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World Journal of Clinical Cases 2024年第9期12卷 1649-1659页

作者： Tie-Gong Wang Liang Tian Xiao-Ling Zhang Lei Zhang Xiu-Lei Zhao De-Shuai Kong Department of Surgery Cangzhou Central HospitalCangzhou 061000Hebei ProvinceChina Department of Pathology Cangzhou Central HospitalCangzhou 061000Hebei ProvinceChina

BACKGROUND postoperative pancreatic fistula(POPF)contributes significantly to morbidity and mortality after pancreaticoduodenectomy(PD).However,the underlying mechanisms remain unclear.This study explored this pathology in the pancreatic stumps and elucidated the mechanisms of POPF following PD.CASE SUMMARY Pathological analysis and 16S rRNA gene sequencing were performed on specimens obtained from two patients who underwent complete pancreatectomy for grade C POPF after PD.Gradient inflammation is present in the pancreatic stump.The apoptosis was lower than that in the normal pancreas.Moreover,neu-trophildominated inflammatory cells are concentrated in the ductal system.No-tably,neutrophils migrated through the ductal wall in acinar duct metaplasia-formed ducts.Additionally,evidence indicates that gut microbes migrate from the digestive tract.Gradient inflammation occurs in pancreatic stumps after PD.CONCLUSION The mechanisms underlying POPF include high biochemical activity in the pancreas,mechanical injury,and digestive reflux.To prevent POPF and address pancreatic inflammation and reflux,breaking the link with anastomotic dehi-scence is practical.

关键词： pancreaticoduodenectomy postoperative pancreatic fistula Inflammation Digestive reflux Case report

Complications of modern pancreaticoduodenectomy:A systematic review and meta-analysis

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Hepatobiliary & pancreatic Diseases International 2022年第6期21卷 527-537页

作者： Stamatios Kokkinakis Evangelos I Kritsotakis Neofytos Maliotis Ioannis Karageorgiou Emmanuel Chrysos Konstantinos Lasithiotakis Department of General Surgery University General Hospital of HeraklionHeraklionCrete 71110Greece Laboratory of Biostatistics Division of Social MedicineSchool of MedicineUniversity of CreteHeraklionCrete 71110Greece

Background:In the past decades,the perioperative management of patients undergoing pancreaticoduo-denectomy(PD)has undergone major changes worldwide.This review aimed to systematically determine the burden of complications of PD performed in the last 10 years.Data sources:A systematic review was conducted in PubMed for randomized controlled trials and ob-servational studies reporting postoperative complications in at least 100 PDs from January 2010 to April 2020.Risk of bias was assessed using the Cochrane RoB2 tool for randomized studies and the method-ological index for non-randomized studies(MINORS).Pooled complication rates were estimated using random-effects meta-analysis.Heterogeneity was investigated by subgroup analysis and meta-regression.Results:A total of 20 randomized and 49 observational studies reporting 63229 PDs were reviewed.Mean MINORS score showed a high risk of bias in non-randomized studies,while one quarter of the ran-domized studies were assessed to have high risk of bias.Pooled incidences of 30-day mortality,overall complications and serious complications were 1.7%(95%CI:0.9%-2.9%;I 2=95.4%),54.7%(95%CI:46.4%-62.8%;I 2=99.4%)and 25.5%(95%CI:21.8%-29.4%;I 2=92.9%),respectively.Clinically-relevant postopera-tive pancreatic fistula risk was 14.3%(95%CI:12.4%-16.3%;I 2=92.0%)and mean length of stay was 14.8 days(95%CI:13.6-16.1;I 2=99.3%).Meta-regression partially attributed the observed heterogeneity to the country of origin of the study,the study design and the American Society of Anesthesiologists class.Conclusions:Pooled complication rates estimated in this study may be used to counsel patients scheduled to undergo a PD and to set benchmarks against which centers can audit their practice.However,cautious interpretation is necessary due to substantial heterogeneity.

