Maria Rachele Angiolini

Role of C-Reactive Protein Assessment as Early Predictor of Surgical Site Infections Development after Pancreaticoduodenectomy

Background: Surgical site infections (SSIs) are extremely common in pancreatic surgery and explain its considerable morbidity and mortality, even in tertiary centers. Early detection of these complications, with the help of laboratory assays, improve clinical outcome. The aim of the present study is to evaluate C-reactive protein (CRP) diagnostic accuracy as early predictor of SSIs after pancreaticoduodenectomy (PD). Methodology: We considered 251 consecutive PD. We prospectively recorded preoperative clinical and anthropometric data, intraoperative details and the postoperative outcome. In the first pool of consecutive patients (n = 150), we analyzed CRP levels from postoperative day 1 to 7 and investigated the prediction of SSIs. We then validated the diagnostic accuracy on the following 101 consecutive cases. Results: At multivariate analysis, high BMI and preoperative biliary stenting appeared to be independently associated with SSIs and organ-space SSI development. The CRP cutoff of 17.27 mg/dl on postoperative day 3 (78% sensitivity, 79% specificity) and of 14.72 mg/dl on postoperative day 4 (87% sensitivity, 82% specificity) was in a position to predict the course of 78.2 and 80.2% of patients, respectively. Conclusions: CRP on postoperative days 3 and 4 seems able to predict postoperative course, selecting patients deserving intensification of diagnostic assessment; patients not satisfying these conditions could be reasonably directed toward early discharge.

Morphological Features of Pancreatic Stump, Other than Wirsung Diameter and Pancreatic Texture, Influence Pancreatic Fistula Rate After Pancreaticoduodenectomy

Context Pancreaticoduodenectomy (PD) is still characterized by high morbidity rates even in high volume centers, mainly represented by postoperative pancreatic fistula (POPF) and its associated further consequences. Wirsung diameter and pancreatic texture are well known features related to increased POPF risk. However, limited information about the relationship between morphological features of pancreatic stump and POPF onset is available. Objective Aim of the study was to evaluate the relationship between pancreatic stump morphology, intra-operatively assessed, and the occurrence of POPF in patients undergoing PD in an high volume center. Methods Between January 2010 and June 2012 we performed 136 PDs for benign and malignant disease; in a subgroup composed by 72 cases we realized a prospective study recording intra-operative measurements of the remnant pancreatic stump, recording surgeon’s judgment about pancreatic texture, and highlighting the caliber of main pancreatic duct, its position and the whole area. Between March 2011 and June 2012, in a consecutive series of 72 PD, we prospectively recorded the following characteristics of the pancreatic stump: surgeon’s judgment about pancreatic texture, diameter of main pancreatic duct, the whole area of pancreatic section (approximately calculated as elliptic), the distance between Wirsung duct and cranio-caudal and antero-posterior margins. In all patients, post-operative complications were recorded. Results Pancreatic fistula occurred in 19 cases (23.8%), 10 of them clinically significant (grade B and C according to ISGPF classification). In univariate analysis, mean Wirsung diameter resulted significantly smaller in patients with POPF (3.18 vs . 4.48 mm; P=0.007) and in patients with clinically significant POPF (P=0.015); searching for a cut off value, Wirsung diameter smaller than 4 mm demonstrated an association with higher POPF incidence (37.5% vs . 4.35%; P=0.003). Similarly, soft pancreas texture resulted associated with an increasing POPF rate (75% vs . 7%; P<0.001). Analyzing pancreatic stump morphology, we observed a relationship between larger stump areas and POFP development (206 mm 2 in POPF cases vs . 131 mm 2 in patients without fistula; P=0.017); moreover, main pancreatic duct decentralization appeared significantly associated with a lower POPF risk (more evident on antero-posterior axis than on cranio-caudal; P=0.019 and P=0.144, respectively). In multivariate analysis, only pancreatic stump soft texture and Wirsung diameter smaller than 4 mm were associated with POPF. Conclusion This study confirms small Wirsung diameter and soft pancreatic texture as the main determinants for POPF development. Moreover, an higher risk of failure of pancreatic anastomosis is also observed in large pancreatic stumps and when main pancreatic duct is centrally located.

