Search

Background: There are few studies that examined the relationship between preoperative zinc (Zn) concentrations and postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP)., Methods: Data from 98 patients who underwent DP between January 2016 and April 2022 were retrospectively reviewed. Patients' clinicopathological and surgical outcomes were analyzed, and we examined the relationship between Zn and clinically relevant POPF (CR-POPF) after DP., Results: In this series, 41 (41.8%) patients had POPF and 31 (31.8%) patients had CR-POPF. The cut-off value for the preoperative Zn concentration was 74 μg/dL for POPF and CR-POPF. Patients with low Zn concentrations were significantly related with high age, low albumin concentrations, higher CRP concentrations, higher NLR, lower PNI, higher rates of POPF and CR-POPF, longer POPF healing time, longer hospital stay, and postoperative complications than patients with high Zn concentrations. The healing time of POPF after DP was significantly negatively correlated with serum Zn concentrations. A multivariate logistic regression analysis showed that preoperative lower Zn concentrations and a prolonged operation time were independent predictors of CR-POPF and the healing time of POPF after DP. The POPF healing time in patients with high Zn was significantly shorter than that in patients with low Zn concentrations., Conclusions: This retrospective study showed the association between the preoperative Zn concentrations and the occurrence of POPF and the healing time after DP. Zn is a simple biomarker for malnutrition, which may lead to POPF after DP., (© 2023 International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Background/aim: Early identification of patients at risk for developing postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) may facilitate drain management. In this context, it was aimed to examine the efficiency of the serum amylase (SA) value on postoperative day (PoD) 1 in predicting the occurrence of POPF., Materials and Methods: A total of 132 patients who underwent PD were studied. Occurrences of POPF were classified according to the International Study Group on Pancreatic Fistula classification as a biochemical leak (BL) or clinically relevant grade b/c POPF (CR-POPF). Receiver operating characteristic analysis identified a threshold value of SA on PoD 1 associated with POPF formation., Results: Overall, 66 (50%) patients had POPF, including 51 (38.7%) with BL and 15 with CR-POPF (11.3%). The threshold value of SA associated with the development of POPF was 120 IU/L (odds ratio [OR]: 3.20; p = 0.002). In the multivariate analysis, independent POPF risk factors were SA ≥120 IU/L, soft pancreatic texture, and high-risk pathology (i.e., duodenal, biliary, ampullary, islet cell, and benign tumors); SA ≥120 IU/L outperformed soft pancreatic texture and high-risk pathology in predicting POPF, respectively (OR: 2.22; p = 0.004 vs. OR: 1.37; p = 0.012 vs. OR: 1.35; p = 0.018). In a subset analysis according to gland texture (soft vs. hard), patients with soft pancreatic texture exhibited a significantly higher incidence of POPF (63.4% vs. 34.4%) and SA ≥120 IU/L (52.1% vs. 27.9%); SA <120 IU/L had a negative predictive value of 82.5% for developing POPF in patients with hard pancreatic texture (OR: 4.28, p = 0.028)., Conclusion: A SA value ≥120 IU/L on the day after PD, which is the strongest predictor for POPF, can be used as a biomarker of the occurrence of POPF. The advantage of SA measurement is that it can contribute to identifying suitable patients for early drain removal., Competing Interests: Conflict of interest: The authors declare that there are no conflicts of interest., (© TÜBİTAK.)

Background: The clinical significance of postoperative serum pancreatic enzyme elevation after pancreatoduodenectomy is understudied. We hypothesized that elevation in serum enzymes predicts morbidity and mortality after pancreatoduodenectomy., Methods: Retrospective review of 677 patients who underwent pancreatoduodenectomy at a single institution from 2013 to 2019. Patients were categorized based on serum enzyme concentrations. Patient characteristics, drain amylase, and outcomes among groups were compared., Results: In total, 415 of 677 patients had postoperative serum amylase concentrations measured. Of these, 243 (59%) were normal, 96 (23%) were classified as postoperative serum hyperamylasemia, and 76 (18%) were classified as postoperative acute pancreatitis. Major morbidity was lower among patients with normal enzyme concentration (10%) and higher in patients with postoperative serum hyperamylasemia (23%) and postoperative acute pancreatitis (18%) (P = .008). Patients with normal enzymes were less likely to develop postoperative pancreatic fistula (5%) compared with patients with postoperative serum hyperamylasemia (26%) and postoperative acute pancreatitis (21%) (P < .001) and less likely to develop delayed gastric emptying (9% vs 23% and 20%, respectively); P = .002. No difference in mortality was seen among groups., Conclusion: Elevated serum pancreatic enzyme concentration occurs frequently after pancreatoduodenectomy and is associated with increased postoperative morbidity. Serum enzyme concentration should be considered in management after pancreatoduodenectomy., (Copyright © 2021. Published by Elsevier Inc.)

