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Delayed gastric emptying (DGE) ranks as one of the most frequent complications in pancreatic surgery. It leads to increased costs for healthcare systems, lengthened hospital stays and reduced quality of life. Data about DGE after distal pancreatectomy (DP) are scarce. The StuDoQ|Pancreas registry of the German Society of General and Visceral Surgery provided data of patients who underwent distal pancreatectomy from 1 January 2014 to 31 December 2018. The retrospective evaluation included comprehensive data: 1688 patients were enrolled; DGE occurred 160 times (9.5%); grade "A" was reported for 98 (61.3%), grade "B" for 41 (25.6%) and grade "C" for 21 (13.1%) patients. In univariate analysis pancreatic fistulas were associated with higher frequencies of intraabdominal abscesses (9.1% vs. 2%, p > 0.001), postpancreatectomy haemorrhage (8.1% vs. 3.7%, >0.001) and DGE (14.5% vs. 6%, p < 0.001). According to multivariate analysis, "abscesses with invasive therapy" (p < 0.001), "other surgical complications" (p < 0.001), prolonged "stays in ICU" (p < 0.001), lengthened duration of surgery (p < 0.001) and conventional surgery (p = 0.007) were identified as independent risk factors for DGE. Perioperative and postoperative factors were identified as risk factors for DGE. Following research should examine this highly relevant topic in a prospective, register-based manner. As there is no causal therapy for DGE, its avoidance is of major importance. [ABSTRACT FROM AUTHOR]

Purpose: Pancreatic neuroendocrine neoplasms (pNENs) are rare, and their surgical management is complex. This study evaluated the current practice of pNEN surgery across Germany, including its adherence with guidelines and its perioperative outcomes. Methods: Patients who underwent surgery for pNENs (April 2013–June 2017) were retrieved from the prospective StuDoQ|Pancreas registry of the German Society of General and Visceral Surgery and retrospectively analyzed. Results: A total of 287 patients (53.7% male) with a mean age of 59.2 ± 14.2 years old underwent pancreatic resection for pNENs. Tumors were localized in the pancreatic head (40.4%), body (23%), or tail (36.6%). A total of 239 (83.3%) patients underwent formal resection with lymphadenectomy, 40 (14%) parenchyma-sparing resection, and 8 (2.8%) only exploration. Fifty (17.4%) patients underwent a minimally invasive approach. Among the 245 patients with complete pathological information, 42 (17.1%) had distant metastases, 78 (31.8%) had stage I tumors, 74 (30.2%) stage II, and 51 (20.8%) stage III. A total of 112 (45.7%) patients had G1 tumors, 101 (41.2%) G2, and 24 (9.8%) G3. Nodal involvement on imaging was an independent predictor of lymph node metastasis according to the multivariable analysis (odds ratio: 0.057; 95% confidence interval: 0.016–0.209; p < 0.01). R0 resection was reported in 240 (83.6%) patients. The 30- and 90-day mortality rates were 2.8% and 4.2%, respectively. Conclusion: In Germany the rate of potential curative resection for pNEN is high. However, formal pancreatic resection seems to be overrepresented, while minimally invasive resection is underrepresented. [ABSTRACT FROM AUTHOR]

Introduction: In pancreatic surgery pre-operative biliary drainage (PBD) is associated with bacteribilia, which increases the risk for surgical site infections (SSIs). Methods: This study is a retrospective observational cohort design that compared micro-organisms of intra-operative bile duct cultures with micro-organisms of SSIs after pancreaticoduodenectomy. Results: From January 2004 until December 2010, 887 patients underwent pancreaticoduodenectomy or hepaticojejunostomy for benign and malignant peri-ampullary lesions. Surgical site infections occurred in 10% (87/887). Cultures of SSIs with corresponding intra-operative bile duct cultures were available for 59 patients. Sixty-four percent (38/59) had undergone PBD. Pre-operative biliary drainage was associated with positive intra-operative bile duct cultures in 95% (36/38), versus 48% (10/21; p≤0.001). The correlation of SSIs with intra-operative bile duct cultures was 59% (35/59). There was a significant association between the micro-organisms cultured from SSIs and the corresponding bile duct cultures for Enterococcus spp., Escherichia coli, Klebsiella pneumoniae, methicillin-resistant Staphylococcus aureus (MRSA), Enterobacteriaceae with extended spectrum ß-lactamase (ESBL), and Candida spp. Conclusion: After pancreaticoduodenectomy, SSIs are often caused by the same micro-organisms that are present on intra-operative bile duct cultures, especially after PBD. Therefore, intra-operative bile duct cultures should be performed routinely to adjust the antibiotic prophylaxis according to the local hospital surveillance data. [ABSTRACT FROM AUTHOR]

