization.METHODS We conducted a retrospective analysis of 303 patients who underwent PD at CR&WISCO General Hospital between January 2017 and May 2023.POPF cases were classified according to both previous and updated diagnostic standards.For statistical analysis,we employed t-tests or Mann-Whitney U tests for continuous variables andχ^(2) tests for categorical data.To identify risk factors associated with POPF under both classification systems,we performed univariate and multivariate logistic regression analyses.RESULTS Univariate analysis identified several factors associated with POPF:Main pancreatic duct diameter(χ^(2)=31.641,P<0.001),main pancreatic duct index(χ^(2)=52.777,P<0.001),portal vein invasion(χ^(2)=6.259,P=0.012),intra-abdominal fat thickness(χ^(2)=7.665,P=0.006),preoperative biliary drainage(χ^(2)=5.999,P=0.014),pancreatic characteristics(χ^(2)=5.544,P=0.019),pancreatic resection margin thickness(t=2.055,P=0.032),pancreatic computed tomography(CT)value(t=-3.224,P=0.002),and preoperative blood amylase level(Z=-2.099,P=0.036).Multivariate logistic regression identified three independent risk factors:Main pancreatic duct index[odds ratio(OR)=0.000,95%confidence interval(CI):0.000-0.011],pancreatic cancer[OR=4.843,95%CI:1.285-18.254],and pancreatic CT value[OR=0.869,95%CI:0.806-0.937](all P<0.05).CONCLUSION The main pancreatic duct index and pancreatic CT value are strongly correlated with pancreatic fistula development after PD.展开更多
BACKGROUND Objective and accurate assessment of blood loss during pancreaticoduodenectomy(PD)is crucial for ensuring the safety and efficacy of the procedure.While the visual method remains the most common clinical me...BACKGROUND Objective and accurate assessment of blood loss during pancreaticoduodenectomy(PD)is crucial for ensuring the safety and efficacy of the procedure.While the visual method remains the most common clinical metric,many scholars argue that it significantly differs from actual blood loss and is inherently subjective.AIM To assess blood loss in PD via delta hemoglobin(ΔHb)and compare it with the visual method to predict bleeding-related risk factors.METHODS In this retrospective analysis,1722 patients who underwent PD from 2017 to 2022 at Shandong Provincial Hospital were divided into three groups:Open PD(OPD),laparoscopic PD(LPD),and conversion to OPD(CTOPD).IntraoperativeΔHb(IΔHb)was calculated via preoperative and 72-hour-postoperative hemoglobin concentrations,and its association with visually obtained estimated blood loss(EBL)was analyzed.PerioperativeΔHb(PΔHb)was calculated via preoperative and predischarge hemoglobin concentrations.We compared the differences in IΔHb and PΔHb among the three groups,and performed univariate and multi-variate regression analyses of IΔHb and PΔHb.RESULTS The preoperative general information of patients showed no statistically si-gnificant difference among the three groups(P>0.05).The IΔHb in the OPD,LPD,and CTOPD groups were 22.00(12.00,36.00),21.00(10.00,33.00),and 33.00(18.12,52.24)g/L,respectively;And the PΔHb in the OPD,LPD,and CTOPD groups were 25.87(13.51,42.00),25.00(14.00,45.00),and 37.48(21.64,59.65)g/L,respectively,values significantly differed(P<0.05).IΔHb and EBL were significantly correlated(r=0.337,P<0.001).The results of univariate and multivariate regression analyses indicated that American Society of Anesthesiologists(ASA)classification IV[95%confidence interval(CI):2.330-37.811,P=0.049]and preoperative total bilirubin>200μmol/L(95%CI:2.805-8.673,P<0.001)were independent risk factors for IΔHb(P<0.05),and ASA classification IV(95%CI:45.934-105.485,P<0.001),body mass index>24 kg/m2(95%CI:1.285-9.890,P=0.011),and preoperative total bilirubin>200μmol/L(95%CI:6.948-16.797,P<0.001)were independent risk factors for PΔHb(P<0.05).CONCLUSION There is a correlation between IΔHb and EBL in PD,so we can assess the patients’intraoperative blood loss by theΔHb method.ASA classification IV,body mass index>24 kg/m²,and preoperative total bilirubin>200μmol/L increased perioperative bleeding risk.展开更多
BACKGROUND The International Study Group of Pancreatic Surgery has established the defi-nition and grading system for postpancreatectomy acute pancreatitis(PPAP).There are no established machine learning models for pr...BACKGROUND The International Study Group of Pancreatic Surgery has established the defi-nition and grading system for postpancreatectomy acute pancreatitis(PPAP).There are no established machine learning models for predicting PPAP following pancreaticoduodenectomy(PD).AIM To explore the predictive model of PPAP,and test its predictive efficacy to guide the clinical work.METHODS Clinical data from consecutive patients who underwent PD between 2016 and 2024 were retrospectively collected.An analysis of PPAP risk factors was performed,various machine learning algorithms[logistic regression,random forest,gradient boosting decision tree,extreme gradient boosting,light gradient boosting machine,and category boosting(CatBoost)]were utilized to develop predictive models.Recursive feature elimination was employed to select several variables to achieve the optimal machine algorithm.RESULTS The study included 381 patients,of whom 88(23.09%)developed PPAP.PPAP patients exhibited a significantly higher incidence of postoperative pancreatic fistula(55.68%vs 14.68%,P<0.001),grade C postoperative pancreatic fistula(9.09%vs 1.37%,P=0.001).The CatBoost algorithm outperformed other algorithms with a mean area under the receiver operating characteristic curve of 0.859[95%confidence interval(CI):0.814-0.905]in the training cohort and 0.822(95%CI:0.717-0.927)in the testing cohort.According to shapley additive explanations analysis,pancreatic texture,main pancreatic duct diameter,body mass index,estimated blood loss,and surgery time were the most important variables based on recursive feature elimination.The CatBoost algorithm based on selected variables demonstrated superior performance,with an area under the receiver operating characteristic curve of 0.837(95%CI:0.788-0.886)in the training cohort and 0.812(95%CI:0.697-0.927)in the testing cohort.CONCLUSION We developed the first machine learning-based predictive model for PPAP following PD.This predictive model can assist surgeons in anticipating and managing this complication proactively.展开更多
Background:The prediction of postoperative pancreatic fistula(POPF)is important.This study aimed to investigate the role of postoperative serum lipase level in predicting POPF.Methods:Data from 234 consecutive patient...Background:The prediction of postoperative pancreatic fistula(POPF)is important.This study aimed to investigate the role of postoperative serum lipase level in predicting POPF.Methods:Data from 234 consecutive patients who underwent pancreaticoduodenectomy(PD)were collected.The predictive values of serum amylase and serum lipase during postoperative days(PODs)1 to 3 for POPF were compared.Subgroup analyses were performed to determine the prognostic value of different levels and durations of elevated serum lipase.Results:Fifty-six patients developed POPF.The POPF group exhibited increased levels of serum amylase and lipase from PODs 1 to 3(all P<0.001).Compared with serum amylase,serum lipase has greater predictive value for POPF.Specifically,serum lipase had the highest area under the receiver operating characteristic curve(AUC)at POD 1(0.791).Body mass index>24 kg/m2[odds ratio(OR)=2.431,95%confidence interval(CI):1.094–5.404,P=0.029],soft pancreatic texture(OR=3.189,95%CI:1.263–8.056,P=0.014),serum lipase>60 U/L at POD 1(OR=5.135,95%CI:1.257–20.982,P=0.023),and C-reactive protein>167 mg/dL at POD 3(OR=3.607,95%CI:1.431–9.090,P=0.007)were identified as independent risk factors for POPF.Patients with serum lipase≤60 U/L at POD 1(n=104)exhibited lower rates of POPF(3.8%vs.40.0%,P<0.001)and severe complications(Clavien-Dindo≥IIIa)(4.8%vs.25.4%,P<0.001)than those with serum lipase>60 U/L at POD 1.Moreover,no additional elevation or duration of serum lipase offered any further prognostic value.Conclusions:Postoperative serum lipase outperformed serum amylase in the prediction of POPF,and patients with normal serum lipase level at POD 1 had favorable outcomes.A sustained increase in the serum lipase level offers no additional prognostic value.展开更多