关键词： pancreaticoduodenectomy postoperative complications Meta-analysis postoperative pancreatic fistula

postoperative mortality and morbidity after D2 lymphadenectomy for gastric cancer:A retrospective cohort study

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World Journal of Gastroenterology 2022年第3期28卷 381-398页

作者： Giuseppe Brisinda Maria Michela Chiarello Anna Crocco Neill James Adams Pietro Fransvea Serafino Vanella Abdominal Surgery Fondazione Policlinico Universitario A Gemelli IRCCSRome 00168Italy Department of Medical and Surgical Sciences UniversitàCattolica del Sacro CuoreRome 00168Italy General Surgery Operative Unit Azienda Sanitaria Provinciale di CrotoneOspedale San Giovanni di DioCrotone 88900Italy Endocrine Surgery Operative Unit Istituto Nazionale TumoriIRCCS Fondazione PascaleNapoli 80100Italy Health Sciences Clinical Microbiology UnitMagna Grecia UniversityCatanzaro 88100Italy Department of Emergency Surgery and Trauma Center Fondazione Policlinico Universitario A Gemelli IRCCSRome 00168Italy Department of General and Oncological Surgery Azienda Ospedaliera San Giuseppe MoscatiAvellino 83100Italy

BACKGROUND Surgery for gastric cancer is a complex procedure and lymphadenectomy is often mandatory.postoperative mortality and morbidity after curative gastric cancer surgery is not insignificant.AIM To evaluate the factors determining mortality and morbidity in a population of patients undergoing R0 resection and D2 lymphadenectomy for gastric cancer.METHODS A retrospective analysis of clinical data and pathological characteristics(age,sex,primary site of the tumor,Lauren histotype,number of positive lymph nodes resected,number of negative lymph nodes resected,and depth of invasion as defined by the standard nomenclature)was conducted in patients with gastric cancer.For each patient we calculated the Kattan’s score.We arbitrarily divided the study population of patients into two groups based on the nomogram score(65 years),and number of lymph nodes retrieved(≤35 lymph nodes or>35 lymph nodes).Uni-and multivariate analysis of clinical and pathological findings were performed to identify the factors affecting postoperative mortality and morbidity.RESULTS One-hundred and eighty-six patients underwent a curative R0 resection with D2 lymphadenectomy.Perioperative mortality rate was 3.8%(7 patients);a higher mortality rate was observed in patients aged>65 years(P=0.002)and in N+patients(P=0.04).Following univariate analysis,mortality was related to a Kattan’s score≥100 points(P=0.04)and the presence of advanced gastric cancer(P=0.03).Morbidity rate was 21.0%(40 patients).Surgical complications were observed in 17 patients(9.1%).A higher incidence of morbidity was observed in patients where more than 35 lymph nodes were harvested(P=0.0005).CONCLUSION Mortality and morbidity rate are higher in N+and advanced gastric cancer patients.The removal of more than 35 lymph nodes does not lead to an increase in mortality.

关键词： Gastric cancer Total gastrectomy Subtotal gastrectomy Lymphadenectomy Kattan’s nomogram Mortality postoperative complications postoperative pancreatic fistula Hemoperitoneum Anastomotic leakage

Is it sufficient to evaluate only preoperative systemic inflammatory biomarkers to predict postoperative complications after pancreaticoduodenectomy?

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World Journal of Gastrointestinal Surgery 2022年第3期14卷 268-270页

作者： Semra Demirli Atici Erdinc Kamer Department of General Surgery University of Health Sciences Tepecik Training and Research Hospitalİzmir 35180Turkey

postoperative morbidity and mortality rates are still very high among patients undergoing pancreaticoduodenectomy(PD).However,mortality rates secondary to morbidities that are detected early and well-managed postoperatively are lower among patients undergoing PD.Since early detection of complications plays a very important role in the management of these patients,many ongoing studies are being conducted on this subject.Recent endoscopic retrograde cholangiopancreatography and biliary drainage history of the patient study group is important for comparison of C-reactive protein(CRP),an inflammatory parameter evaluated in the retrospective study by Coppola et al published in the World Journal of Gastrointestinal Surgery and titled“Utility of preoperative systemic inflammatory biomarkers in predicting postoperative complications after pancreaticoduodenectomy:Literature review and single center experience”.Therefore,it may be more appropriate to compare CRP values in randomized patients.