Background: After pancreatic surgery hepaticojejunostomy (HJ) stricture is a rare condition. Usually, management is conservative, while operative revision ('redo') is only rarely performed. Methods: This was an observational cohort design that analyzed the outcome of patients who had a surgical revision of HJ strictures after pancreatic surgery at a specialized pancreatic center. Results: During a period of 7 years from January 2004 until December 2010, 887 patients underwent pancreaticoduodenectomy (PD) or HJ. Among this patient population, 3 % (23/887) underwent a redo of the HJ secondary to stricture formation. Major symptoms of HJ strictures were recurrent cholangitis in 91 % (21/23) and jaundice in 39 % (9/23). The median time from the index operation until redo of the HJ was 16 ± 27 months. The median survival of patients with malignancy after redo of the HJ was 45 ± 67 months. Major surgical morbidity was 9 % (2/23), and mortality was 0 % (0/23). In 78 % (18/23), there were no further episodes of cholangitis after a median follow of 49 ± 73 months, while none of the patients with redo of the HJ developed a restenosis of the HJ. Conclusion: Surgical revision (redo) of HJ strictures can be safely performed by an experienced pancreatic surgeon with a low morbidity without mortality with good long-term results. [ABSTRACT FROM AUTHOR]

Introduction: After pancreatectomy, an isolated bile leak from the hepaticojejunostomy is a severe surgical complication that is underrepresented both, in the literature and in the awareness of pancreatic surgeons. The goal of this study was to analyze the incidence and outcome of isolated bile leaks after pancreatectomy. Material and Methods: A retrospective study of patients who underwent duodenopancreatectomy or total pancreatectomy at a single-center institution was performed, which analyzed incidence and course of patients with postoperative bile leaks from the hepaticojejunostomy. Results: During a period of 42 months, 209 patients underwent pancreatic head resection or total pancreatectomy. Bile leaks occurred in 4% (8/209) and were more common in patients with distal bile duct cancer. Bile leaks led to longer hospital stay and were associated with abscess formation and other infectious complications. Unlike expected, most postoperative bile leaks occurred in the late postoperative period. Three patients required relaparotomy for biliary peritonitis or delayed visceral hemorrhage, while the other five patients underwent conservative management, including CT drainage and antibiotic therapy. One patient with a postoperative bile leak died due to delayed visceral hemorrhage. Conclusion: In contrast to recently published data, isolated postoperative bile leaks after pancreatectomy often occur in the late postoperative period and more frequently require a relaparotomy than the literature suggests. The presented study results may sensitize surgeons for this often disregarded topic and activate the discussion on treatment options. [ABSTRACT FROM AUTHOR]

Abstract: Background: Hard pancreas is welcome by surgeons performing resective pancreatic surgery, because it is believed to offer better suture holding capacity (SHC), thus decreasing the risk for a postoperative leak. However, neither the actual SHC of pancreatic tissue in humans nor its determinants have been studied. Methods: We directly measured SHC for polydioxanone 5–0 suture and tissue hardness at the pancreatic isthmus in 53 human pancreata using a dynamometer and a durometer. A histologic score based on fibrosis grade, fat content, pancreatic duct size, and signs of chronic pancreatitis was calculated for every sample. We tested the hypothesis that SHC of the pancreas was proportional to tissue hardness, and evaluated the role of different possible histomorphologic determinants of SHC. Results: Suture-holding capacity correlated perfectly with tissue hardness (r = 0.98; P < 0.001; 95% confidence interval, 0.96–0.99). The histologic score showed a stronger correlation with both parameters than any single histologic parameter. The SHC of transductal sutures was significantly higher than that of pure transparenchymal sutures. The SHC and hardness were significantly lower in patients who developed a clinically relevant pancreatic fistula postoperatively. Conclusions: A mixture of histomorphologic features of human pancreas determines its tissue hardness and SHC. Involvement of the main pancreatic duct in the suture line appears to increase the mechanical strength of the pancreatic anastomosis. [Copyright &y& Elsevier]

BACKGROUND: After pancreatic head resection, bile leaks from a difficult hepaticojejunostomy secondary to a small or fragile common hepatic duct may be reduced by a T tube at the side of the anastomosis. METHODS: A retrospective analysis of patients who underwent a difficult hepaticojejunostomy without or with a T tube was performed. RESULTS: In 48%(55/114) of patients, a T tube was placed at the side of the hepaticojejunostomy; 52% (59/114) did not have a T tube. Bile leaks occurred in 12% (14/114) (9%[5/55] in patients with a T tube vs 15%[9/59] without a T tube, P = .316). Bile leaks were associated with mortality, abscess formation, hemorrhage, and sepsis. Seven percent (8/114) of patients required revisional laparotomy (2% [1/55] with a T tube vs 12% [7/59] without a T tube, P = .036). Mortality was not different between the groups. Minor T-tube-associated complications occurred in 15% (8/55) without major complications. CONCLUSIONS: Augmentation of anastomosis with a T tube cannot prevent biliary leakage but does reduce the severity of bile leaks, resulting in less reoperations. [ABSTRACT FROM AUTHOR]