BACKGROUND Non-alcoholic fatty liver disease(NAFLD)is characterized by the accumulation of fat in the liver in individuals who do not consume alcohol.Several risk factors influencing the onset of NAFLD after laparosco...BACKGROUND Non-alcoholic fatty liver disease(NAFLD)is characterized by the accumulation of fat in the liver in individuals who do not consume alcohol.Several risk factors influencing the onset of NAFLD after laparoscopic pancreaticoduodenectomy(LPD)have been identified.This study investigated the risk factors associated with the development of fatty liver after laparoscopic duodenum-preserving pancreatic total head resection(LDPPHRt)and LPD.AIM To compare the effects of LDPPHRt and LPD on the development of postoperative NAFLD.METHODS This retrospective cohort study included 59 patients who were histologically diagnosed with benign or low-grade malignant pancreatic tumors and who underwent laparoscopic pancreatic surgery(LDPPHRt or LPD)between May 2020 and April 2023.Patient data on perioperative and postoperative variables were analyzed and compared.Multivariate logistic regression was used to identify pre-,peri-,and postoperative risk factors for NAFLD,with statistical significance set at P<0.05.RESULTS Of the 59 patients included in the study,17(28.8%)developed NAFLD within 6-12 months post-surgery.The incidence of NAFLD was significantly higher in the LPD group compared to the LDPPHRt group(40.0%vs 12.5%,P=0.022).Multivariable analysis identified the LDPPHRt surgical approach(compared to LPD)as an independent protective factor against the development of postoperative NAFLD,with an odds ratio of 0.208(95%confidence interval:0.046-0.931;P=0.040).CONCLUSION Our findings indicate that LDPPHRt is more effective than LPD in reducing the incidence of postoperative NAFLD,which may inform surgical decision-making and optimize patient outcomes after laparoscopic pancreatic surgery.展开更多
We report the successful application of a surgical and medical co‐management(SMC)strategy in an 82‐year‐old man with hemophilia A(HA)undergoing pancreaticoduodenectomy for pancreatic head carcinoma.No major complic...We report the successful application of a surgical and medical co‐management(SMC)strategy in an 82‐year‐old man with hemophilia A(HA)undergoing pancreaticoduodenectomy for pancreatic head carcinoma.No major complications or perioperative bleeding occurred.Optimal management of HA patients undergoing major surgery requires multidisciplinary coordination to avoid postoperative complications.The SMC team integrates internists(who assess chronic disease status,adjust medications,and determine best hemostatic therapies)and surgeons(who evaluate the surgical feasibility of procedures and rely on advanced surgical skills)to improve perioperative planning to minimize complications and promote recovery.This case illustrates the utility of a shift from passive and conservative treatment to active and preventive treatment and highlights the value of SMC in many complex clinical situations.展开更多
To study the risk factors for early complications after pancreaticoduodenectomy （PD）. Methods： Two hundred patients undergoing PD at our hospital between December 1996 and September 2002 were reviewed retrospective...To study the risk factors for early complications after pancreaticoduodenectomy （PD）. Methods： Two hundred patients undergoing PD at our hospital between December 1996 and September 2002 were reviewed retrospectively. Standard PD was performed on 176 cases, standard PD with extended lymphadenectomy on 24 patients, whereas pylorus-preserving PD was not used. An end-toside combined with mucosa-to-mucosa pancreaticojejunostomy was performed on the patients with a hard pancreas and a dilated pancreatic duct, and a traditional end-to-end invagination pancreaticojejunostomy on the patients with a soft pancreas and a non-dilated duct. The risk factors with the potential to affect the incidence of complications were analyzed with SAS 8.12 software. Logistic regression was then used to determine the effect of multiple factors on early complications. Results： The overall rate of the major com- plications was 21% （42/200）, with the failure of pancreaticojejunal anastomosis being the most frequently encountered. Age （odds ratio [OR] 2.162）, diabetes mellitus （OR 4.086）, total serum bilirubin level （OR 7.556）, end-to-end pancreaticojejunostomy （OR 2.616）, T tube through the choledochojejunostomy （OR 0.100）, and blood transfusion over 1000 mL （OR 2.410） were the significant risk factors for the morbidity. Conclusion： The results from published series concerning morbidity after pancreaticoduodenectomy are not comparable because of lack of homogeneity between them. The knowledge of the complications rate in each particular department turns out essentially to provide the patient with tailored information about risks before surgery. Additionally, management of postoperative complications is essential for improving the results of this operation.展开更多
Pylorus-preserving pancreaticoduodenectomy （PPPD） is nowadays considered the treatment of choice for periampullary tumors, namely carcinoma of the head, neck, or uncinate process of the pancreas, the ampulla of Vate...Pylorus-preserving pancreaticoduodenectomy （PPPD） is nowadays considered the treatment of choice for periampullary tumors, namely carcinoma of the head, neck, or uncinate process of the pancreas, the ampulla of Vater, distal common bile duct or carcinoma of the peri-Vaterian duodenum. Delayed gastric emptying （DGE） comprises one of the most troublesome complications of this procedure. A search of the literature using Pubmed/IVledline was performed to identify clinical trials examining the incidence rate of DGE following standard Whipple pancreaticoduodenectomy （PD） vs PPPD. Additionally we performed a thorough in-depth analysis of the implicated pathomechanism underlying the occurrence of DGE after PPPD. In contrast to early studies, the majority of recently performed clinical trials demonstrated no significant association between the occurrence of DGE with either PD or PPPD. PD and PPPD procedures are equally effective operations regarding the postoperative occurrence of DGE. Further randomized trials are required to investigate the efficacy of a recently reported （but not yet tested in largescale studies） modification, that is, PPPD with antecolic duodenojejunostomy.展开更多
Pancreatic head cancer still represents an insurmountable barrier for patients and pancreatic surgeons.Pancreaticoduodenectomy(PD)continues to be the operative standard of care and potentially curative procedure for p...Pancreatic head cancer still represents an insurmountable barrier for patients and pancreatic surgeons.Pancreaticoduodenectomy(PD)continues to be the operative standard of care and potentially curative procedure for pancreatic head cancer.Despite the rapid development of minimally invasive techniques,whether the efficacy of minimally invasive pancreaticoduodenectomy(MIPD)is noninferior or superior to open pancreaticoduodenectomy(OPD)remains unclear.In this review,we summarized the history of OPD and MIPD and the latest staging and classification information for pancreatic head cancer as well as the proposed recommendations for MIPD indications for patients with pancreatic head cancer.By reviewing the MIPD-vs.OPD-related literature,we found that MIPD shows noninferiority or superiority to OPD in terms of safety,feasibility,enhanced recovery after surgery(ERAS)and several short-term and long-term outcomes.In addition,we analyzed and summarized the different MIPD outcomes in the USA,Europe and China.Certain debates over MIPD have continued,however,selection bias,the large number of low-volume centers,the steep MIPD learning curve,high conversion rate and administration of neoadjuvant therapy may limit the application of MIPD for pancreatic head cancer.展开更多
We present a case of afferent loop syndrome(ALS)occurring after pancreaticoduodenectomy(PD)in a patient who had previously undergone total gastrectomy(TG),and review the English-language literature concerning reconstr...We present a case of afferent loop syndrome(ALS)occurring after pancreaticoduodenectomy(PD)in a patient who had previously undergone total gastrectomy(TG),and review the English-language literature concerning reconstruction procedures following PD in patients who had undergone TG.The patient was a69-year-old man who had undergone TG reconstruction by a Roux-en-Y method at age 58 years.The patient underwent PD for pancreas head adenocarcinoma.A jejunal limb previously made at the prior TG was used for pancreaticojejunostomy and hepaticojejunostomy.Despite normal patency of the hepaticojejunostomy,he suffered from repeated postoperative cholangitis which was brought on by ALS due to shortness of the jejunal limb(15 cm in length).We therefore performed receliotomy in which the hepaticojejunostomy was disconnected and reconstructed using a new Y limb 40-cm in length constructed in a double Roux-en-Y fashion.The refractory cholangitis resolved immediately after the receliotomy and did not recur.Review of the literature revealed the lack of any current consensus for a standard procedure for reconstruction following PD in patients who had previously undergone TG.This issue warrants further attention,particularly given the expected future increase in the number of PDs in patients with a history of gastric cancer.展开更多