关键词： pancreaticoduodenectomy Biliary drainage Complications C-reactive protein CRP postoperative pancreatic fistula Preoperative inflammatory markers

Tailored pancreatic reconstruction after pancreaticoduodenectomy: a single-center experience of 892 cases

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Hepatobiliary & pancreatic Diseases International 2017年第5期16卷 528-536页

作者： Ayman El Nakeeb Ahmad M Sultan Ehab Atef Ali Salem Mostaffa Abu Zeid Ahmed Abu El Eneen Gamal El Ebidy Mohamed Abdel Wahab Gastroenterology Surgical Center Mansoura UniversityMansoura 35516 Egypt

BACKGROUND: pancreatic reconstruction following pancreaticoduodenectomy(PD) is still debatable even for pancreatic surgeons. Ideally, pancreatic reconstruction after PD should reduce the risk of postoperative pancreatic fistula(POPF) and its severity if developed with preservation of both exocrine and endocrine pancreatic functions. It must be tailored to control the morbidity linked to the type of reconstruction.This study was to show the best type of pancreatic reconstruction according to the characters of pancreatic stump. METHODS: We studied all patients who underwent PD in our center from January 1993 to December 2015. Patients were categorized into three groups depending on the presence of risk factors of postoperative complications: low-risk group(absent risk factor), moderate-risk group(presence of one risk factor) and high-risk group(presence of two or more risk factors). RESULTS: A total of 892 patients underwent PD for resection of periampullary tumor. BMI >25 kg/m~2, cirrhotic liver, soft pancreas, pancreatic duct diameter pancreatic duct location from posterior edge postoperative complications. POPF developed in 128(14.3%) patients. Delayed gastric emptying occurred in 164(18.4%) patients, biliary leakage developed in 65(7.3%) and pancreatitis presented in 20(2.2%). POPF in low-, moderate-and high-risk groups were 26(8.3%), 65(15.7%) and 37(22.7%) patients, respectively. postoperative morbidity and mortality were significantly lower with pancreaticogastrostomy(PG) in high-risk group, while pancreaticojejunostomy(PJ) decreases incidence of postoperative steatorrhea in all groups. CONCLUSIONS: Selection of proper pancreatic reconstruction according to the risk factors of patients may reduce POPF and postoperative complications and mortality. PG is superior to PJ as regards short-term outcomes in high-risk group but PJ provides better pancreatic function in all groups and therefore, PJ is superior in low-and moderate-risk groups.

关键词： periampullary tumor pancreaticogastrostomy pancreaticojejunostomy pancreaticoduodenectomy postoperative pancreatic fistula

Strategies for pancreatic anastomosis after pancreaticoduodenectomy:What really matters?

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Hepatobiliary & pancreatic Diseases International 2018年第1期17卷 22-26页

作者： Jin Xu Shun-Rong Ji Bo Zhang Quan-Xing Ni Xian-Jun Yu Department of pancreatic Surgery Fudan University Shanghai Cancer Center Shanghai 200032 China Department of Oncology Shanghai Medical College Fudan Univeristy Shanghai 200032 China Shanghai pancreatic Cancer Institute Shanghai 200032 China pancreatic Cancer Institute Fudan Univeristy Shanghai 200032 China

Background: The postoperative pancreatic fistula rate remains approximately 10–20% even in institutions treating a high-volume of pancreatic cases. The best strategy to restore the continuity between the pancreatic remnant and the digestive tract is still in debate.Data sources: Studies were identified by searching Pub Med for studies published between January 1934 (when pancreaticogastrostomy was technically feasible) and December 2016. The following search terms were used: "duct-to-mucosa", "invagination", "pancreaticojejunostomy", "pancreaticogastrostomy," and"pancreaticoduodenectomy". The search was limited to English publications.Results: Many technical methods have been developed and optimized to restore pancreaticoenteric continuity, including pancreaticojejunostomy, pancreaticogastrostomy, and stented drainage of the pancreatic duct, among other modifications. Researchers have also attempted to decrease the postoperative pancreatic fistula after pancreaticoduodenectomy by using fibrin glue and somatostatin analogues. However, no significant decrease in postoperative pancreatic fistula has been observed in most of these studies, and only an external pancreatic duct stent has been found to decrease the leakage rate of pancreatic anastomosis after pancreaticojejunostomy.Conclusion: pancreatic surgeons should choose a suitable technique according to the characteristics of individual cases.

