Matteo De Pastena

Discordance Between Perioperative Antibiotic Prophylaxis and Wound Infection Cultures in Patients Undergoing Pancreaticoduodenectomy

IMPORTANCE Wound infections after pancreaticoduodenectomy (PD) are common. The standard antibiotic prophylaxis given to prevent the infections is often a cephalosporin. However, this decision is rarely guided by microbiology data pertinent to PD, particularly in patients with biliary stents. OBJECTIVE To analyze the microbiology of post-PD wound infection cultures and the effectiveness of institution-based perioperative antibiotic protocols. DESIGN, SETTING, AND PARTICIPANTS The pancreatic resection databases of 3 institutions (designated as institutions A, B, or C) were queried on patients undergoing PD from June 1, 2008, to June 1, 2013, and a total of 1623 patients were identified. Perioperative variables as well as microbiology data for intraoperative bile and postoperative wound cultures were analyzed from June 1, 2008, to June 1, 2013. INTERVENTIONS Perioperative antibiotic administration. MAIN OUTCOMES AND MEASURES Wound infection microbiology analysis and resistance patterns. RESULTS Of the 1623 patients who underwent PD, 133 with wound infections (8.2%) were identified. The wound infection rate did not differ significantly across the 3 institutions. The predominant perioperative antibiotics used at institutions A, B, and C were cefoxitin sodium, cefazolin sodium with metronidazole, and ampicillin sodium-sulbactam sodium, respectively. Of the 133 wound infections, 89 (67.1%) were deep-tissue infection, occurring at a median of 8 (range, 1-57) days after PD. A total of 53 (40.0%) of the wound infections required home visiting nurse services on discharge, and 73 (29.1%) of all PD readmissions were attributed to wound infection. Preoperative biliary stenting was the strongest predictor of postoperative wound infection (odds ratio, 2.5; 95% CI, 1.58-3.88; P = .03). There was marked institutional variation in the type of microorganisms cultured from both the intraoperative bile and wound infection cultures (Streptococcus pneumoniae, 114 cultures [47.9%] in institution A vs 3 [4.5%] in institution B; P = .001) and wound infection cultures (predominant microorganism in institution A: Enterococcus faecalis, 18 cultures [51.4%]; institution B: Staphylococcus aureus, 8 [43.9%]; and institution C: Escherichia coli, 17 [36.2%], P = .001). Similarly, antibiotic resistance patterns varied (resistance pattern in institution A: cefoxitin, 29 cultures [53.1%]; institution B: ampicillin-sulbactam, 9 [69.2%]; and institution C: penicillin, 32 [72.7%], P < .001). Microorganisms isolated in intraoperative bile cultures were similar to those identified in wound cultures in patients with post-PD wound infections. CONCLUSIONS AND RELEVANCE The findings of this large-scale, multi-institutional study indicate that intraoperative bile cultures should be routinely obtained in patients who underwent preoperative endoscopic retrograde cholangiopancreatography since the isolated microorganisms closely correlate with those identified on postoperative wound cultures. Institution-specific internal reviews should amend current protocols for antibiotic prophylaxis to reduce the incidence of wound infections following PD.

Alternative Fistula Risk Score for Pancreatoduodenectomy (a-FRS): Design and International External Validation

Objective: The aim of this study was to develop an alternative fistula risk score (a-FRS) for postoperative pancreatic fistula (POPF) after pancreatoduodenectomy, without blood loss as a predictor. Background: Blood loss, one of the predictors of the original-FRS, was not a significant factor during 2 recent external validations. Methods: The a-FRS was developed in 2 databases: the Dutch Pancreatic Cancer Audit (18 centers) and the University Hospital Southampton NHS. Primary outcome was grade B/C POPF according to the 2005 International Study Group on Pancreatic Surgery (ISGPS) definition. The score was externally validated in 2 independent databases (University Hospital of Verona and University Hospital of Pennsylvania), using both 2005 and 2016 ISGPS definitions. The a-FRS was also compared with the original-FRS. Results: For model design, 1924 patients were included of whom 12% developed POPF. Three predictors were strongly associated with POPF: soft pancreatic texture [odds ratio (OR) 2.58, 95% confidence interval (95% CI) 1.80–3.69], small pancreatic duct diameter (per mm increase, OR: 0.68, 95% CI: 0.61–0.76), and high body mass index (BMI) (per kg/m2 increase, OR: 1.07, 95% CI: 1.04–1.11). Discrimination was adequate with an area under curve (AUC) of 0.75 (95% CI: 0.71–0.78) after internal validation, and 0.78 (0.74–0.82) after external validation. The predictive capacity of a-FRS was comparable with the original-FRS, both for the 2005 definition (AUC 0.78 vs 0.75, P = 0.03), and 2016 definition (AUC 0.72 vs 0.70, P = 0.05). Conclusion: The a-FRS predicts POPF after pancreatoduodenectomy based on 3 easily available variables (pancreatic texture, duct diameter, BMI) without blood loss and pathology, and was successfully validated for both the 2005 and 2016 POPF definition. The online calculator is available at www.pancreascalculator.com.