AIM To analyze the risk factors for pancreatic fistula after pancreaticoduodenectomy.METHODS We conducted a retrospective analysis of 539 successive cases of pancreaticoduodenectomy performed at our hospital from Marc...AIM To analyze the risk factors for pancreatic fistula after pancreaticoduodenectomy.METHODS We conducted a retrospective analysis of 539 successive cases of pancreaticoduodenectomy performed at our hospital from March 2012 to October 2015. Pancreatic fistula was diagnosed in strict accordance with the definition of pancreatic fistula from the International Study Group on Pancreatic Fistula. The risk factors for pancreatic fistula were analyzed by univariate analysis and multivariate logistic regression analysis.RESULTS A total of 269(49.9%) cases of pancreatic fistula occurred after pancreaticoduodenectomy,including 71(13.17%) cases of grade A pancreatic fistula,178(33.02%) cases of grade B,and 20(3.71%) cases of grade C. Univariate analysis showed no significant correlation between postoperative pancreatic fistula(POPF) and the following factors: age,hypertension,alcohol consumption,smoking,history of upper abdominal surgery,preoperative jaundice management,preoperative bilirubin,preoperative albumin,pancreatic duct drainage,intraoperative blood loss,operative time,intraoperative blood transfusion,Braun anastomosis,and pancreaticoduodenectomy(with or without pylorus preservation). Conversely,a significant correlation was observed between POPF and the following factors: gender(male vs female: 54.23% vs 42.35%,P = 0.008),diabetes(non-diabetic vs diabetic: 51.61% vs 39.19%,P = 0.047),body mass index(BMI)(≤ 25 vs > 25: 46.94% vs 57.82%,P = 0.024),blood glucose level(≤ 6.0 mmol/L vs > 6.0 mmol/L: 54.75% vs 41.14%,P = 0.002),pancreaticojejunal anastomosis technique(pancreatic duct-jejunum double-layer mucosa-to-mucosa pancreaticojejunal anastomosis vs pancreatic-jejunum single-layer mucosa-tomucosa anastomosis: 57.54% vs 35.46%,P = 0.000),diameter of the pancreatic duct(≤ 3 mm vs > 3 mm: 57.81% vs 38.36%,P = 0.000),and pancreatic texture(soft vs hard: 56.72% vs 29.93%,P = 0.000). Multivariate logistic regression analysis showed that gender(male),BMI > 25,pancreatic duct-jejunum double-layer mucosa-to-mucosa pancreaticojejunal anastomosis,pancreatic duct diameter ≤ 3 mm,and soft pancreas were risk factors for pancreatic fistula after pancreaticoduodenectomy.CONCLUSION Gender(male),BMI > 25,pancreatic duct-jejunum double-layer mucosa-to-mucosa pancreaticojejunal anastomosis,pancreatic duct diameter ≤ 3 mm,and soft pancreas were risk factors for pancreatic fistula after pancreaticoduodenectomy.展开更多
AIM:To investigate the effect of early enteral nutrition(EEN)combined with parenteral nutritional support in patients undergoing pancreaticoduodenectomy(PD).METHODS:From January 2006,all patients were given EEN combin...AIM:To investigate the effect of early enteral nutrition(EEN)combined with parenteral nutritional support in patients undergoing pancreaticoduodenectomy(PD).METHODS:From January 2006,all patients were given EEN combined with parenteral nutrition(PN)(EEN/PN group,n=107),while patients prior to this date were given total parenteral nutrition(TPN)(TPN group,n=67).Venous blood samples were obtained for a nutrition-associated assessment and liver function tests on the day before surgery and 6 d after surgery.The assessment of clinical outcome was based on postoperative complications.Follow-up for infectious and noninfectious complications was carried out for 30 d after hospital discharge.Readmission within 30 d afterdischarge was also recorded.RESULTS:Compared with the TPN group,a significant decrease in prealbumin(PAB)(P=0.023)was seen in the EEN/PN group.Total bilirubin(TB),direct bilirubin(DB)and lactate dehydrogenase(LDH)were significantly decreased on day 6 in the EEN/PN group(P=0.006,0.004 and 0.032,respectively).The rate of gradeⅠcomplications,gradeⅡcomplications and the length of postoperative hospital stay in the EEN/PN group were significantly decreased(P=0.036,0.028and 0.021,respectively),and no hospital mortality was observed in our study.Compared with the TPN group(58.2%),the rate of infectious complications in the EEN/PN group(39.3%)was significantly decreased(P=0.042).Eleven cases of delayed gastric emptying were noted in the TPN group,and 6 cases in the EEN/PN group.The rate of delayed gastric emptying and hyperglycemia was significantly reduced in the EEN/PN group(P=0.031 and P=0.040,respectively).CONCLUSION:Early enteral combined with PN can greatly improve liver function,reduce infectious complications and delayed gastric emptying,and shorten postoperative hospital stay in patients undergoing PD.展开更多
BACKGROUND Laparoscopy has been widely used in general surgical procedures,but total laparoscopic pancreaticoduodenectomy(TLPD)is still a complex and challenging surgery that is only performed in a small number of pat...BACKGROUND Laparoscopy has been widely used in general surgical procedures,but total laparoscopic pancreaticoduodenectomy(TLPD)is still a complex and challenging surgery that is only performed in a small number of patients at a few large academic medical centers.Although the safety and feasibility of TLPD have been established,few studies have compared it with open pancreaticoduodenectomy(OPD)with regard to perioperative and oncological outcomes.Therefore,we carried out a meta-analysis to evaluate whether TLPD is superior to OPD.AIM To compare the treatment outcomes of TLPD and OPD in order to assess the safety and feasibility of TLPD.METHODS We conducted a systematic search of studies comparing TLPD with OPD that were published in the PubMed,EMBASE,and Cochrane Library databases through December 31,2018.The studies comparing TLPD and OPD with at least one of the outcomes we were interested in and with more than 10 cases in each group were included in this analysis.The Newcastle-Ottawa scale was used to assess the quality of the nonrandomized controlled trials and the Jadad scale was used to assess the randomized controlled trials.Intraoperative data,postoperative complications,and oncologic outcomes were evaluated.The metaanalysis was performed using Review Manager Software version 5.3.Random or fixed-effects meta-analyses were undertaken to measure the pooled estimates.RESULTS A total of 4790 articles were initially identified for our study.After screening,4762 articles were excluded and 28 studies representing 39771 patients(3543 undergoing TLPD and 36228 undergoing OPD)were eventually included.Patients who underwent TLPD had less intraoperative blood loss[weighted mean difference(WMD)=-260.08 mL,95%confidence interval(CI):(-336.02,-184.14)mL,P<0.00001],a lower blood transfusion rate[odds ratio(OR)=0.51,95%CI:0.36-0.72,P=0.0001],a lower perioperative overall morbidity(OR=0.82,95%CI:0.73-0.92,P=0.0008),a lower wound infection rate(OR=0.48,95%CI:0.34-0.67,P<0.0001),a lower pneumonia rate(OR=0.72,95%CI:0.60-0.85,P=0.0002),a shorter duration of intensive care unit(ICU)stay[WMD=-0.28 d,95%CI(-2.88,-1.29)d,P<0.00001]and a shorter length of hospital stay[WMD=-3.05 d,95%CI(-3.93,-2.17),P<0.00001],a lower rate of discharge to a new facility(OR=0.55,95%CI:0.39-0.78,P=0.0008),and a lower 30-d readmission rate(OR=0.81,95%CI:0.68-0.95,P=0.10)than those who underwent OPD.In addition,the TLPD group had a higher R0 rate(OR=1.28,95%CI:1.13-1.44,P=0.0001)and more lymph nodes harvested(WMD=1.32,95%CI:0.57-2.06,P=0.0005)than the OPD group.However,the patients who underwent TLPD experienced a significantly longer operative time(WMD=77.92 min,95%CI:40.89-114.95,P<0.0001)and had a smaller tumor size than those who underwent OPD[WMD=-0.32 cm,95%CI:(-0.58,-0.07)cm,P=0.01].There were no significant differences between the two groups in the major morbidity,postoperative pancreatic fistula,delayed gastric emptying,postpancreatectomy hemorrhage,bile leak,gastroenteric anastomosis fistula,intra-abdominal abscess,bowel obstruction,fluid collection,reoperation,ICU admission,or 30-d and 90-d mortality rates.For malignant tumors,the 1-,2-,3-,4-and 5-year overall survival rates were not significantly different between the two groups.CONCLUSION This meta-analysis indicates that TLPD is safe and feasible,and may be a desirable alternative to OPD,although a longer operative time is needed and only smaller tumors can be treated.展开更多