Background: Several scoring systems predict risks of clinically relevant postoperative pancreatic fistula after pancreatectomy, but none have emerged as the gold standard. This study aimed to evaluate the accuracy of postoperative day 1 drain amylase and serum C-reactive protein levels in predicting clinically relevant postoperative pancreatic fistula compared with intraoperative pancreatic characteristics., Methods: Patients who underwent pancreatectomy between 2017 and 2019 were included prospectively. Cutoff values were determined using receiver operating characteristic curves, and a score combining postoperative day 1 drain amylase and serum C-reactive protein was tested in a multivariate logistic regression model to evaluate clinically relevant postoperative pancreatic fistula risk., Results: A total of 274 pancreatic resections (182 pancreaticoduodenectomies and 92 distal pancreatectomies) were included. The pancreatic gland texture was "soft" in 47.8% (n = 131), and 55.8% (n = 153) had a small size main pancreatic duct (≤3 mm). Clinically relevant postoperative pancreatic fistula occurred in 58 patients (21.2%). Drain amylase ≥1,000 UI/L and serum C-reactive protein ≥90 mg/L were identified as the optimal cutoffs to predict clinically relevant postoperative pancreatic fistula. On multivariate analysis these cutoffs were independent predictors of clinically relevant postoperative pancreatic fistula after both pancreaticoduodenectomies (drain amylase: P < .001, serum C-reactive protein: P = .006) and distal pancreatectomies (drain amylase: P = .009, serum C-reactive protein: P = .001). The postoperative day 1 "90-1000" model, a 2-value score relying on these cutoffs, significantly (P < .001) outperformed intraoperative pancreatic parenchymal characteristics in predicting clinically relevant postoperative pancreatic fistula after both pancreaticoduodenectomies and distal pancreatectomies. A postoperative day 1 "90-1000" score = 0 had a negative predictive value of 97% and 94%, respectively, after pancreaticoduodenectomy and distal pancreatectomies., Conclusion: A combined score relying on postoperative day 1 values of drain amylase and serum C-reactive protein levels was accurate in predicting risks of clinically relevant postoperative pancreatic fistula after pancreatectomy., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Postoperative pancreatic fistula (POPF) represents the most common complication following pancreaticoduodenectomy (PD). Predictive models are needed to select patients with a high risk of POPF. This study was aimed to establish an effective predictive nomogram for POPF following PD., Methods: Consecutive patients who had undergone PD between January 2016 and May 2020 at a single institution were analysed retrospectively. A predictive nomogram was established based on a training cohort, and Lasso regression and multivariable logistic regression analysis were used to evaluate predictors. The predictive abilities of the predicting model were assessed for internal validation by the area under the receiver operating characteristic curve (AUC) and calibration plot using bootstrap resampling. The performance of the nomogram was compared with that of the currently used a-FRS model., Results: A total of 459 patients were divided into a training cohort (n = 302) and a validation cohort (n = 157). No significant difference was observed between the two groups with respect to clinicopathological characteristics. The POPF rate was 16.56%. The risk factors of POPF POPF were albumin difference, drain amylase value on postoperative day 1, pancreas texture, and BMI, which were all selected into a nomogram. Nomogram application revealed good discrimination (AUC = 0.87, 95% CI: 0.81-0.94, P <  0.001) as well as calibration abilities in the validation cohort. The predictive value of the nomogram was better than that of the a-FRS model (AUC: 0.87 vs 0.62, P <  0.001)., Conclusions: This predictive nomogram could be used to evaluate the individual risk of POPF in patients following PD, and albumin difference is a new, accessible predictor of POPF after PD., Trial Registration: This study was registered in the Chinese Clinical Trial Register ( ChiCTR2000034435 ).

Background: Postoperative hyperamylasemia is a frequent finding after pancreatoduodenectomy, but its incidence and clinical implications have not yet been analyzed systematically. The aim of this review is to reappraise the concept of postoperative hyperamylasemia with postoperative acute pancreatitis, including its definition, interpretation, and correlation., Methods: Online databases were used to search all available relevant literature published through June 2019. The following search terms were used: "pancreaticoduodenectomy," "amylase," and "pancreatitis." Surgical series reporting data on postoperative hyperamylasemia or postoperative acute pancreatitis were selected and screened., Results: Among 379 screened studies, 39 papers were included and comprised data from a total of 9,220 patients. Postoperative hyperamylasemia was rarely defined in most of these series, and serum amylase values were measured at different cutoff levels and reported on different postoperative days. The actual levels of serum amylase activity and the representative cutoff levels required to reach a diagnosis of postoperative acute pancreatitis were markedly greater on the first postoperative days and tended to decrease over time. Most studies analyzing postoperative hyperamylasemia focused on its correlation with postoperative pancreatic fistula and other postoperative morbidities. The incidence of postoperative acute pancreatitis varied markedly between studies, with its definition completely lacking in 40% of the analyzed papers. A soft pancreatic parenchyma, a small pancreatic duct, and pathology differing from cancer or chronic pancreatitis were all predisposing factors to the development of postoperative hyperamylasemia., Conclusion: Postoperative hyperamylasemia has been proposed as the biochemical expression of pancreatic parenchymal injury related to localized ischemia and inflammation of the pancreatic stump. Such phenomena, analogous to those associated with acute pancreatitis, could perhaps be renamed as postoperative acute pancreatitis from a clinical standpoint. Patients with postoperative acute pancreatitis experienced an increased rate of all postoperative complications, particularly postoperative pancreatic fistula. Taken together, the discrepancies among previous studies of postoperative hyperamylasemia and postoperative acute pancreatitis outlined in the present review may provide a basis for stronger evidence necessary for the development of universally accepted definitions for postoperative hyperamylasemia and postoperative acute pancreatitis., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The mortality following pancreaticoduodenectomy has markedly decreased but remains an important challenge for the complexity of operation and technical skills involved. The present study aimed to clarify the impact of individualized pancreaticoenteric anastomosis and management to postoperative pancreatic fistula., Methods: Data from 529 consecutive pancreaticoduodenectomies were retrospectively analysed from the Hepatobiliary and Pancreatic Surgery Unit I, Peking Cancer Hospital. The pancreaticoenteric anastomosis was determined based on the pancreatic texture and diameter of the main pancreatic duct. The amylase value of the drainage fluid was dynamically monitored postoperatively on days 3, 5 and 7. A low speed intermittent irrigation was performed in selected patients. Intraoperative and postoperative results were collected and compared between the pancreaticogastrostomy (PG) group and pancreaticojejunostomy (PJ) group., Results: From 2010 to 2019, 529 consecutive patients underwent pancreaticoduodenectomy. Pancreaticogastrostomy was performed in 364 patients; pancreaticojejunostomy was performed in 150 patients respectively. The clinically relevant pancreatic fistula (CR-POPF) was 9.8% and mortality was zero. The soft pancreas, diameter of main pancreatic duct≤3 mm, BMI ≥ 25, operation time > 330 min and pancreaticogastrostomy was correlated with postoperative pancreatic fistula significantly. The CR-POPF of PJ was significantly higher than that of PG in soft pancreas patients; the operation time of PJ was shorter than that of PG significantly in hard pancreas patients. Intraoperative blood loss and operation time of PG was less than that of PJ significantly in normal pancreatic duct patients (p < 0.05)., Conclusions: Individualized pancreaticoenteric anastomosis should be determined based on the pancreatic texture and pancreatic duct diameter. The appropriate anastomosis and postoperative management could prevent mortality.