Impact of preoperative biliary drainage on postoperative outcome after pancreaticoduodenectomy: An analysis of 1500 consecutive cases

Implications of preoperative biliary drain on morbidity and mortality after pancreatoduodenectomy are still controversial. The present study aims to assess the impact of preoperative biliary drain on postoperative outcome and to define optimal serum bilirubin cut‐off to recommend biliary drainage in patients undergoing pancreatoduodenectomy.

Pancreaticoduodenectomy in patients ≥ 75 years of age: Are there any differences with other age ranges in oncological and surgical outcomes? Results from a tertiary referral center

AIM To compare surgical and oncological outcomes after pancreaticoduodenectomy (PD) in patients ≥ 75 years of age with two younger cohorts of patients. METHODS The prospectively maintained Institutional database of pancreatic resection was queried for patients aged ≥ 75 years (late elderly, LE) submitted to PD for any disease from January 2010 to June 2015. We compared clinical, demographic and pathological features and survival outcomes of LE patients with 2 exact matched cohorts of younger patients [≥ 40 to 64 years of age (adults, A) and ≥ 65 to 74 years of age (young elderly, YE)] submitted to PD, according to selected variables. RESULTS The final LE population, as well as the control groups, were made of 96 subjects. Up to 71% of patients was operated on for a periampullary malignancy and pancreatic cancer (PDAC) accounted for 79% of them. Intraoperative data (estimated blood loss and duration of surgery) did not differ among the groups. The overall complication rate was 65.6%, 61.5% and 58.3% for LE, YE and A patients, respectively, P = NS). Reoperation and cardiovascular complications were significantly more frequent in LE than in YE and A groups (P = 0.003 and P = 0.019, respectively). When considering either all malignancies and PDAC only, the three groups did not differ in survival. Considering all benign diseases, the estimated mean survival was 58 and 78 mo for ≥ and < 75 years of age (YE + A groups), respectively (P = 0.012). CONCLUSION Age is not a contraindication for PD. A careful selection of LE patients allows to obtain good surgical and oncological results.

Palliative therapy in pancreatic cancer—interventional treatment with radiofrequency ablation/irreversible electroporation

Pancreatic cancer (PC) is a solid tumor with still a dismal prognosis. Diagnosis is usually late, when the disease is metastatic or locally advanced (LAPC). Only 20% of PC are amenable to surgery at the time of diagnosis and the vast majority of them, despite radically resected will unavoidably recur. The treatment of LAPC is a challenge. Current guidelines suggest to adopt systemic therapies upfront, based on multi-drugs chemotherapy regimens. However, the vast majority of patients will never experience conversion to surgical exploration and radical resection. Thus, there a large subgroup of LAPC patients where the only therapeutic chance is to offer palliative treatments, such as interventional ablative treatments, in order to obtain a cytoreduction of the tumor, trying to delay its growth and spread. Radiofrequency ablation (RFA) and irreversible electroporation (IRE) demonstrated to be safe and effective in obtaining a local control of the disease with some promising oncological results in terms of overall survival (OS). However, they should be adopted as a treatment strategy to adopt in parallel with other systemic therapies, within multidisciplinary choices. They are not free from complications, even serious, thus they should applied only in specialized centers of pancreatology. This review depicts the state of the art of the two techniques.

Laparoscopic hemi-splenectomy

Laparoscopic splenectomy is now established as a safe and feasible procedure. However, it remains associated with some short- and long-term postoperative complications, especially infectious complications. To our knowledge, this is the first report (with video) focusing on the safety and feasibility of laparoscopic hemi-splenectomy and its surgical outcomes for the treatment of splenic abscesses causing septic emboli. This technique combines the immunological benefits of partial splenectomy and the postoperative benefits of a minimally invasive approach. Further studies are needed to standardize this technique and to assess its immunological and surgical benefits.

Chyle leak after pancreatic surgery: validation of the International Study Group of Pancreatic Surgery classification