Background: The proportion of octogenarians requiring surgery for pancreatic disease is rapidly growing. This trend will be continued during the next decades, posing a challenge to surgeons and the health care system worldwide. This study aimed to analyze the results of pancreatic surgery in octogenarians in terms of safety and survival based on a cohort of patients at a European high-volume center. Methods: During a 7-year period, 1,705 operations were performed, 76 in patients ≥80 years of age. Data on the octogenarians were retrospectively reviewed and compared to those of the whole collective and to contemporary data from the literature. Primary endpoints were mortality, morbidity, and survival. Results: Overall, 80 % had a malignant disease, and resections were performed in 50 % of all cases. Mortality was 11.8 % and morbidity 72.4 %. There were significantly more medical than surgical complications: 56.6 versus 34.2 %. Pancreatic fistula occurred in 5.3 %, postoperative bleeding in 3.9 %, and delayed gastric emptying in 19.7 %. The median hospital stay was 15 days and the intensive care unit stay 2 days. Mean survival was 28.2 months and in patients with cancer 22.6 months. The 1-, 3-, and 5-year survival rates were 61.4, 31.3, and 18.8 %, respectively. Conclusions: Despite high mortality and morbidity rates, surgery remains the only chance for cure in most octogenarians with pancreatic disease. Careful patient selection is the key to success and improved long-term survival in this group, which will represent a substantial fraction of the population in the near future. [ABSTRACT FROM AUTHOR]

Purpose: To compare health-related quality of life (QoL) before and after surgery for pancreatic disease. Methods: A retrospective analysis of prospectively gathered data is presented. A total of 174 patients of 230 planned for pancreatic surgery between March and December 2009 at a German high-volume center completed the Short Form-36 (SF-36) Health Survey preoperatively, 133 of them at 3 months and 83 at 24 months after surgery. Data was analysed according to diagnosis and procedure, and compared to German population norms. Results: QoL in the study group was worse than that of age-matched healthy population at all time points. It decreased continuously in the cancer group, decreased early and showed a trend toward recovery late in patients with benign tumors and chronic pancreatitis. Distal pancreatectomy was the best tolerated and total pancreatectomy the worst tolerated procedure. Older age and development of pancreatic insufficiency affected negatively QoL. Conclusions: In patients with pancreatic disease, diagnosis determined QoL preoperatively and late after surgery, while in the early postoperative period, type and extent of surgery was the leading factor. Total pancreatectomy had a profound negative effect on QoL and should be reserved for carefully selected patients only. [ABSTRACT FROM AUTHOR]

Background. In pancreatic surgery, preoperative biliary drainage (PBD) leads to bacteribilia. Whether positive bile duct cultures are associated with a higher postoperative morbidity might be related to the resistance of the species isolated from bile. Study. Intraoperative bile duct cultures were collected from all patients who underwent pancreatic surgery. Postoperative morbidity was analyzed according to the species and the resistance found on bile duct cultures. Results. Fifty-five percent (166/301) of patients had PBD, while 45% (135/301) underwent primary operation. PBD was associated with a positive bile duct culture in 87% (144/166) versus 21% (28/135) in patients without PBD ( p = 0.001) and polymicrobial infections in 53% (88/166) versus 6% (8/135) ( p = 0.001). Postoperative morbidity was 40% (121/301); mortality was 3% (9/301). PBD was not associated with morbidity and mortality, but resistant species on bile duct cultures lead to significantly more postoperative complications, 54% (25/46) versus 38% (96/255) ( p = 0.033), with significantly more antibiotic therapies. Conclusion. PBD is associated with polymicrobial infections with resistant microorganisms, resulting in more postoperative complications. Since PBD cannot always be avoided, surgeons and gastroenterologists must be aware of their institutional surveillance data to identify patients at risk for postoperative complications. [ABSTRACT FROM AUTHOR]