Purpose: The level of albumin declines after surgery, and whether the difference between preoperative and postoperative albumin levels on postoperative day 1 has an effect on the development of postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) is unclear. Our aim was to evaluate the effect of albumin difference on POPF., Methods: A retrospective analysis of consecutive patients who had undergone DP between January 2016 and October 2018 at a single institution was conducted. Patient demographic data and perioperative data were analysed using univariate and multivariate models. Pancreatic fistula was defined by the 2016 International Study Group of Pancreatic Surgery criteria. All patients were followed for up to 90 days., Results: A total of 211 consecutive patients were identified. The POPF rate was 15.64%, and no 90-day mortality was observed. Five predictors were independently associated with POPF: albumin difference (OR 6.60, 95% CI 2.36-18.45, P < 0.001), pancreatic texture (OR 4.15, 95% CI 1.62-10.63, P = 0.003), operative time (OR 3.13, 95% CI 1.19-8.24, P = 0.021), intraoperative fluid transfusion (OR 4.85, 95% CI 1.70-13.79, P = 0.003), and cardiovascular disease (OR 5.38, 95% CI 1.99-14.55, P = 0.001)., Conclusions: Although DP can be performed with a low rate of mortality, POPF remains a common complication. Albumin difference is a new, accessible predictor for POPF following DP.

Background/aim: The usefulness of C-reactive protein-to-albumin ratio (CAR) as a predictive indicator for clinically-relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD) is unclear. We performed a retrospective analysis to identify reliable inflammatory indicators for prediction of CR-POPF after PD., Patients and Methods: We enrolled 160 consecutive patients who underwent PD. Multivariate logistic regression analysis was performed. The areas under curves (AUCs) were compared with the discriminatory ability of inflammatory indicators, namely, C-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), platelet count multiplied by C-reactive protein (P-CRP), and CAR., Results: The AUC for CAR on POD 3 to predict CR-POPF was 0.782 (p<0.001) and higher than that for CRP (0.773), NLR (0.652), PLR (0.504), and P-CRP (0.703). Multivariate analysis revealed that CAR on POD 3 was an independent predictive indicator of CR-POPF., Conclusion: CAR on POD 3 is a reliable predictor of CR-POPF after PD., (Copyright© 2019, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Objective: To investigate the prognostic factors of hyperamylasemia following pancreaticoduodenectomy (PD) . Methods: Clinical data of 359 patients were collected prospectively who underwent PD by the same group at Changhai Hospital of Navy Medical University from January 2017 to June 2018.There were 212 males and 147 females.The median age was 63 years old (range: 23 to 82 years old) .According to whether the patient's serum amylase was greater than 120 U/L at 0 or 1 day after surgery,the patients were divided into hyperamylasemia group and non-hyperamylasemia group. Univariate analysis and multivariate analysis were used to find out the prognostic factors of hyperamylasemia after PD. Results: Of the 359 patients, 238 cases (66.3%) developed hyperamylasemia.The incidence rate of clinically related pancreatic fistula (15.1% vs .2.5%, P< 0.01) , grade B/C post pancreatectomy hemorrhage (8.8% vs . 2.5%, P< 0.01) , and surgical site infection (9.2% vs . 3.3%, P= 0.04) was significantly higher in the hyperamylasemia group.The severity of complications (CD grade≥Ⅲ: 11.3% vs .4.1%, P= 0.023) and postoperative hospital stay (11 days vs . 9 days, P= 0.001) were higher in the hyperamylasemia group.In the multivariate analysis, the main pancreatic duct diameter (MPD) ≤3 mm ( OR= 4.469, 95% CI : 2.563-7.793, P< 0.01) , pathological type of disease (pancreatic cancer or pancreatitis) ( OR= 0.230, 95% CI : 0.122-0.436, P< 0.01) and soft texture of pancreas ( OR= 3.297, 95% CI : 1.930-5.635, P< 0.01) were independent prognostic factors for hyperamylasemia. Conclusions: Post-PD hyperamylasemia increased the incidence and severity of postoperative complications after PD.MPD≤3 mm, soft texture of pancreas and pathological type of disease were independent prognostic factors of hyperamylasemia.