Background: Chyle leak is an uncommon complication after pancreatic surgery. The chyle leak incidence, definition, diagnosis, and treatment had been reported heterogeneously so far. Recently a consensus definition and grading system was published by the International Study Group for Pancreatic Surgery. This study aims to evaluate the differences in the clinical and economic burden of chyle leak applying the new definition. Methods: All data from patients who underwent pancreatic surgery for any disease from January 2014 to December 2016 were retrieved from the institutional prospective database. The 2017 International Study Group for Pancreatic Surgery definition and classification were applied. The classification was validated analyzing the differences in major complications, length of stay, and hospitalization costs. Results: A total of 945 patients was the final population. A chyle leak was reported in 43 patients (4.5%). Grade A chyle leak occurred in 10 patients (23.3%), Grade B chyle leak in 31 patients (72.1%), and Grade C chyle leak in 2 patients (4.6%). Chyle leak occurred as unique postoperative complication in 29 cases (67.4%). The economic analysis showed that the average costs of the 3 grades were 2,806, 7,150 and 15,684 euros respectively (P < .001). Furthermore, the length of stay, the rates of septic events, and major complications were significantly different among the 3 grades (P = .008, P = .004, and P < .001, respectively). Of note, we did not find any intraoperative factor associated with chyle leak. Conclusion: The present study confirms the validity of the International Study Group for Pancreatic Surgery classification of chyle leak. The 3 grades of chyle leak proposed identify reliably clinical and economical differences among the chyle leak cases.

Screening/surveillance programs for pancreatic cancer in familial high-risk individuals: A systematic review and proportion meta-analysis of screening results

BACKGROUND/OBJECTIVES Screening/surveillance programs for pancreatic cancer (PC) in familial high-risk individuals (FPC-HRI) have been widely reported, but their merits remain unclear. The data reported so far are heterogeneous-especially in terms of screening yield. We performed a systematic review and meta-analysis of currently available data coming from screening/surveillance programs to evaluate the proportion of screening goal achievement (SGA), overall surgery and unnecessary surgery. METHODS We searched MEDLINE, Embase, PubMed and the Cochrane Library database from January 2000 to December 2016to identify studies reporting results of screening/surveillance programs including cohorts of FPC-HRI. The main outcome measures were weighted proportion of SGA, overall surgery, and unnecessary surgery among the FPC-HRI cohort, using a random effects model. SGA was defined as any diagnosis of resectable PC, PanIN3, or high-grade dysplasia intraductal papillary mucinous neoplasm (HGD-IPMN). Unnecessary surgery was defined as any other final pathology. RESULTS In a meta-analysis of 16 studies reporting on 1551 FPC-HRI cases, 30 subjects (1.82%), received a diagnosis of PC, PanIN3 or HGD-IPMNs. The pooled proportion of SGA was 1.4%(95% CI 0.8-2, p < 0.001, I2 = 0%). The pooled proportion of overall surgery was 6%(95% CI 4.1-7.9, p < 0.001, I2 = 60.91%). The pooled proportion of unnecessary surgery was 68.1%(95% CI 59.5-76.7, p < 0.001, I2 = 4.05%); 105 subjects (6.3%) received surgery, and the overall number of diagnoses from non-malignant specimens was 156 (1.5 lesion/subject). CONCLUSIONS The weighted proportion of SGA of screening/surveillance programs published thus far is excellent. However, the probability of receiving surgery during the screening/surveillance program is non-negligible, and unnecessary surgery is a potential negative outcome.

Postoperative Management in Patients Undergoing Major Pancreatic Resections

Perioperative care following pancreatectomy in “high-volume” center is based on the application of standardized protocols. The clinical practice includes multimodal strategies that aim to limit postoperative complications, to improve recovery, and to reduce the length of hospital stay after surgery. This chapter discusses the perioperative care of patients undergoing pancreatic resections focusing on major topics such as fluid management, antimicrobial prophylaxis, feeding, drain management, administration of prophylactic somatostatin or its analogues, and radiological findings following surgery.

Laparoscopic Pancreatoduodenectomy With Modified Blumgart Pancreaticojejunostomy

Minimally invasive pancreatic resections are technically demanding but rapidly increasing in popularity. In contrast to laparoscopic distal pancreatectomy, laparoscopic pancreatoduodenectomy (LPD) has not yet obtained wide acceptance, probably due to technical challenges, especially regarding the pancreatic anastomosis. The study describes and demonstrates all steps of LPD, including the modified Blumgart pancreaticojejunostomy. Indications for LPD are all pancreatic and peri-ampullary tumors without vascular involvement. Relative contra-indications are body mass index >35 kg/m2, chronic pancreatitis, mid-cholangiocarcinomas and large duodenal cancers. The patient is in French position, 6 trocars are placed, and dissection is performed using an (articulating) sealing device. A modified Blumgart end-to-side pancreaticojejunostomy is performed with 4 large needles (3/0) barbed trans-pancreatic sutures and 4 to 6 duct-to-mucosa sutures using 5/0 absorbable multifilament combined with a 12 cm, 6 or 8 Fr internal stent using 3D laparoscopy. Two surgical drains are placed alongside the pancreaticojejunostomy. The described technique for LPD including a modified Blumgart pancreatico-jejunostomy is well standardized, and its merits are currently studied in the randomized controlled multicenter trial. This complex operation should be performed at high-volume centers where surgeons have extensive experience in both open pancreatic surgery and advanced laparoscopic gastro-intestinal surgery.