Post-operative acute pancreatitis after major pancreatic resections: from a clinical insight to an International Study Group of Pancreatic Surgery research project

Starting from an insight that emerged in the daily clinical practice, postoperative acute pancreatitis has become an increasingly recognized complication after major pancreatic resections, but its incidence and clinical impact, and even its existence quickly became a matter of debate. The aim of the project was to observe, describe, analyze, and eventually develop a universally accepted definition for standardized reporting and outcome comparison. The phenomenon was initially observed and described on a retrospectively collected series of consecutive major pancreatic resection. Results were then reproduced and confirmed on a prospectively collected series of patients. At this point, a comprehensive systematic review of the literature of post-operative acute pancreatitis and post-operative hyperamylasemia was carried out to obtain a complete picture of the available evidence. The phenomenon was deeply analyzed using the prospective series to identify specific characteristics able to give a unique definition. All data collected were shared among the members of the International Study Group of Pancreatic Surgery and, eventually, a universally accepted definition of post-pancreatectomy acute pancreatitis was reached. The whole project is developed in a series of six papers published on surgical journals from 2018 to 2021. In the final paper, the ISGPS defines PPAP as an acute inflammatory condition of the pancreatic remnant occurring in the setting of a partial pancreatic resection and initiated early in the perioperative period within the first 3 postoperative days. This pathophysiologic process can present various degrees of severity and several local and systemic complications, resulting in a deviation from the expected postoperative course. A sustained increase in serum amylase activity greater than the specific institutional upper limit of normal, which persists within at least the first 48 hours postoperatively, is necessary for the diagnosis. To be defined as PPAP, however, this condition needs to be confirmed by cross-sectional imaging and to be clinically relevant to the patient. The presence of a consensus definition and grading system will serve as a foundation to open new perspectives in identifying diagnostic and prognostic criteria for PPAP and recognizing all the complications associated with this condition. Hopefully, treatments to decrease the occurrence or the burden of complications related directly to PPAP will then be established

Open pancreaticoduodenectomy: setting the benchmark of time to functional recovery

Purpose No accepted benchmarks for open pancreaticoduodenectomy (PD) exist. The study assessed the time to functional recovery after open PD and how this could be affected by the magnitude of midline incision (MI).Materials and methods Prospective snapshot study during 1 year. Time to functional recovery (TtFR) was assessed for the entire cohort. Further analyses were conducted after excluding patients developing a Clavien-Dindo >= 2 morbidity and after stratifying for the relative length of MI.Results The overall median TtFR was 7 days (n = 249), 6 days for uncomplicated patients (n = 124). A short MI (SMI, < 60% of xipho-pubic distance, n = 62) was compared to a long MI (LMI, n = 62) in uncomplicated patients. The choice of a SMI was not affected by technical issues and provided a significantly shorter TtFR ( 5 vs 6 days, p = 0.002) especially for pain control (4 vs. 5 days, p = 0.048) and oral food intake (5 vs. 6 days, p = 0.001).Conclusion Functional recovery after open PD with MI is achieved within 1 week from surgery in half of the patients. This should be the appropriate benchmark for comparison with minimally invasive PD. Moreover, PD with a SMI is feasible, safe, and associated with a faster recovery

Identifying key outcome metrics in pancreatic surgery, and how to optimally achieve them

Background: Indicators of effectiveness and quality of care are of greatest importance in gauging the direct benefit of a new surgical technique, such as minimally-invasive pancreatic resections, when being compared with established approaches.Methods: Current expert opinion on minimally-invasive pancreatic resection (MIPR) was presented at the first MIPR state of the art conference during 12th world congress of the International HepatoPancreato-Biliary Association.Results: Studies exploring outcome of the minimally-invasive approach, alone or compared with open surgery, should consider all the necessary indicators of quality ensuring a high level of clinical care. Such studies should be implemented in a context that guarantees the correct indication for surgery, lower mortality rates, a low burden of post-operative morbidity through early recognition of adverse events and prevention of predictable complications, high standards of oncological "radicality", prompt recovery with access to adjuvant therapy as soon as possible, and reduction of health-care related costs.Discussion: Only by integrating MIPR with the outcome-improving effect of a dedicated pancreatic team will it be possible to assess more precisely the putative benefits of this minimally-invasive approach

Cystic Pancreatic Lesions Beyond the Guidelines: Can we Make an Evidence-Based Decision Whether to Resect or to Observe?