关键词： pancreaticoduodenectomy pancreatic anastomosis postoperative pancreatic fistula

Efficacy of octreotide in the prevention of complications after pancreaticoduodenectomy in patients with soft pancreas and non-dilated pancreatic duct: A prospective randomized trial

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Hepatobiliary & pancreatic Diseases International 2018年第1期17卷 59-63页

作者： Ayman El Nakeeb Ahmed El Gawalby Mahmoud A.Ali Ahmed Shehta Hosam Hamed Mohamed El Refea Ahmed Moneer Ahmed Abd El Rafee Gastroenterology Surgical Center Mansoura University

Background: The efficacy of octreotide to prevent postoperative pancreatic fistula(POPF) of pancreaticoduodenectomy(PD) is still controversial. This study aimed to evaluate the effect of postoperative use of octreotide on the outcomes after PD.Methods: This is a prospective randomized controlled trial for postoperative use of octreotide in patients undergoing PD. Patients with soft pancreas and pancreatic duct postoperative octreotide. Group II received postoperative octreotide. The primary end of the study is to compare the rate of POPF.Results: A total of 104 patients were included in the study and were divided into two randomized groups.There were no significant difference in overall complications and its severity. POPF occurred in 11 patients(21.2%) in group I and 10(19.2%) in group II, without statistical significance(P = 0.807). Also, there was no significant differences between both groups regarding the incidence of biliary leakage(P = 0.083), delayed gastric emptying(P = 0.472), and early postoperative mortality(P = 0.727).Conclusions: Octreotide did not reduce postoperative morbidities, reoperation and mortality rate. Also, it did not affect the incidence of POPF and its clinically relevant variants.

关键词： pancreaticoduodenectomy postoperative pancreatic fistula Octreotide Periampullary tumor

The “Colonial Wig” pancreaticojejunostomy:zero leaks with a novel technique for reconstruction after pancreaticoduodenectomy

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Hepatobiliary & pancreatic Diseases International 2017年第5期16卷 545-551页

作者： Xihua Yang Pouya Aghajafari Naeem Goussous Shirali T Patel Steven C Cunningham Department of Surgery Saint Agnes Hospital and Cancer Center Baltimore MD USA

BACKGROUND: postoperative pancreatic fistula(POPF) remains common and morbid after pancreaticoduodenectomy(PD). A major advance in the study of POPF is the fistula risk score(FRS).METHODS: We analyzed 48 consecutive patients undergoing PD. The 'Colonial Wig' pancreaticojejunostomy(CWPJ) technique was used in the last 22 PDs, we compared 22 CWPJ to 26 conventional PDs. RESULTS: postoperative morbidity was 49%(27% Clavien grade >2). The median length of hospital stay was 11 days. In the first 26 PDs, the PJ was performed according to standard techniques and the clinically relevant POPF(CR-POPF) rate was 15%, similar to the FRS-predicted rate(14%). In the next 22 PJs, the CWPJ was employed. Although the FRS-predicted rates were similar in these two groups(14% vs 13%), the CRPOPF rate in the CWPJ group was 0(P=0.052).CONCLUSION: Early experience with the CWPJ is encouraging, and this anastomosis may be a safe and effective way to lower POPF rates.

关键词： pancreatectomy postoperative pancreatic fistula fistula risk score anastomosis novel surgical technique

Risk factors and managements of hemorrhage associated with pancreatic fistula after pancreaticoduodenectomy

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Hepatobiliary & pancreatic Diseases International 2017年第5期16卷 537-544页

作者： Xing Liang Li-Gang Shi Jun Hao An-An Liu Dan-Lei Chen Xian-Gui Hu Cheng-Hao Shao Department of pancreatic-biliary Surgery Changzheng Hospital Second Military Medical University Department of pancreatic Surgery Changhai Hospital Second Military Medical University