Background. This study aimed to analyse the most common current indications for total pancreatectomy (TP) at a high-volume pancreas center. Method. Prospectively collected data on indications and short-term outcome of all TP's performed from January 2004 until June 2008 were analysed. Results. The total pancreatectomies (TP) were 63, i.e., 6.7% of all pancreatic procedures (n = 948). Indications for TP were classified into 4 groups: tumors of advanced stage, n = 23 (36.5%), technical problems due to soft pancreatic tissue, n = 18 (28.6%), troubles due to perioperative surgical complications, n = 15 (23.8%), and therapy-resistant pain due to chronic pancreatitis, n = 7 (11.1%). Surgical complications occurred in 23 patients (36.5%). The mortality in elective TP was 6.25%. Median postoperative stay was 21 days. Mortality, morbidity and the other perioperative parameters differed substantially according to the indication for pancreatectomy. Conclusion. Total pancreatectomy is definitely indicated for a limited range of elective and emergency situations. Indications can be: size or localisation of pancreatic tumor, trouble, technical difficulties and therapy-refractory pain in chronic pancreatitis. A TP due to perioperative complications (troubles) after pancreatic resections is doomed by extremely high morbidity and mortality and should be avoided. [ABSTRACT FROM AUTHOR]

Background: Improving results have led to an extension of indications for re-resection of recurrent pancreatic carcinoma. Methods: Among 410 patients who received surgery for histologically proven pancreatic cancer, 17 underwent re-resection for a suspected local recurrence and were evaluated for overall survival, clinicopathological and perioperative data. Results: At the initial operation, resection was curative (R0/R1) in all 17 patients. Indication for re-resection was a suspected or proven recurrence of pancreatic cancer in all patients. Re-resection was possible in 5 patients. The remaining patients received a redo of the pancreaticojejunostomy or bilioenteric anastomosis (n = 2), exploration with biopsy (n = 4), and a palliative bypass (n = 6). Perioperative mortality was 6%. Median overall survival was 25 months (range 10–152 months) and 7 months following re-resection (5–29 months). In 5 of 17 patients, histology showed chronic pancreatitis (n = 4) or a benign stricture at the hepaticojejunostomy (n = 1), whereas all other patients had histologically proven recurrence. Re-resection or redo of the anastomosis was possible in 5 of 5 patients with chronic pancreatitis but only in 2 of 12 patients with true recurrence (p = 0.003). Conclusions: Curative reoperation for recurrent pancreatic carcinoma is rarely feasible. Due to the potential for chronic pancreatitis or benign strictures as an underlying pathology, operable patients should be explored. Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Pancreatic redo procedures belong to the most difficult abdominal operations because of altered anatomy, significant adhesions, and the potential of recurrent disease. We report on our experience with 15 redo procedures among a series of 350 consecutive pancreatic operations.Patient and Methods: From January 1, 2004 to May 31, 2006 a total of 350 patients underwent pancreatic surgery in our department. There were 15 patients identified who had pancreatic redo surgery for benign (14) or malignant (1) disease. Perioperative parameters and outcome of 15 patients undergoing redo surgery after pancreatic resections were evaluated.Results: Operative procedures included revision and redo of the pancreaticojejunostomy after resection of the pancreatic margin (6), completion pancreatectomy (3), conversion from duodenum-preserving pancreatic head resection to pylorus-preserving pancreaticoduodenectomy (3), classic pancreaticoduodenectomy after nonresective pancreatic surgery (1), redo of left-sided pancreatectomy (1), and classic pancreaticoduodenectomy after left-sided pancreatectomy (1). Histology revealed chronic pancreatitis in 14 and a mucinous adenocarcinoma of the pancreas in 1 patient. Median operative time was 335 min (235-615 min) and median intraoperative blood loss was 600 ml (300-2,800 ml). Median postoperative ICU stay was 20 h (4-113 h) and median postoperative hospital stay was 15 days (7-30 days). There was no perioperative mortality and morbidity was 33%.Conclusion: Pancreatic redo surgery can be performed with low morbidity and mortality. Redo surgery has a defined spectrum of indications, but to achieve good results surgery may be performed at high-volume centers. [ABSTRACT FROM AUTHOR]

Surgical procedures for esophageal cancer and chronic pancreatitis are demanding and still characterized by high morbidity and mortality. Cases of one-stage combined operations on the pancreas and esophagus with a long-term follow-up are rarely reported. We present the case of a 54-year-old woman with a Barrett’s carcinoma and an 8-year history of severe chronic pancreatitis complicated with multiple episodes of cholangitis and resistant to conservative treatment. After a successful one-stage operation consisting of esophagogastrectomy and pancreaticoduodenectomy, a 30-month disease-free follow-up with a good quality of life has been observed. Complicated surgical procedures such as one-stage multiple organ resections may offer, in selected cases, satisfactory long-term results, provided that patients are treated at a high-volume center by a multidisciplinary team. [ABSTRACT FROM AUTHOR]