AIM: To establish a scoring system to predict clinicallyrelevant postoperative pancreatic fistula(CR-POPF)after pancreaticoduodenectomy(PD).METHODS: The clinical records of 921 consecutive patients who underwent PD be...AIM: To establish a scoring system to predict clinicallyrelevant postoperative pancreatic fistula(CR-POPF)after pancreaticoduodenectomy(PD).METHODS: The clinical records of 921 consecutive patients who underwent PD between 2008 and 2013 were reviewed retrospectively. Postoperative pancreatic fistula(POPF) was defined and classified by the international study group of pancreatic fistula(ISGPF).We used a logistic regression model to determine the independent risk factors of CR-POPF and developed a scoring system based on the regression coefficient of the logistic regression model. The optimal cut-off value to divide the risk strata was determined by the Youden index. The patients were divided into two groups(low risk and high risk). The independent sample t test was used to detect differences in the means of drain amylase on postoperative day(POD) 1, 2 and 3. The optimal cut-off level of the drain amylase to distinguish CR-POPF from non-clinical POPF in the two risk strata groups was determined using the receiver operating characteristic(ROC) curves.RESULTS: Grade A POPF occurred in 106(11.5%)patients, grade B occurred in 57(6.2%) patients,and grade C occurred in 32(3.5%) patients. A predictive scoring system for CR-POPF(0-6 points) was constructed using the following four factors: 1 point for each body mass index ≥ 28 [odds ratio(OR) = 3.86;95% confidence interval(CI): 1.92-7.75, P = 0.00],soft gland texture(OR = 4.50; 95%CI, 2.53-7.98, P =0.00), and the difference between the blood loss and transfusion in operation ≥ 800 mL(OR = 3.45; 95%CI,1.92-7.75, P = 0.00); and from 0 points for a 5 mm or greater duct diameter to 3 points for a less than 2 mm duct(OR = 8.97; 95%CI: 3.70-21.77, P = 0.00). The ROC curve showed that the area under the curve of this score was 0.812. A score of 3 points was suggested to be the best cut-off value(Youden index = 0.485). In the low risk group, a drain amylase level ≥ 3600 U/L on POD3 could distinguish CR-POPF from non-clinicalPOPF(the sensitivity and specificity were 75% and85%, respectively). In the high risk group, the best cutoff was a drain amylase level of 1600(the sensitivity and specificity were 77 and 63%, respectively).CONCLUSION: A 6-point scoring system accurately predicted the occurrence of CR-POPF. In addition, a drain amylase level on POD3 might be a predictor of this complication.展开更多
AIM:To compare laparoscopic pancreaticoduodenectomy(TLPD) during the initial learning curve with open pancreaticoduodenectomy in terms of outcome and costs.METHODS:This is a retrospective review of the consecutive pat...AIM:To compare laparoscopic pancreaticoduodenectomy(TLPD) during the initial learning curve with open pancreaticoduodenectomy in terms of outcome and costs.METHODS:This is a retrospective review of the consecutive patients who underwent TLPD between December 2009 and April 2014 at our institution.The experiences of the initial 15 consecutive TLPD cases,considered as the initial learning curve of each surgeon,were compared with the same number of consecutive laparotomy cases with the same spectrum of diseases in terms of outcome and costs.Laparoscopic patients with conversion to open surgery were excluded.Preoperative demographic and comorbidity data were obtained.Postoperative data on intestinal movement,pain score,mortality,complications,and costs were obtained for analysis.Complications related to surgery included pneumonia, intra-abdominal abscess,postpancreatectomy hemorrhage,biliary leak,pancreatic fistula,delayed gastric emptying,and multiple organ dysfunction syndrome.The total costs consisted of cost of surgery,anesthesia,and admission examination.RESULTS:A total of 60 patients,including 30 consecutive laparoscopic cases and 30 consecutive open cases,were enrolled for review.Demographic and comorbidity characteristics of the two groups were similar.TLPD required a significantly longer operative time(513.17 ± 56.13 min vs 371.67 ± 85.53 min,P < 0.001).The TLPD group had significantly fewer mean numbers of days until bowel sounds returned(2.03 ± 0.55 d vs 3.83 ± 0.59 d,P < 0.001) and exhaustion(4.17 ± 0.75 d vs 5.37 ± 0.81 d,P < 0.001).The mean visual analogue score on postoperative day 4 was less in the TLPD group(3.5 ± 9.7 vs 4.47 ± 1.11,P < 0.05).No differences in surgery-related morbidities and mortality were observed between the two groups.Patients in the TLPD group recovered more quickly and required a shorter hospital stay after surgery(9.97 ± 3.74 d vs 11.87 ± 4.72 d,P < 0.05).A significant difference in the total cost was found between the two groups(TLPD 81317.43 ± 2027.60 RMB vs laparotomy 78433.23 ± 5788.12 RMB,P < 0.05).TLPD had a statistically higher cost for both surgery(24732.13 ± 929.28 RMB vs 19317.53 ± 795.94 RMB,P < 0.001)and anesthesia(6192.37 ± 272.77 RMB vs 5184.10 ± 146.93 RMB,P < 0.001),but a reduced cost for admission examination(50392.93 ± 1761.22 RMB vs 53931.60 ± 5556.94 RMB,P < 0.05).CONCLUSION:TLPD is safe when performed by experienced pancreatobiliary surgeons during the initial learning curve,but has a higher cost than open pancreaticoduodenectomy.展开更多
文摘Postoperative bleeding(POB)is a major complication following pancreaticoduodenectomy(PD),leading to significant morbidity and potential mortality.This minireview focuses on the prevention and management strategies for POB,synthesizing current evidence on surgical techniques,perioperative management,and postoperative interventions.Effective prevention strategies include the use of regional vessel wrapping,optimal pancreatic anastomosis,and meticulous intraoperative hemostasis.Postoperative management strategies,such as early detection using predictive models and advanced imaging,along with endovascular interventions like angiographic embolization and stent graft placement,are essential for timely intervention.Risk factors,including pancreatic texture,anticoagulation therapy,and patient comorbidities,further influence bleeding outcomes.The minireview also identifies gaps in current research and emphasizes the need for prospective randomized controlled trials to establish standardized protocols.Overall,a multidisciplinary approach combining surgical expertise,predictive analytics,and personalized care is essential to improving patient out comes and minimizing the risk of POB following PD.
文摘BACKGROUND Acute pancreatitis(AP)is a potentially life-threatening complication of pancreaticoduodenectomy that increases morbidity and mortality in patients.Interleukin-17A(IL-17a)the potential preoperative marker for predicting postoperative outcomes.The purpose of this study is to retrospectively assess the prognostic value of preoperative IL-17a level in prediction of AP and related postoperative pancreatic fistula(POPF)following pancreaticoduodenectomy.AIM To retrospectively assess the prognostic value of preoperative IL-17a levels in predicting AP and related POPF following pancreaticoduodenectomy.METHODS Retrospective analysis of pancreaticoduodenectomies performed on patients 150 patients between 2017 and 2023.Clinical data including pre-operative IL-17a levels were collected.The primary composite outcomes were postoperative AP and postoperative pancreatic(PP),and the predictive performances of IL-17a levels and fluid load status for postoperative complications were evaluated by statistical analysis.RESULTS A total of 150 patients were included,and 26 patients(17.3%)developed postoperative AP and 34 patients(22.7%)developed PP.Preoperative IL-17a was a risk factor for postoperative AP(P=0.03).Furthermore,excessive intraoperative fluid load was a significantly associated(P=0.01)with PP.The model(IL-17a levels+fluid load status)was highly accurate.CONCLUSION Preoperative IL-17a levels and intravascular volume status may serve as useful predictors of AP and subsequent PP following PD.These parameters provide means to evaluate preoperative risk and may guide clinical decision making to enhance postoperative recovery.