Pancreatic cystic neoplasms (PCNs) are no longer considered as rare entities because their prevalence in the general population ranges from 3–20%. They are usually asymptomatic, incidentally discovered, and diagnosed in the seventh decade of life. The main clinical concern with regard to PCNs is related to their risk of malignant progression, which is relevant for those PCNs that produce mucin. Since 2006, several sets of international guidelines have proposed algorithms for the management of PCNs, and these have been subsequently validated by several studies. Retrospective review of the literature shows that current treatment of PCNs remains unsatisfactory because the guidelines are based on a low level of evidence. However, the guidelines are able to correctly identify lesions that can be safely followed and, as occurs in vaccination campaigns, they are able to exercise a preventive effect in the general population

Postoperative hyperamylasemia (POH) and acute pancreatitis after pancreatoduodenectomy (POAP): State of the art and systematic review

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

Pancreaticoduodenectomy for distal cholangiocarcinoma: surgical results, prognostic factors, and long-term follow-up

Purpose Prognostic indicators for distal cholangiocarcinoma have not been widely confirmed because of its rarity. Despite the early appearance of symptoms, it has a very poor prognosis. The aim of this study was to identify prognostic factors in patients undergoing pancreaticoduodenectomy (PD) for distal bile duct cancer (DBDC) in a high-volume center for pancreatic disease. Methods From January 2000 to December 2013, 1490 PD were performed for periampullary disease. Data from all patients with histologically proven cholangiocarcinoma were reviewed. Preoperative data, post-operative complications, pathologic features, and survival were investigated. Results Among 50 histologically proven DBDC (3.3 %), 4 patients who underwent CBD resection were excluded. Thus, the study population consisted of 46 patients. Overall surgical morbidity rate was 67.4 %; mortality was nil. Major complications were pancreatic fistula (47.8 %), abdominal collections (34.8 %), post-pancreatectomy hemorrhage (21.7 %), and delayed gastric emptying (10.9 %). The majority of resections were R0 (73.9 %). The presence of metastatic lymph nodes (N1) was identified in 76.1 % of cases. Among N1 cases, the most frequently involved lymph nodes were pancreaticoduodenal nodes (50 %), hepatoduodenal ligament nodes (21.7 %), superior mesenteric artery nodes (8.7 %), and anterior hepatic artery nodes (4.3 %). Overall, survival rates were 88.8, 40, and 18 % at 1, 3, and 5 years, respectively. Median survival was 31 months. By univariate analysis, only tumor grading and nodal metastasis were predictors of poor prognosis (p<0.05). These findings were not confirmed in multivariate analysis. Conclusions This study shows that DBDC is a rare entity even if large surgical series are reviewed. Tumor differentiation and nodal status have been confirmed as important prognostic factors. Pancreaticoduodenectomy remains the procedure of choice in order to obtain free surgical margins and in order to harvest the correct number of lymph nodes for a correct staging

Postoperative Acute Pancreatitis Following Pancreaticoduodenectomy: A Determinant of Fistula Potentially Driven by the Intraoperative Fluid Management

OBJECTIVE: The aim of the study is to characterize postoperative acute pancreatitis (POAP). SUMMARY BACKGROUND DATA: A standardized definition of POAP after pancreaticoduodenectomy (PD) has been recently proposed, but specific studies are lacking. METHODS: The patients were extracted from the prospective database of The Pancreas Institute of Verona. POAP was defined as an elevation of the serum pancreatic amylase levels above the upper limit of normal (52\u200aU/L) on postoperative day (POD) 0 or 1. The endpoints included defining the incidence and predictors of POAP and investigating the association of POAP with postoperative pancreatic fistula (POPF). RESULTS: The study population consisted of 292 patients who underwent PD. The POAP and POPF rates were 55.8% and 22.3%, respectively. POAP was an independent predictor of POPF (OR 3.8), with a 92% sensitivity and 53.7% specificity (AUC 0.79). Preoperative exocrine insufficiency (OR 0.39), neoadjuvant therapy (OR 0.29) additional resection of the pancreatic stump margin (OR 0.25), soft pancreatic texture (OR 4.38), and Main Pancreatic Duct (MPD) diameter 643\u200amm (OR 2.86) were independent predictors of POAP. In high-risk patients, an intraoperative fluid administration of 643\u200aml/kg/h was associated with an increased incidence of POAP (24.6 vs. 0%, P = 0.04) and POPF (27.6 vs. 11.4%, P = 0.05). CONCLUSION: This study represents the first clinical application of the only available definition of POAP as a specific complication of pancreatic surgery. POAP is associated with an increased occurrence of POPF and overall morbidity and could potentially be avoided through a specific intraoperative fluid regimen in high-risk pancreas

Seasonal variations in pancreatic surgery outcome A retrospective time-trend analysis of 2748 Whipple procedures

Observing cyclic patterns in surgical outcome is a common experience. We aimed to measure this phenomenon and to hypothesize possible causes using the experience of a high-volume pancreatic surgery department

Characterization of postoperative acute pancreatitis (POAP) after distal pancreatectomy

Postoperative acute pancreatitis has recently been reported as a specific complication after pancreatoduodenectomy. The aim of this study was to characterize postoperative acute pancreatitis after distal pancreatectomy