BACKGROUND: Post-pancreaticoduodenectomy pancreatic fistula associated hemorrhage (PPFH) is one of the leading lethal complications. Our study was to analyze the risk factors and managements of hemorrhage associated with pancreatic fistula after pancreaticoduodenectomy, and to evaluate treatment options. METHOD: We analyzed 445 patients who underwent pancreaticoduodenectomy or pylorus-preserving pancreaticoduodenectomy and evaluated the relevance between clinical data and PPFH. RESULTS: The incidence of postoperative pancreatic fistula (POPF) was 27.42% (122/445), and the incidence of PPFH was 4.49% (20/445). Among the 20 patients with PPFH, 7 died and 13 were cured. Interventional angiographic therapy was performed for 10 patients and 5 were successfully treated. Relaparotomy was performed for 5 patients and 2 were successfully cured. Univariate logistic regression analysis indicated that several risk factors were related to PPFH: the nature of tumor (carcinoid/low-grade or high-grade malignancy), preoperative day 1. serum prealbumin, preoperative day 1 total bilirubin (TBIL), operative time, blood loss in the operation, operative method (vascular resection and revascularization), postoperative day 3 TBIL, biliary fistula, and the grade of POPF. The multivariate stepwise logistic regression analysis demonstrated that the nature of tumor and the grade of POPF were independently risk factors of PPFH. Receiver operating characteristic curve indicated that preoperative day 1 serum prealbumin level postoperative day 3 TBIL level.***.68.tmol/L were the risk factors of PPFH. CONCLUSIONS; The risk of PPFH was found to be increased with high potential malignancy and high grade of POPE Angiography-embolization is one of the major and effective therapies for PPFH. Extraluminal-intraluminal PPFH is more serious and needs more aggressive treatments.

关键词： pancreatic neoplasms pancreaticoduodenectomy postoperative pancreatic fistula hemorrhage risk factors

Risk prediction platform for pancreatic fistula after pancreatoduodenectomy using artificial intelligence

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World Journal of Gastroenterology 2020年第30期26卷 4453-4464页

作者： In Woong Han Kyeongwon Cho Youngju Ryu Sang Hyun Shin Jin Seok Heo Dong Wook Choi Myung Jin Chung Oh Chul Kwon Baek Hwan Cho Department of Surgery Samsung Medical CenterSungkyunkwan University School of MedicineSeoul 06351South Korea Medical Artificial Intelligence Research Center Department of Medical Device Management and ResearchSAIHSTSamsung Medical CenterSungkyunkwan University School of MedicineSeoul 06351South Korea Department of Radiology Samsung Medical CenterSungkyunkwan University School of MedicineSeoul 06351South Korea Artificial Intelligence Research Center Medical DataBase IncorporatedSeoul 06048South Korea

BACKGROUND Despite advancements in operative technique and improvements in postoperative managements,postoperative pancreatic fistula(POPF)is a life-threatening complication following pancreatoduodenectomy(PD).There are some reports to predict POPF preoperatively or intraoperatively,but the accuracy of those is questionable.Artificial intelligence(AI)technology is being actively used in the medical field,but few studies have reported applying it to outcomes after PD.AIM To develop a risk prediction platform for POPF using an AI model.METHODS Medical records were reviewed from 1769 patients at Samsung Medical Center who underwent PD from 2007 to 2016.A total of 38 variables were inserted into AI-driven algorithms.The algorithms tested to make the risk prediction platform were random forest(RF)and a neural network(NN)with or without recursive feature elimination(RFE).The median imputation method was used for missing values.The area under the curve(AUC)was calculated to examine the discriminative power of algorithm for POPF prediction.RESULTS The number of POPFs was 221(12.5%)according to the International Study Group of pancreatic fistula definition 2016.After median imputation,AUCs using 38 variables were 0.68±0.02 with RF and 0.71±0.02 with NN.The maximal AUC using NN with RFE was 0.74.Sixteen risk factors for POPF were identified by AI algorithm:pancreatic duct diameter,body mass index,preoperative serum albumin,lipase level,amount of intraoperative fluid infusion,age,platelet count,extrapancreatic location of tumor,combined venous resection,co-existing pancreatitis,neoadjuvant radiotherapy,American Society of Anesthesiologists’score,sex,soft texture of the pancreas,underlying heart disease,and preoperative endoscopic biliary decompression.We developed a web-based POPF prediction platform,and this application is freely available at http://popfrisk.***.org.CONCLUSION This study is the first to predict POPF with multiple risk factors using AI.This platform is reliable(AUC 0.74),so it could be used to select pat

关键词： postoperative pancreatic fistula Pancreatoduodenectomy Neural networks Recursive feature elimination