文摘BACKGROUND Postoperative pancreatic fistula(POPF)is the most frequent cause of morbimortality after pancreaticoduodenectomy,but the best technique to use to prevent its development is unclear.The choice of drainage method external duct stent(EDS),internal duct stent(IDS),or non-ductal stent(NDS)is also controversial.AIM To compare the three groups(EDS,IDS and NDS),analyzing the patient characteristics,perioperative examinations and survival.METHODS Patients who underwent pancreaticoduodenectomy and pancreaticojejunostomy between 2012 and 2020,were divided into the EDS,IDS and NDS groups.RESULTS Of the 244 patients included,129 were in the EDS group,71 in the IDS group,and 44 in the NDS group.Except for preoperative pancreatitis in the NDS patients,comorbidities were similar among the groups.Patients in the NDS group had a high caliber of the Wirsung duct and frequently presented with a hard pancreas(P<0.001).A lower rate of grade C POPF was observed in the EDS(1.6%)compared to the NDS(9.1%)and IDS group(14.1%)(P=0.009).The groups showed similar findings for delayed gastric emptying,postoperative hemorrhage,reoperation,and 5-year survivals.Ninety-day mortality rate was significantly higher in the IDS group(5.6%)compared to the EDS(1.6%)and NDS(4.5%)groups(P=0.046).Multivariate analysis showed that the use of EDS was a protective factor for grade B/C POPF(P=0.034),and 90-day mortality(P=0.018).Additionally,a Wirsung duct diameter<3 mm was the only risk factor for grade B/C POPF(P=0.001),and 90-day mortality(P=0.031).CONCLUSION The use of the EDS was a protective factor for grade B/C POPF and 90-day mortality,and the Wirsung duct<3 mm was a risk factor for grade B/C POPF and 90-day mortality.
文摘Background:Laparoscopic pancreaticoduodenectomy(LPD)has gained growing acceptance for the resection of periampullary carcinoma.However,postoperative ascites(POA)frequently occurs after LPD,yet little is known about the underlying factors that promote POA under this laparoscopic approach.This study aimed to explore the clinical influence of POA after LPD and its potential predictors.Methods:Patients diagnosed with periampullary carcinoma who subsequently underwent LPD from December 2015 to February 2023 were reviewed.Patients were assigned to the two groups by whether daily abdominal drainage>500 mL for at least three consecutive days,followed by subgroup analysis of pancreatic fistula(PF)-POA and non-PF-POA.Variables,including preoperative laboratory tests,past history,surgery-related factors,and incidence of complications,were compared.In addition,logistic regression analysis was applied to reveal the potential independent risk factors for PF-POA and non-PF-POA.Results:A total of 38 patients(17.4%)developed POA,with 17 having PF-POA and 21 having non-PF-POA.Patients with grade B PF-POA experienced a higher incidence of intra-abdominal infection,and a longer hospital stay compared with other groups.Multivariate analysis demonstrated that prothrombin time>14 s and main pancreatic duct diameter<3 mm were independent risk factors for PF-POA.Moreover,male sex,total bilirubin>34.2μmol/L and platelet count<100×10^(9)/L were independent risk factors for non-PF-POA.The areas under the receiver operating characteristic curve were 0.682 and 0.786 for predicting PF-POA and non-PF-POA,respectively.Conclusions:LPD recovery and postoperative complications are impacted by POA,where PF-POA is the most clinically relevant POA.Prolonged prothrombin time and narrowed main pancreatic duct were independent risk factors for PF-POA;male sex,elevated total bilirubin level,and decreased platelet count were independent risk factors for non-PF-POA.
文摘BACKGROUND This study aimed to compare and analyze risk factors for pancreatic fistula following pancreaticoduodenectomy(PD)using different definition criteria,and to develop a predictive model for standardized pancreatic fistula risk assessment.AIM To identify and compare risk factors for postoperative pancreatic fistula(POPF)following PD using both the 2005 International Study Group of Pancreatic Fistula and updated 2016 International Study Group on Pancreatic Surgery diagnostic criteria,and to develop a clinically applicable predictive model based on objective preoperative parameters for standardized pancreatic fistula risk assessment and perioperative management optimization.METHODS We conducted a retrospective analysis of 303 patients who underwent PD at CR&WISCO General Hospital between January 2017 and May 2023.POPF cases were classified according to both previous and updated diagnostic standards.For statistical analysis,we employed t-tests or Mann-Whitney U tests for continuous variables andχ^(2) tests for categorical data.To identify risk factors associated with POPF under both classification systems,we performed univariate and multivariate logistic regression analyses.RESULTS Univariate analysis identified several factors associated with POPF:Main pancreatic duct diameter(χ^(2)=31.641,P<0.001),main pancreatic duct index(χ^(2)=52.777,P<0.001),portal vein invasion(χ^(2)=6.259,P=0.012),intra-abdominal fat thickness(χ^(2)=7.665,P=0.006),preoperative biliary drainage(χ^(2)=5.999,P=0.014),pancreatic characteristics(χ^(2)=5.544,P=0.019),pancreatic resection margin thickness(t=2.055,P=0.032),pancreatic computed tomography(CT)value(t=-3.224,P=0.002),and preoperative blood amylase level(Z=-2.099,P=0.036).Multivariate logistic regression identified three independent risk factors:Main pancreatic duct index[odds ratio(OR)=0.000,95%confidence interval(CI):0.000-0.011],pancreatic cancer[OR=4.843,95%CI:1.285-18.254],and pancreatic CT value[OR=0.869,95%CI:0.806-0.937](all P<0.05).CONCLUSION The main pancreatic duct index and pancreatic CT value are strongly correlated with pancreatic fistula development after PD.
基金Supported by the Shandong Provincial Natural Science Foundation General Project,No.ZR2020MH248.
文摘BACKGROUND Objective and accurate assessment of blood loss during pancreaticoduodenectomy(PD)is crucial for ensuring the safety and efficacy of the procedure.While the visual method remains the most common clinical metric,many scholars argue that it significantly differs from actual blood loss and is inherently subjective.AIM To assess blood loss in PD via delta hemoglobin(ΔHb)and compare it with the visual method to predict bleeding-related risk factors.METHODS In this retrospective analysis,1722 patients who underwent PD from 2017 to 2022 at Shandong Provincial Hospital were divided into three groups:Open PD(OPD),laparoscopic PD(LPD),and conversion to OPD(CTOPD).IntraoperativeΔHb(IΔHb)was calculated via preoperative and 72-hour-postoperative hemoglobin concentrations,and its association with visually obtained estimated blood loss(EBL)was analyzed.PerioperativeΔHb(PΔHb)was calculated via preoperative and predischarge hemoglobin concentrations.We compared the differences in IΔHb and PΔHb among the three groups,and performed univariate and multi-variate regression analyses of IΔHb and PΔHb.RESULTS The preoperative general information of patients showed no statistically si-gnificant difference among the three groups(P>0.05).The IΔHb in the OPD,LPD,and CTOPD groups were 22.00(12.00,36.00),21.00(10.00,33.00),and 33.00(18.12,52.24)g/L,respectively;And the PΔHb in the OPD,LPD,and CTOPD groups were 25.87(13.51,42.00),25.00(14.00,45.00),and 37.48(21.64,59.65)g/L,respectively,values significantly differed(P<0.05).IΔHb and EBL were significantly correlated(r=0.337,P<0.001).The results of univariate and multivariate regression analyses indicated that American Society of Anesthesiologists(ASA)classification IV[95%confidence interval(CI):2.330-37.811,P=0.049]and preoperative total bilirubin>200μmol/L(95%CI:2.805-8.673,P<0.001)were independent risk factors for IΔHb(P<0.05),and ASA classification IV(95%CI:45.934-105.485,P<0.001),body mass index>24 kg/m2(95%CI:1.285-9.890,P=0.011),and preoperative total bilirubin>200μmol/L(95%CI:6.948-16.797,P<0.001)were independent risk factors for PΔHb(P<0.05).CONCLUSION There is a correlation between IΔHb and EBL in PD,so we can assess the patients’intraoperative blood loss by theΔHb method.ASA classification IV,body mass index>24 kg/m²,and preoperative total bilirubin>200μmol/L increased perioperative bleeding risk.