Postoperative pancreatic fistula (PF) remains one of the most significant complications after pancreaticoduodenectomy (PD). Recently, studies have suggested that post-PD serum hyperamylasemia (HA) may be a risk factor. In this study, we evaluate the relationship of pancreas texture and post-operative serum amylase levels in determining PF risk. This retrospective cohort study evaluated all patients who underwent PD at Thomas Jefferson University from 2009 to 2014. The highest postoperative serum amylase level from postoperative day (POD) 0 to POD 5 was obtained. Chi-square analyses and odds ratio (OR) evaluated the relationship between pancreas texture, serum amylase level, and the development of PF. Data from 524 consecutive patients were analyzed. Serum amylase threshold value of 165 IU/L yielded greatest accuracy from the receiver operating characteristic curve analysis (Sensitivity, 0.70; specificity, 0.72). Grade B or C PF were more common among HA patients (20 vs 3%; P < 0.001). HA was associated with increased rates of PD-associated complications. On multivariable analysis, early postoperative serum HA was more predictive of PF risk (OR, 4.87; P < 0.001) than either pancreatic duct size ≤3 mm (OR, 2.97; P = 0.01) or pancreas texture (OR,1.87; P = 0.05)., Conclusion: The presence of HA on POD 0 or POD 1 is more predictive than soft pancreas texture or small pancreas duct size alone.

Background: Postoperative pancreatic fistula and pancreas-specific complications have a significant influence on patient management and outcomes after pancreatoduodenectomy. The aim of the study was to assess the value of serum C-reactive protein on the postoperative day 1 as early predictor of pancreatic fistula and pancreas-specific complications., Methods: Between 2013 and 2016, 110 patients underwent pancreaticoduodenectomy. Clinical, biological, intraoperative, and pathological characteristics were prospectively recorded. Pancreatic fistula was graded according to the International Study Group on Pancreatic Fistula classification. A composite endpoint was defined as pancreas-specific complications including pancreatic fistula, intra-abdominal abscess, postoperative hemorrhage, and bile leak. The diagnostic accuracy of serum C-reactive protein on postoperative day 1 in predicting adverse postoperative outcomes was assessed by ROC curve analysis., Results: Six patients (5%) died and 87 (79%) experienced postoperative complications (pancreatic-specific complications: n = 58 (53%); pancreatic fistula: n = 48 (44%)). A soft pancreatic gland texture, a main pancreatic duct diameter < 3 mm and serum C-reactive protein ≥ 100 mg/L on postoperative day 1 were independent predictors of pancreas-specific complications (p < 0.01) and pancreatic fistula (p < 0.01). ROC analysis showed that serum C-reactive protein ≥ 100 mg/L on postoperative day 1 was a significant predictor of pancreatic fistula (AUC: 0.70; 95%CI: 0.60-0.79, p < 0.01) and pancreas-specific complications (AUC: 0.72; 95%CI: 0.62-0.82, p < 0.01). ROC analysis showed that serum C-reactive protein ≥ 50 mg/L at discharge was a significant predictor of 90-day hospital readmission (AUC: 0.70; 95%CI: 0.60-0.79, p < 0.01)., Conclusions: C-reactive protein levels reliably predict risks of pancreatic fistula, pancreas-specific complications, and hospital readmission, and should be inserted in risk-stratified management algorithms after pancreaticoduodenectomy.

Introduction: Postoperative pancreatic fistula (POPF) is a serious complication after gastrectomy for gastric cancer. It is vitally important to detect signs of POPF in the early postoperative period and perform adequate management to avoid patient death. The aim of this study was to investigate the predictive indicators of POPF after laparoscopic gastrectomy for gastric cancer., Methods: The current study included 197 patients who were pathologically diagnosed with adenocarcinoma and underwent laparoscopic gastrectomy between January 2010 and December 2014 in our hospital., Result: Nine patients (5.6%) developed POPF of grade III or higher according to the Clavien-Dindo classification. There was no statistical difference between POPF and various clinicopathological indicators, including age, gender, BMI, extent of lymph node dissection, and operative procedure. With respect to postoperative laboratory data, however, the serum level of C-reactive protein on postoperative day 3 was significantly related to the development of POPF. Receiver-operating characteristic analysis indicated that optimal cut-off value of the serum level of C-reactive protein on postoperative day 3 was 17.0 mg/dL, with a sensitivity of 74.0, specificity of 88.0, positive predictive value of 0.14, and negative predictive value of 0.99., Conclusion: An elevated C-reactive protein level on postoperative day 3 can help physicians predict the likelihood of POPF and facilitate decision making regarding prompt clinical evaluation and therapeutic approaches for POPF., (© 2017 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd.)

Objectives: The evaluation of the risk of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy is crucial to optimize perioperative strategies. Many risk factors of POPF have been identified and were included in scores. Performances of these scores have to be improved because of the use of subjective and/or intraoperative factors. We tried to identify new risk factors of POPF that could improve the performance of validated scores., Methods: We analyzed data from a prospective database of 191 consecutive patients who underwent a pancreaticoduodenectomy. Recorded data included a comprehensive inventory of pre-, intra- and postoperative clinical, biological and radiological data., Results: The rate of POPF was significantly increased in patients with a normal preoperative lipase serum level (LSL) (29.8% vs 6.8%; P = 0.001). After multivariate analysis, a normal preoperative LSL was a strong independent risk factor of both POPF (odds ratio, 7.06; P = 0.001) and clinically relevant POPF (odds ratio, 3.11; P = 0.036). The addition of the normality of the preoperative LSL to the Fistula Risk Score significantly improved its performance (P < 0.001)., Conclusions: A normal preoperative LSL was a strong, easy, and objective preoperative risk factor of POPF. Its addition to the Fistula Risk Score improved its performance and allows a more accurate evaluation of the risk of POPF.