Enucleation of Pancreatic Head Tumors Combined With Pre-Operative Wirsung Stenting, Intra-Operative Ultrasounds and Absorbable Fibrin Sealant Patch Application: Experience on 13 Cases

Context Benign/low malignant tumors or metastasis from renal cancer of the pancreatic head can be treated by enucleation; this procedure is technically demanding and it is often followed by high morbidity rates. Objective To analyze the peri-operative outcome of our series of enucleations for tumors of the pancreatic head. Methods From January 2010 to June 2012 29 out of 149 resected periampullary tumors were cystic neoplasms, 15 were neuroendocrine tumors (NET), 1 was metastasis from renal cancer and 1 was pseudopapillary solid tumor; in 13 of them (28% of 46 patients with pancreatic diseases eligible for atypical resection) an enucleation was performed. Enucleation was contraindicated when the lesion was deeply embedded in gland’s parenchyma involving Wirsung or originating from main pancreatic duct itself (main duct type IPMN), and in case of overt malignant appearance. We analyze the features of patients who underwent enucleation. Endoscopic ultrasound was performed preoperatively in 10 patients. ERCP with Wirsung stenting was realized when the distance between the main pancreatic duct and the lesion was less than 3 mm (4 cases). In patients submitted to stent positioning the mean distance between the lesion and the Wirsung duct was 1.9 mm while in the other group of patients it was 5 mm (P<0.05, t test). Intra-operative US was performed in all patients. At the end an absorbable fibrin sealant patch (Tachosil ® ) was placed on the area of enucleation. Results The mean diameter of the lesion was 1.9±1.1 cm (range: 1-4.5 cm); histology revealed 2 benign side branch IPMNs, 9 G1 NET, 1 metastasis from renal cancer and 1 pseudopapillary solid tumor. Mean operative time was 209.9±60.3 minutes and mean blood loss was 97.7±63.8 mL. No mortality was observed. Overall morbidity was 46% (including POPF rate of 31%): 4 POPF (2 grade B and 2 grade A). Mean length of hospital stay was 8.5±2.7 days. The reoperation rate was nihil. Readmission regarded only 1 patient. Conclusion Enucleation is a good alternative to pancreaticoduodenectomy in benign/low malignant tumors of the pancreatic head. Pre-operative Wirsung stenting, intra-operative ultrasounds and Tachosil ® application appear related to a satisfactory postoperative outcome.

Laparoscopic Versus Open Left Pancreatectomy: Short Term Outcome and Cost-Benefit Analysis

Context An increasing number of surgeons are today performing laparoscopic left pancreatectomy (LLP), since available nonrandomized studies demonstrated its feasibility, safety and oncologic adequacy. However, most existing data come from small single-institution reports or from heterogeneously composed multicenter comparisons. Moreover, there is very limited information about economic implications of minimally invasive pancreatic surgery. Objective This study reports our experience in laparoscopic left pancreatectomy compared with open technique (OLP), assessing perioperative outcomes and financial impact of this procedure in a high volume surgical setting. Methods Between February 2009 and June 2011 we performed 112 left pancreatectomies, 53 of which (47%) were LLP. Excluding the initial learning curve, the remaining 43 patients were matched with a control group selected from our perspective electronic database. Match criteria were gender, age, ASA score, BMI, lesion site, malignant or benign disease. Results Mean operative time was similar (LLP 216±61 min; OLP 214±7 min; P=0.885), blood loss was reduced in LLP (388±371 mL vs. 571±599 mL, P=0.092), especially in cancer patients (514±350 mL vs . 946±787 mL, P=0.072); intraoperative transfusion and unplanned splenectomy rates were similar. Larger lesions were associated with increased unplanned splenectomy rate. Conversion rate (CR) was 18%; higher BMI (>30 kg/m 2 ) and pancreatic body site were associated with increased CR. There were no differences in positive margin rates, number of nodes examined and number of N1 patients. There was no mortality in both groups. Overall morbidity was equable (63% in LLP, 60% in OLP; P=0.958), as well as major complication rate (7% in LLP, 3% in OLP; P=0.604). Clinically significant pancreatic fistula rate was 14% in LLP and 9% in OLP (P=0.728). No grade C fistulas were observed. An equal proportion of patients in each group was discharged before removing surgical drain. Delayed gastric empting, wound and urinary tract infection were more frequent in OLP. Mean LOS was 8.37 days in LLP vs . 8.81 days in OLP (P=0.481); LOS in non complicated patients was 6.96 days in LLP vs . 7.50 days in OLP (P=0.220). Mean number of diagnostic test, transfusion rate, antibiotic administration and readmission rate were similar. Each patient of LLP group saved €168.47 because of shorter LOS and slightly fewer complication cost, generating however an extra cost of €767,01 due to more expensive surgical instruments. Conclusion This study confirms safety and oncologic adequacy of this technique, identifying probable risk factors for conversion and demonstrating economic sustainability of LLP. Final balance still have to be realized considering indirect costs as shorter home convalescence, quality of life and better cosmetic result.