文摘BACKGROUND The International Study Group of Pancreatic Surgery has established the defi-nition and grading system for postpancreatectomy acute pancreatitis(PPAP).There are no established machine learning models for predicting PPAP following pancreaticoduodenectomy(PD).AIM To explore the predictive model of PPAP,and test its predictive efficacy to guide the clinical work.METHODS Clinical data from consecutive patients who underwent PD between 2016 and 2024 were retrospectively collected.An analysis of PPAP risk factors was performed,various machine learning algorithms[logistic regression,random forest,gradient boosting decision tree,extreme gradient boosting,light gradient boosting machine,and category boosting(CatBoost)]were utilized to develop predictive models.Recursive feature elimination was employed to select several variables to achieve the optimal machine algorithm.RESULTS The study included 381 patients,of whom 88(23.09%)developed PPAP.PPAP patients exhibited a significantly higher incidence of postoperative pancreatic fistula(55.68%vs 14.68%,P<0.001),grade C postoperative pancreatic fistula(9.09%vs 1.37%,P=0.001).The CatBoost algorithm outperformed other algorithms with a mean area under the receiver operating characteristic curve of 0.859[95%confidence interval(CI):0.814-0.905]in the training cohort and 0.822(95%CI:0.717-0.927)in the testing cohort.According to shapley additive explanations analysis,pancreatic texture,main pancreatic duct diameter,body mass index,estimated blood loss,and surgery time were the most important variables based on recursive feature elimination.The CatBoost algorithm based on selected variables demonstrated superior performance,with an area under the receiver operating characteristic curve of 0.837(95%CI:0.788-0.886)in the training cohort and 0.812(95%CI:0.697-0.927)in the testing cohort.CONCLUSION We developed the first machine learning-based predictive model for PPAP following PD.This predictive model can assist surgeons in anticipating and managing this complication proactively.
基金supported by grants from the Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences(2019-I2M-5–056)the National Natural Science Foundation of China(81930119,82090050,and 82090053)。
文摘Background:The prediction of postoperative pancreatic fistula(POPF)is important.This study aimed to investigate the role of postoperative serum lipase level in predicting POPF.Methods:Data from 234 consecutive patients who underwent pancreaticoduodenectomy(PD)were collected.The predictive values of serum amylase and serum lipase during postoperative days(PODs)1 to 3 for POPF were compared.Subgroup analyses were performed to determine the prognostic value of different levels and durations of elevated serum lipase.Results:Fifty-six patients developed POPF.The POPF group exhibited increased levels of serum amylase and lipase from PODs 1 to 3(all P<0.001).Compared with serum amylase,serum lipase has greater predictive value for POPF.Specifically,serum lipase had the highest area under the receiver operating characteristic curve(AUC)at POD 1(0.791).Body mass index>24 kg/m2[odds ratio(OR)=2.431,95%confidence interval(CI):1.094–5.404,P=0.029],soft pancreatic texture(OR=3.189,95%CI:1.263–8.056,P=0.014),serum lipase>60 U/L at POD 1(OR=5.135,95%CI:1.257–20.982,P=0.023),and C-reactive protein>167 mg/dL at POD 3(OR=3.607,95%CI:1.431–9.090,P=0.007)were identified as independent risk factors for POPF.Patients with serum lipase≤60 U/L at POD 1(n=104)exhibited lower rates of POPF(3.8%vs.40.0%,P<0.001)and severe complications(Clavien-Dindo≥IIIa)(4.8%vs.25.4%,P<0.001)than those with serum lipase>60 U/L at POD 1.Moreover,no additional elevation or duration of serum lipase offered any further prognostic value.Conclusions:Postoperative serum lipase outperformed serum amylase in the prediction of POPF,and patients with normal serum lipase level at POD 1 had favorable outcomes.A sustained increase in the serum lipase level offers no additional prognostic value.
基金Supported by National Natural Science Foundation of China,No.82273442.
文摘BACKGROUND Non-alcoholic fatty liver disease(NAFLD)is characterized by the accumulation of fat in the liver in individuals who do not consume alcohol.Several risk factors influencing the onset of NAFLD after laparoscopic pancreaticoduodenectomy(LPD)have been identified.This study investigated the risk factors associated with the development of fatty liver after laparoscopic duodenum-preserving pancreatic total head resection(LDPPHRt)and LPD.AIM To compare the effects of LDPPHRt and LPD on the development of postoperative NAFLD.METHODS This retrospective cohort study included 59 patients who were histologically diagnosed with benign or low-grade malignant pancreatic tumors and who underwent laparoscopic pancreatic surgery(LDPPHRt or LPD)between May 2020 and April 2023.Patient data on perioperative and postoperative variables were analyzed and compared.Multivariate logistic regression was used to identify pre-,peri-,and postoperative risk factors for NAFLD,with statistical significance set at P<0.05.RESULTS Of the 59 patients included in the study,17(28.8%)developed NAFLD within 6-12 months post-surgery.The incidence of NAFLD was significantly higher in the LPD group compared to the LDPPHRt group(40.0%vs 12.5%,P=0.022).Multivariable analysis identified the LDPPHRt surgical approach(compared to LPD)as an independent protective factor against the development of postoperative NAFLD,with an odds ratio of 0.208(95%confidence interval:0.046-0.931;P=0.040).CONCLUSION Our findings indicate that LDPPHRt is more effective than LPD in reducing the incidence of postoperative NAFLD,which may inform surgical decision-making and optimize patient outcomes after laparoscopic pancreatic surgery.
文摘We report the successful application of a surgical and medical co‐management(SMC)strategy in an 82‐year‐old man with hemophilia A(HA)undergoing pancreaticoduodenectomy for pancreatic head carcinoma.No major complications or perioperative bleeding occurred.Optimal management of HA patients undergoing major surgery requires multidisciplinary coordination to avoid postoperative complications.The SMC team integrates internists(who assess chronic disease status,adjust medications,and determine best hemostatic therapies)and surgeons(who evaluate the surgical feasibility of procedures and rely on advanced surgical skills)to improve perioperative planning to minimize complications and promote recovery.This case illustrates the utility of a shift from passive and conservative treatment to active and preventive treatment and highlights the value of SMC in many complex clinical situations.
文摘To study the risk factors for early complications after pancreaticoduodenectomy （PD）. Methods： Two hundred patients undergoing PD at our hospital between December 1996 and September 2002 were reviewed retrospectively. Standard PD was performed on 176 cases, standard PD with extended lymphadenectomy on 24 patients, whereas pylorus-preserving PD was not used. An end-toside combined with mucosa-to-mucosa pancreaticojejunostomy was performed on the patients with a hard pancreas and a dilated pancreatic duct, and a traditional end-to-end invagination pancreaticojejunostomy on the patients with a soft pancreas and a non-dilated duct. The risk factors with the potential to affect the incidence of complications were analyzed with SAS 8.12 software. Logistic regression was then used to determine the effect of multiple factors on early complications. Results： The overall rate of the major com- plications was 21% （42/200）, with the failure of pancreaticojejunal anastomosis being the most frequently encountered. Age （odds ratio [OR] 2.162）, diabetes mellitus （OR 4.086）, total serum bilirubin level （OR 7.556）, end-to-end pancreaticojejunostomy （OR 2.616）, T tube through the choledochojejunostomy （OR 0.100）, and blood transfusion over 1000 mL （OR 2.410） were the significant risk factors for the morbidity. Conclusion： The results from published series concerning morbidity after pancreaticoduodenectomy are not comparable because of lack of homogeneity between them. The knowledge of the complications rate in each particular department turns out essentially to provide the patient with tailored information about risks before surgery. Additionally, management of postoperative complications is essential for improving the results of this operation.