Aim: To investigate potential biomarkers for predicting postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD)., Methods: We prospectively recruited 83 patients to this study. All patients underwent PD (Child's procedure) at the Division of Hepatobiliary and Pancreas Surgery at the First Bethune Hospital of Jilin University between June 2011 and April 2015. Data pertaining to demographic variables, clinical characteristics, texture of pancreas, surgical approach, histopathological results, white blood cell count, amylase and choline levels in the serum, pancreatic/gastric drainage fluid, and choline and amylase levels in abdominal drainage fluid were included in the analysis. Potential correlations between these parameters and postoperative complications such as, POPF, acute pancreatitis, hemorrhage, delayed gastric emptying, and biliary fistula, were assessed., Results: Twenty-eight out of the 83 (33.7%) patients developed POPF. The severity of POPF was classified as Grade A in 8 (28%) patients, grade B in 16 (58%), and grade C in 4 (14%), according to the pancreatic fistula criteria. On univariate and multivariate logistic regression analyses, higher amylase level in the abdominal drainage fluid on postoperative day (POD)1 and higher serum amylase levels on POD4 showed a significant correlation with POPF ( P < 0.05). On receiver operating characteristic curve analysis, amylase cut-off level of 2365.5 U/L in the abdominal drainage fluid was associated with a 78.6% sensitivity and 80% specificity [area under the curve (AUC): 0.844; P = 0.009]. A cut-off serum amylase level of 44.2 U/L was associated with a 78.6% sensitivity and 70.9% specificity (AUC: 0.784; P = 0.05)., Conclusion: Amylase level in the abdominal drainage fluid on POD1 and serum amylase level on POD4 represent novel biomarkers associated with POPF development., Competing Interests: Conflict-of-interest statement: We declare that we do not have any commercial or associative interest that represents a conflict of interest in connection with the work submitted.

Background: An early recognition of clinically relevant pancreatic fistula (PF) after pancreaticoduodenectomy (PD) is essential., Methods: All consecutive patients who underwent PD in two institutions were included (2013-2015). In all patients amylase value in drains (AVD) was evaluated in postoperative day 1 (POD1). White-blood cell count (WBC), serum pancreatic amylase (SPA) and C-reactive protein (CRP) were routinely evaluated in POD1, POD2, and POD3. Receiver operator characteristic (ROC) curves were performed. Significant diagnostic cut-offs were tested in a multivariate model., Results: Overall, 463 patients underwent PD. Postoperative morbidity and mortality were 58% and 4%, respectively. Sixty-four patients (14%) had a clinically relevant PF (grade B or C). ROC curve analyses revealed that AVD on POD1 had the greatest area under the curve value (0.881, P < 0.0001) followed by CRP on POD3 (0.796, P < 0.0001). Multivariable analysis identified male gender (OR 2.29 95%CI: 1.12-4.70, P = 0.023), AVD on POD1>500 U/l (OR 21.72, 95%CI: 7.41-63.67, P < 0.0001), CRP on POD2 > 150 mg/l (OR 3.480, 95%CI: 1.21-9.99, P = 0.021), and CRP on POD3 > 185 mg/l (OR 6.738, 95%CI: 1.91-23.78, P = 0.003) as independent predictors of clinically relevant PF., Conclusion: The combination of CRP and AVD was effective in the early prediction of clinically relevant POPF after PD., (Copyright © 2017 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Early diagnosis of postoperative pancreatic fistula (POPF) is important for proper interventions. The preoperative, intraoperative and early postoperative biochemical markers have predictive value of POPF. The present study was to evaluate several simple biochemical parameters in the prediction of POPF., Methods: Patients who underwent pancreaticoduodenectomy in our center between 2006 and 2015 were reviewed retrospectively. Preoperative and early postoperative biochemical parameters were evaluated. Additionally, the relationship between POPF and pH and lactate level at the end of surgery were analyzed, and neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and red cell distribution width-to-platelet ratio (RPR) were calculated for postoperative days (PODs) 1 and 3. Diagnosis and grading of POPF were performed according to the standards of the International Study Group on Pancreatic Fistula. The patients were divided into two groups: Group 1 with no fistula or grade-A fistula; group 2 with grade-B or -C fistula. These simple biochemical markers were then compared between the two groups., Results: Serum amylase level was significantly higher at POD3, and pH level was significantly lower at the end of operation in group 2 compared with those in group 1. However, the serum amylase was below the upper limit of normal serum level and therefore, the difference was not significant in clinical practice. Receiver operating charecteristic curve analysis showed that pH level was a reliable predictor of POPF (area under the curve: 0.713; 95% CI: 0.573-0.853)., Conclusions: A low pH level at the end of pancreaticoduodenectomy was a risk factor of POPF. NLR, PLR, and RPR had no predictive value of POPF after pancreaticoduodenectomy.

Early detection of postoperative pancreatic fistula (POPF) may help to improve the outcome following pancreatic surgery, and exclusion of POPF may allow early drain removal which can accelerate recovery. The aim of this study was to evaluate the diagnostic accuracy of drain/plasma pancreatic amylase values on postoperative day 1 (DPA1/PPA1) in POPF by means of a systemic review and meta-analysis.Online journal databases and a manual search up to March 2015 were used. Studies clearly documenting DPA1 or PPA1 in predicting overall POPF (Grade 0 vs A+B+C) or clinically relevant POPF (Grade 0+A vs B+C) following pancreatic surgery were selected. Pooled predictive parameters were performed using STATA 12.0.Fifteen studies were finally identified with a total of 4331 patients. The pooled sensitivity and specificity of DPA1 were 0.92 (95% confidence interval (CI) 0.81-0.96) and 0.77 (95% CI 0.64-0.86) for predicting overall POPF and 0.79 (95% CI 0.61-0.90) and 0.83 (95% CI 0.74-0.89) for predicting clinically relevant POPF. The pooled sensitivity and specificity of PPA1 were 0.74 (95% CI 0.63-0.82) and 0.62 (95% CI 0.55-0.70) for overall POPF. After the DPA1 at/over cutoff values for overall POPF or clinically relevant POPF, corresponding post-test probability (Post-test (+)) (if pretest probability was 50%) was 80% and 82% respectively, while, if values were below the cutoff values, the post-test probability (Post-test (-)) was 10% and 20% respectively. Post-test (+) and Post-test (-) of PPA1 for overall POPF were 66% and 30% respectively. In subgroup analysis, the summary sensitivities of cutoff <1000 group and cutoff >1000 group were 0.96 (0.92-0.98) and 0.85 (0.64-0.95), respectively; the summary specificities were 0.59 (0.44-0.72) and 0.86 (0.80-0.91) respectively. Positive LR were 2.3 (1.7-3.3) and 6.2 (3.7-10.2) respectively. Negative LR were 0.06 (0.03-0.14) and 0.18 (0.07-0.47) respectively.DPA1 is a useful predictive test for overall POPF and clinically relevant POPF which has good sensitivity and specificity based on the current studies. Meanwhile, it should be cautiously applied to clinical practice because cutoffs had a wide range between studies.

Background: Anastomotic insufficiency after pancreatoduodenectomy (PD) represents a major complication in pancreatic surgery. Early detection and treatment of pancreatic fistulas (PF) are essential for the outcome of affected patients. Procalcitonin (PCT) is a biochemical marker which allows detection of bacterial infections. The aim of this study was to evaluate if PCT is suitable for early detection of PF after PD., Methods: In this prospective study patients undergoing PD from 08/2010 to 09/2012 were included into three groups: (1) patients without complications (n = 19), (2) patients with postoperative infections (n = 14) and (3) PF (n = 7). Using a defined study protocol, clinical (e.g., vital signs, drain fluid, etc.) and laboratory parameters (full blood count, inflammatory markers) were assessed daily for the first ten postoperative days., Results: 76 patients were assessed. 40 (52.6%) patients underwent PD and were included. CRP and PCT demonstrated an initial peak at the 1st to 3rd postoperative day with subsequent normalization. Patients with postoperative infections and PF showed a significant increase of PCT and CRP (p < 0.05) compared to patients without complications. Leucocyte counts demonstrated a variance in all three groups and clinical use for detection of complications was not evident., Conclusions: Patients with a postoperative complication revealed significantly increased levels of PCT and CRP without the expected normalization. PCT and/or CRP did not enable a distinction between patients with PF or postoperative infections. Thus, PCT does not seem to be suitable for detecting PF after PD and its use in the postoperative course after PD cannot be recommended.

Objectives: Despite improvements in surgical techniques, instruments and perioperative management, postoperative pancreatic fistula (POPF) remains a serious complication after pancreaticoduodenectomy. The aim of the present study was to characterize a high-risk group for POPF after pancreaticoduodenectomy using perioperative clinical variables of patients., Patients and Methods: This retrospective study comprised of 247 patients who had undergone pancreaticoduodenectomy between May 2000 and May 2013. Perioperative risk factors pertinent to development of POPF were investigated using univariate and multivariate analyses., Results: POPF developed in 43 out of 247 patients (17.4 %). In univariate analysis, male gender (p=0.005), higher postoperative serum amylase (p=0.025) and lower postoperative serum albumin (p=0.041) were significant risk factors for POPF. In multivariate analysis, male gender (p=0.008) and lower postoperative serum albumin (p=0.010) were found to be independent risk factors., Conclusion: Male gender and postoperative lower serum albumin were associated with the development of POPF after pancreaticoduodenectomy., (Copyright© 2015 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.)

Aim: To identify sensitive predictors of clinically relevant postoperative pancreatic fistula (POPF) at the acute phase after pancreatectomy., Methods: This study included 153 patients diagnosed as having POPFs at postoperative day (POD) 3 after either open pancreatoduodenectomy or distal pancreatectomy between January 2008 and March 2013. The POPFs were categorized into three grades based on the International Study Group on Pancreatic Fistula Definition, and POPFs of grades B or C were considered to be clinically relevant. The predictive performance for the clinically relevant POPF formation of values at PODs 1, 3 and 5 as well as time-dependent changes in levels of inflammatory markers, including white blood cell count, neutrophil count, total lymphocyte count, C-reactive protein (CRP), procalcitonin level, platelet-to-lymphocyte ratio and neutrophil-to-lymphocyte ratio, and amylase content in the drain fluid were compared using the receiver operating characteristic (ROC) curve and multivariable analyses. A scoring system for the prediction of clinically relevant POPFs was created using five risk factors identified in this study, and its diagnostic performance was also evaluated., Results: Over time, 77 (50%) of 153 enrolled patients followed a protracted course and were categorized as having clinically relevant POPFs. ROC curve analyses revealed that changes in CRP levels from POD 1 to POD 3 had the greatest area under the curve value (0.767) and that an elevated CRP level of 28.4 mg/L yielded the most optimal predictive value for clinically relevant POPFs. Multivariable analyses for the risk factors of clinically relevant POPFs identified invasive carcinomas of the pancreas and elevation of the CRP level (≥ 28.4 mg/L, from POD 1 to POD 3) as independent diagnostic factors for clinically relevant POPFs (OR 2.94, 95%CI: 1.08-8.55, P = 0.035 and OR 4.82, 95%CI: 1.25-20.2, P = 0.022, respectively). A gradual increase in the prevalence of clinically relevant POPFs in proportion to the risk classification score was confirmed. A highly elevated CRP level and a risk score ≥ 8 were significantly associated with a prolonged duration of drain placement and postoperative hospitalization., Conclusion: A steep rise in the serum CRP level from POD 1 to POD 3 was a highly predictive factor for subsequent clinically relevant POPFs.