文摘Pylorus-preserving pancreaticoduodenectomy （PPPD） is nowadays considered the treatment of choice for periampullary tumors, namely carcinoma of the head, neck, or uncinate process of the pancreas, the ampulla of Vater, distal common bile duct or carcinoma of the peri-Vaterian duodenum. Delayed gastric emptying （DGE） comprises one of the most troublesome complications of this procedure. A search of the literature using Pubmed/IVledline was performed to identify clinical trials examining the incidence rate of DGE following standard Whipple pancreaticoduodenectomy （PD） vs PPPD. Additionally we performed a thorough in-depth analysis of the implicated pathomechanism underlying the occurrence of DGE after PPPD. In contrast to early studies, the majority of recently performed clinical trials demonstrated no significant association between the occurrence of DGE with either PD or PPPD. PD and PPPD procedures are equally effective operations regarding the postoperative occurrence of DGE. Further randomized trials are required to investigate the efficacy of a recently reported （but not yet tested in largescale studies） modification, that is, PPPD with antecolic duodenojejunostomy.
基金supported by grants from the National Natural Science Foundation of China (No. 81772639, No. 81802475)Natural Science Foundation of Beijing (No. 7192157)China Postdoctoral Science Foundation (No. 198831)
文摘Pancreatic head cancer still represents an insurmountable barrier for patients and pancreatic surgeons.Pancreaticoduodenectomy(PD)continues to be the operative standard of care and potentially curative procedure for pancreatic head cancer.Despite the rapid development of minimally invasive techniques,whether the efficacy of minimally invasive pancreaticoduodenectomy(MIPD)is noninferior or superior to open pancreaticoduodenectomy(OPD)remains unclear.In this review,we summarized the history of OPD and MIPD and the latest staging and classification information for pancreatic head cancer as well as the proposed recommendations for MIPD indications for patients with pancreatic head cancer.By reviewing the MIPD-vs.OPD-related literature,we found that MIPD shows noninferiority or superiority to OPD in terms of safety,feasibility,enhanced recovery after surgery(ERAS)and several short-term and long-term outcomes.In addition,we analyzed and summarized the different MIPD outcomes in the USA,Europe and China.Certain debates over MIPD have continued,however,selection bias,the large number of low-volume centers,the steep MIPD learning curve,high conversion rate and administration of neoadjuvant therapy may limit the application of MIPD for pancreatic head cancer.
文摘We present a case of afferent loop syndrome(ALS)occurring after pancreaticoduodenectomy(PD)in a patient who had previously undergone total gastrectomy(TG),and review the English-language literature concerning reconstruction procedures following PD in patients who had undergone TG.The patient was a69-year-old man who had undergone TG reconstruction by a Roux-en-Y method at age 58 years.The patient underwent PD for pancreas head adenocarcinoma.A jejunal limb previously made at the prior TG was used for pancreaticojejunostomy and hepaticojejunostomy.Despite normal patency of the hepaticojejunostomy,he suffered from repeated postoperative cholangitis which was brought on by ALS due to shortness of the jejunal limb(15 cm in length).We therefore performed receliotomy in which the hepaticojejunostomy was disconnected and reconstructed using a new Y limb 40-cm in length constructed in a double Roux-en-Y fashion.The refractory cholangitis resolved immediately after the receliotomy and did not recur.Review of the literature revealed the lack of any current consensus for a standard procedure for reconstruction following PD in patients who had previously undergone TG.This issue warrants further attention,particularly given the expected future increase in the number of PDs in patients with a history of gastric cancer.
文摘AIM To analyze the risk factors for pancreatic fistula after pancreaticoduodenectomy.METHODS We conducted a retrospective analysis of 539 successive cases of pancreaticoduodenectomy performed at our hospital from March 2012 to October 2015. Pancreatic fistula was diagnosed in strict accordance with the definition of pancreatic fistula from the International Study Group on Pancreatic Fistula. The risk factors for pancreatic fistula were analyzed by univariate analysis and multivariate logistic regression analysis.RESULTS A total of 269(49.9%) cases of pancreatic fistula occurred after pancreaticoduodenectomy,including 71(13.17%) cases of grade A pancreatic fistula,178(33.02%) cases of grade B,and 20(3.71%) cases of grade C. Univariate analysis showed no significant correlation between postoperative pancreatic fistula(POPF) and the following factors: age,hypertension,alcohol consumption,smoking,history of upper abdominal surgery,preoperative jaundice management,preoperative bilirubin,preoperative albumin,pancreatic duct drainage,intraoperative blood loss,operative time,intraoperative blood transfusion,Braun anastomosis,and pancreaticoduodenectomy(with or without pylorus preservation). Conversely,a significant correlation was observed between POPF and the following factors: gender(male vs female: 54.23% vs 42.35%,P = 0.008),diabetes(non-diabetic vs diabetic: 51.61% vs 39.19%,P = 0.047),body mass index(BMI)(≤ 25 vs > 25: 46.94% vs 57.82%,P = 0.024),blood glucose level(≤ 6.0 mmol/L vs > 6.0 mmol/L: 54.75% vs 41.14%,P = 0.002),pancreaticojejunal anastomosis technique(pancreatic duct-jejunum double-layer mucosa-to-mucosa pancreaticojejunal anastomosis vs pancreatic-jejunum single-layer mucosa-tomucosa anastomosis: 57.54% vs 35.46%,P = 0.000),diameter of the pancreatic duct(≤ 3 mm vs > 3 mm: 57.81% vs 38.36%,P = 0.000),and pancreatic texture(soft vs hard: 56.72% vs 29.93%,P = 0.000). Multivariate logistic regression analysis showed that gender(male),BMI > 25,pancreatic duct-jejunum double-layer mucosa-to-mucosa pancreaticojejunal anastomosis,pancreatic duct diameter ≤ 3 mm,and soft pancreas were risk factors for pancreatic fistula after pancreaticoduodenectomy.CONCLUSION Gender(male),BMI > 25,pancreatic duct-jejunum double-layer mucosa-to-mucosa pancreaticojejunal anastomosis,pancreatic duct diameter ≤ 3 mm,and soft pancreas were risk factors for pancreatic fistula after pancreaticoduodenectomy.
基金Supported by Grants from Jiangsu Provincial GovernmentChinaNo.ZX200605
文摘AIM:To investigate the effect of early enteral nutrition(EEN)combined with parenteral nutritional support in patients undergoing pancreaticoduodenectomy(PD).METHODS:From January 2006,all patients were given EEN combined with parenteral nutrition(PN)(EEN/PN group,n=107),while patients prior to this date were given total parenteral nutrition(TPN)(TPN group,n=67).Venous blood samples were obtained for a nutrition-associated assessment and liver function tests on the day before surgery and 6 d after surgery.The assessment of clinical outcome was based on postoperative complications.Follow-up for infectious and noninfectious complications was carried out for 30 d after hospital discharge.Readmission within 30 d afterdischarge was also recorded.RESULTS:Compared with the TPN group,a significant decrease in prealbumin(PAB)(P=0.023)was seen in the EEN/PN group.Total bilirubin(TB),direct bilirubin(DB)and lactate dehydrogenase(LDH)were significantly decreased on day 6 in the EEN/PN group(P=0.006,0.004 and 0.032,respectively).The rate of gradeⅠcomplications,gradeⅡcomplications and the length of postoperative hospital stay in the EEN/PN group were significantly decreased(P=0.036,0.028and 0.021,respectively),and no hospital mortality was observed in our study.Compared with the TPN group(58.2%),the rate of infectious complications in the EEN/PN group(39.3%)was significantly decreased(P=0.042).Eleven cases of delayed gastric emptying were noted in the TPN group,and 6 cases in the EEN/PN group.The rate of delayed gastric emptying and hyperglycemia was significantly reduced in the EEN/PN group(P=0.031 and P=0.040,respectively).CONCLUSION:Early enteral combined with PN can greatly improve liver function,reduce infectious complications and delayed gastric emptying,and shorten postoperative hospital stay in patients undergoing PD.