Objectives: Drainage after pancreaticoduodenectomy (PD) remains controversial because the risk for uncontrolled postoperative pancreatic fistula (POPF) must be balanced against the potential morbidity associated with prolonged and possibly unnecessary drainage. This study investigated the utility of the level of serum amylase on the night of surgery [postoperative day (PoD) 0 serum amylase] to predict POPF., Methods: A total of 185 patients who underwent PD were studied. Occurrences of POPF were graded using the International Study Group on Pancreatic Fistula (ISGPF) classification. Receiver operating characteristic (ROC) analysis identified a threshold value of PoD 0 serum amylase associated with clinically significant POPF (ISGPF Grades B and C) in a test cohort (n = 45). The accuracy of this threshold value was then tested in a validation cohort (n = 140)., Results: Overall, 43 (23.2%) patients developed clinically significant POPF. The threshold value of PoD 0 serum amylase for the identification of clinically significant POPF was ≥ 130 IU/l (P = 0.003). Serum amylase of <130 IU/l had a negative predictive value of 88.8% for clinically significant POPF (P < 0.001). Serum amylase of ≥ 130 IU/l on PoD 0 and a soft pancreatic parenchyma were independent risk factors for clinically significant POPF., Conclusions: Postoperative day 0 serum amylase of <130 IU/l allows for the early and accurate categorization of patients at least risk for clinically significant POPF and may identify patients suitable for early drain removal., (© 2013 International Hepato-Pancreato-Biliary Association.)

Introduction: Early identification of patients at risk for developing pancreatic fistula (PF) after pancreaticoduodenectomy (PD) may facilitate prevention or treatment strategies aimed at reducing its associated morbidity., Materials and Methods: A retrospective review of 176 consecutive PD performed between 2006 and 2011 was conducted in order to analyze the association between the serum amylase on postoperative day 1 (POD1) and the development of PF., Results: Serum amylase was recorded on POD1 in 146 of 176 PD cases (83.0 %). Twenty-seven patients (18.5 %) developed a postoperative PF: 6 type A, 19 type B, and 2 type C. Patients with a PF had a mean serum amylase on POD1 of 659 ± 581 compared to 246 ± 368 in those without a fistula (p < 0.001). On logistic regression, a serum amylase >140 U/L on POD1 was strongly associated with developing a PF (OR, 5.48; 95 % CI, 1.94-15.44). Sensitivity and specificity of a postoperative serum amylase >140 U/L was 81.5 and 55.5 %, respectively. Positive and negative predictive values were 29.3 and 93.0 %, respectively., Conclusion: An elevated serum amylase on POD1 may be used, in addition to other prognostic factors, to help stratify risk for developing PF following PD.

Introduction: Pancreaticoduodenectomy (PD) has a high morbidity rate. Previous work has shown that hypoalbuminemia on postoperative day 1 (POD) to be contributory to post-esophagectomy complications. We set out to determine the impact of blood urea nitrogen (BUN) and albumin on POD 1 for patients undergoing PD., Methods: We examined 446 consecutive patients who underwent PD at the Thomas Jefferson University Hospital between January 1, 2000 and December 31, 2008. Complications were graded using the Clavien scale. We examined the incidence of complications based on POD 1 albumin <2.5 versus ≥2.5 mg/dl, as well as POD 1 BUN <10 vs. ≥10 g/dL., Results: Patients with a BUN <10 had a significantly decreased risk of any complication (p < 0.001), serious complication (p < 0.001), and pancreatic fistula (p = 0.011). On multivariate analysis, BUN ≥ 10 was the most significant predictor of grade III or above complication (p = 0.0019, hazard ration (HR) = 2.7) and pancreatic fistula (p = 0.016, HR = 2.6). POD 1 albumin <2.5 mg/dl was also an independent predictor of serious complication (p = 0.01, HR = 2.3). Patients with both risk factors had a 31 % chance of developing serious complications and 18.5 % risk of developing pancreatic fistula, while those patients with neither risk factor had a 6.5 and 3.6 % risk, respectively., Conclusion: Serum albumin and BUN on POD 1 are important predictors of perioperative morbidity following PD. These low-cost and easily accessible tests can be used as a prognostic tool to predict adverse surgical outcomes.

Objectives: Pancreatic fistula or pancreas-related infectious complications are one of the most common surgical complications after pancreatic surgery. The aims of this study were, first, to reveal the risk factors for clinically relevant pancreas-related infectious complications and, second, to identify those risk factors that are obtainable within the first 3 postoperative days., Methods: One hundred seven consecutive patients who underwent pancreaticoenteral anastomosis between October 2007 and November 2010 were enrolled., Results: There were 36 patients with clinical pancreas-related infectious complications among 107 in this series of patients. Univariate and multivariate analyses revealed that a narrow main pancreatic duct diameter (<3 mm) was an independent risk factor for clinically relevant pancreas-related infectious complication. Univariate and multivariate analyses also revealed that a body temperature of 38°C or higher on postoperative day 3 (POD3), a leukocyte count of 9.8 × 10(9)/L or greater on POD3, and a drain fluid amylase level of 3000 IU/L or higher on POD3 were significant predictive factors for clinically relevant pancreas-related infectious complication for 58 patients with a narrow main pancreatic duct., Conclusions: In view of the clinical variables obtained on POD3, such as amylase levels in drain effluent, body temperature, and leukocyte count, clinically relevant pancreas-related infections could be predicted well.

Background/aims: Treatment of blunt injury of the pancreas in children remains controversial. Some prefer non-surgical treatment, whereas others prefer surgical management in selected cases. This report reviews our management strategies of children with blunt pancreatic trauma and their outcomes., Methodology: Medical records of 7 children with traumatic pancreatic injury were retrospectively analyzed in our institutions. In addition, we reviewed the pertinent literature., Results: There were 2 males and 5 females with a median age of 7.6 years. Pancreatic injury was classified in 3 patients as grade I, in 2 patients as grade II, and in 2 patients as grade III (AAST). The two grade III children underwent ERCP preoperatively. ERCP showed injury to the main pancreatic duct in both of these patients, and emergency surgery was performed for both of them. These operative methods were spleen-preserving distal pancreatectomy and only drainage at the margin of the pancreas with non-resection, respectively. All 7 cases survived., Conclusions: ERCP is helpful for the diagnosis of suspected cases in pancreatic injury with grade III. In hemorrhagic shock state, appropriate surgical procedures with only drainage at the margin of the pancreas are useful for the treatment of pancreatic fistula in children.

Unlabelled: BACKGROUND/STUDY AIMS: Somatostatin and total parenteral nutrition (TPN) are routinely used in the treatment of pancreatic and enterocutaneous fistulae. The objective of this clinical randomised cross-over study was to investigate the serum levels of somatostatin infused alongside TPN by a separate intravenous line, and when it had been added to the TPN mixture., Patients/methods: The subjects were recruited by the treating physicians and the nutrition nurses. From the patients who started the study, no one dropped out. Ten patients were treated with a standard TPN mixture and somatostatin 6 mg/day. Patients were randomised to two possible regimens: 'somatostatin plus TPN--somatostatin separately--somatostatin plus TPN' or 'somatostatin separately--somatostatin plus TPN--somatostatin separately'. Each regimen consisted of 3 x 3 days of therapy, during which, serum levels of somatostatin were measured daily. Pre- and posttreatment samples were also analysed., Results: When somatostatin was infused separately, the mean serum level was 884.8 pg/ml (SD: 557.3; range: 54-1900). When added to TPN, the mean serum level was 807.5 pg/ml (SD: 505.8; range 162-2279) (p value of difference = 0,473). The mean pretreatment level was 17.1 pg/ml (SD: 7.5; range: 8-33), and posttreatment was 32.8 pg/ml (SD: 26.5; range: 16-97)., Conclusions: These results demonstrate that serum levels of somatostatin are similar in both treatment regimens and therefore may be added to a TPN mixture.

Background: Internal pancreatic fistulas are well recognized complications of chronic pancreatitis., Methods: Six patients with internal pancreatic fistulas were treated over a period of 5 years from 1995 to 1999. Four patients presented with ascites, one patient presented with ascites and bilateral pleural effusion and the sixth patient presented with left-sided pleural effusion. Five patients were chronic alcoholics and in one patient the cause of pancreatitis was not clear. Although the serum amylase was mildly elevated the levels of amylase in the aspirated fluid were consistently elevated (more than 800 Somogyi units/100 mL), along with the level of proteins (> or = 3 g/100 mL), and on this basis the diagnosis was made. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated pancreatic ductal disruption in four cases. Initial treatment was conservative, consisting of nasogastric aspiration, nil per oral, antisecretory drugs, repeated paracentesis or thoracocenthesis and total parenteral nutrition (TPN). In two patients naso-pancreatic drains (NPD) were placed across the disrupted pancreatic duct., Results: In one patient conservative treatment with NPD was successful, and the remaining five patients required surgical intervention. There was no mortality. Two patients developed surgery-related complications that were successfully managed, but they required an extended hospital stay., Conclusion: Internal pancreatic fistulas should be treated initially non-operatively; if this is not effective, operative therapy should be considered without delay.

Discovery on a protein electrophoregram of a bisalbuminemia can orientate according to its migration fast or slow to an hereditary mutation of an amino acid, or an acquired form by excess of beta lactamines due to renal insufficiency or by the rupture of a pancreatic pseudocyst in the peritoneum. This is this late mechanism that we report in this case of bisalbuminemia related to an opened pancreatic pseudocyst secondary to an adenoma of the parathyroid gland.

The penetration of ciprofloxacin in pancreatic juice was investigated in 5 patients with pancreatic fistula. The drug was administered as a single oral dose of 500 mg after which serial samples of pancreatic juice and serum were collected for ciprofloxacin assay. The following pharmacokinetic parameters (mean +/- SD) were estimated from the serum level versus time curves: clearance 11.51 +/- 2.85 (ml/min/kg); Vd area 3.08 +/- 1.20 ml/kg; terminal half-life 3.10 +/- 0.92 h; mean residence time 5.64 +/- 1.40 h. Ciprofloxacin serum levels declined rapidly after the third hour, whereas concentrations in pancreatic juice remained elevated (above 1 mg/1) for nearly 12 h. The pancreatic juice/serum ciprofloxacin concentration ratio increased gradually fom 0.63 +/- 0.45 after 0.5 h to 6.18 +/- 4.59 after 12 h (mean +/- SD). Our data indicate that while the drug elimination half-life from the serum is short, the time-course of ciprofloxacin levels in the pancreatic juice conforms to a much slower disappearance rate. In particular, the ciprofloxacin levels achieved in pancreatic juice are constantly greater than the MICs of the bacteria generally responsible for pancreatic infections.