文摘BACKGROUND Laparoscopy has been widely used in general surgical procedures,but total laparoscopic pancreaticoduodenectomy(TLPD)is still a complex and challenging surgery that is only performed in a small number of patients at a few large academic medical centers.Although the safety and feasibility of TLPD have been established,few studies have compared it with open pancreaticoduodenectomy(OPD)with regard to perioperative and oncological outcomes.Therefore,we carried out a meta-analysis to evaluate whether TLPD is superior to OPD.AIM To compare the treatment outcomes of TLPD and OPD in order to assess the safety and feasibility of TLPD.METHODS We conducted a systematic search of studies comparing TLPD with OPD that were published in the PubMed,EMBASE,and Cochrane Library databases through December 31,2018.The studies comparing TLPD and OPD with at least one of the outcomes we were interested in and with more than 10 cases in each group were included in this analysis.The Newcastle-Ottawa scale was used to assess the quality of the nonrandomized controlled trials and the Jadad scale was used to assess the randomized controlled trials.Intraoperative data,postoperative complications,and oncologic outcomes were evaluated.The metaanalysis was performed using Review Manager Software version 5.3.Random or fixed-effects meta-analyses were undertaken to measure the pooled estimates.RESULTS A total of 4790 articles were initially identified for our study.After screening,4762 articles were excluded and 28 studies representing 39771 patients(3543 undergoing TLPD and 36228 undergoing OPD)were eventually included.Patients who underwent TLPD had less intraoperative blood loss[weighted mean difference(WMD)=-260.08 mL,95%confidence interval(CI):(-336.02,-184.14)mL,P<0.00001],a lower blood transfusion rate[odds ratio(OR)=0.51,95%CI:0.36-0.72,P=0.0001],a lower perioperative overall morbidity(OR=0.82,95%CI:0.73-0.92,P=0.0008),a lower wound infection rate(OR=0.48,95%CI:0.34-0.67,P<0.0001),a lower pneumonia rate(OR=0.72,95%CI:0.60-0.85,P=0.0002),a shorter duration of intensive care unit(ICU)stay[WMD=-0.28 d,95%CI(-2.88,-1.29)d,P<0.00001]and a shorter length of hospital stay[WMD=-3.05 d,95%CI(-3.93,-2.17),P<0.00001],a lower rate of discharge to a new facility(OR=0.55,95%CI:0.39-0.78,P=0.0008),and a lower 30-d readmission rate(OR=0.81,95%CI:0.68-0.95,P=0.10)than those who underwent OPD.In addition,the TLPD group had a higher R0 rate(OR=1.28,95%CI:1.13-1.44,P=0.0001)and more lymph nodes harvested(WMD=1.32,95%CI:0.57-2.06,P=0.0005)than the OPD group.However,the patients who underwent TLPD experienced a significantly longer operative time(WMD=77.92 min,95%CI:40.89-114.95,P<0.0001)and had a smaller tumor size than those who underwent OPD[WMD=-0.32 cm,95%CI:(-0.58,-0.07)cm,P=0.01].There were no significant differences between the two groups in the major morbidity,postoperative pancreatic fistula,delayed gastric emptying,postpancreatectomy hemorrhage,bile leak,gastroenteric anastomosis fistula,intra-abdominal abscess,bowel obstruction,fluid collection,reoperation,ICU admission,or 30-d and 90-d mortality rates.For malignant tumors,the 1-,2-,3-,4-and 5-year overall survival rates were not significantly different between the two groups.CONCLUSION This meta-analysis indicates that TLPD is safe and feasible,and may be a desirable alternative to OPD,although a longer operative time is needed and only smaller tumors can be treated.
文摘AIM: To establish a scoring system to predict clinicallyrelevant postoperative pancreatic fistula(CR-POPF)after pancreaticoduodenectomy(PD).METHODS: The clinical records of 921 consecutive patients who underwent PD between 2008 and 2013 were reviewed retrospectively. Postoperative pancreatic fistula(POPF) was defined and classified by the international study group of pancreatic fistula(ISGPF).We used a logistic regression model to determine the independent risk factors of CR-POPF and developed a scoring system based on the regression coefficient of the logistic regression model. The optimal cut-off value to divide the risk strata was determined by the Youden index. The patients were divided into two groups(low risk and high risk). The independent sample t test was used to detect differences in the means of drain amylase on postoperative day(POD) 1, 2 and 3. The optimal cut-off level of the drain amylase to distinguish CR-POPF from non-clinical POPF in the two risk strata groups was determined using the receiver operating characteristic(ROC) curves.RESULTS: Grade A POPF occurred in 106(11.5%)patients, grade B occurred in 57(6.2%) patients,and grade C occurred in 32(3.5%) patients. A predictive scoring system for CR-POPF(0-6 points) was constructed using the following four factors: 1 point for each body mass index ≥ 28 [odds ratio(OR) = 3.86;95% confidence interval(CI): 1.92-7.75, P = 0.00],soft gland texture(OR = 4.50; 95%CI, 2.53-7.98, P =0.00), and the difference between the blood loss and transfusion in operation ≥ 800 mL(OR = 3.45; 95%CI,1.92-7.75, P = 0.00); and from 0 points for a 5 mm or greater duct diameter to 3 points for a less than 2 mm duct(OR = 8.97; 95%CI: 3.70-21.77, P = 0.00). The ROC curve showed that the area under the curve of this score was 0.812. A score of 3 points was suggested to be the best cut-off value(Youden index = 0.485). In the low risk group, a drain amylase level ≥ 3600 U/L on POD3 could distinguish CR-POPF from non-clinicalPOPF(the sensitivity and specificity were 75% and85%, respectively). In the high risk group, the best cutoff was a drain amylase level of 1600(the sensitivity and specificity were 77 and 63%, respectively).CONCLUSION: A 6-point scoring system accurately predicted the occurrence of CR-POPF. In addition, a drain amylase level on POD3 might be a predictor of this complication.
文摘AIM:To compare laparoscopic pancreaticoduodenectomy(TLPD) during the initial learning curve with open pancreaticoduodenectomy in terms of outcome and costs.METHODS:This is a retrospective review of the consecutive patients who underwent TLPD between December 2009 and April 2014 at our institution.The experiences of the initial 15 consecutive TLPD cases,considered as the initial learning curve of each surgeon,were compared with the same number of consecutive laparotomy cases with the same spectrum of diseases in terms of outcome and costs.Laparoscopic patients with conversion to open surgery were excluded.Preoperative demographic and comorbidity data were obtained.Postoperative data on intestinal movement,pain score,mortality,complications,and costs were obtained for analysis.Complications related to surgery included pneumonia, intra-abdominal abscess,postpancreatectomy hemorrhage,biliary leak,pancreatic fistula,delayed gastric emptying,and multiple organ dysfunction syndrome.The total costs consisted of cost of surgery,anesthesia,and admission examination.RESULTS:A total of 60 patients,including 30 consecutive laparoscopic cases and 30 consecutive open cases,were enrolled for review.Demographic and comorbidity characteristics of the two groups were similar.TLPD required a significantly longer operative time(513.17 ± 56.13 min vs 371.67 ± 85.53 min,P < 0.001).The TLPD group had significantly fewer mean numbers of days until bowel sounds returned(2.03 ± 0.55 d vs 3.83 ± 0.59 d,P < 0.001) and exhaustion(4.17 ± 0.75 d vs 5.37 ± 0.81 d,P < 0.001).The mean visual analogue score on postoperative day 4 was less in the TLPD group(3.5 ± 9.7 vs 4.47 ± 1.11,P < 0.05).No differences in surgery-related morbidities and mortality were observed between the two groups.Patients in the TLPD group recovered more quickly and required a shorter hospital stay after surgery(9.97 ± 3.74 d vs 11.87 ± 4.72 d,P < 0.05).A significant difference in the total cost was found between the two groups(TLPD 81317.43 ± 2027.60 RMB vs laparotomy 78433.23 ± 5788.12 RMB,P < 0.05).TLPD had a statistically higher cost for both surgery(24732.13 ± 929.28 RMB vs 19317.53 ± 795.94 RMB,P < 0.001)and anesthesia(6192.37 ± 272.77 RMB vs 5184.10 ± 146.93 RMB,P < 0.001),but a reduced cost for admission examination(50392.93 ± 1761.22 RMB vs 53931.60 ± 5556.94 RMB,P < 0.05).CONCLUSION:TLPD is safe when performed by experienced pancreatobiliary surgeons during the initial learning curve,but has a higher cost than open pancreaticoduodenectomy.
