Nomogram predicts CR-POPF in open central pancreatectomy patients with benign or low-grade malignant pancreatic neoplasms

Abstract

IntroductionCentral pancreatectomy (CP) is a standard surgical procedure for benign and low-grade malignant pancreatic neoplasms in the body and neck of the pancreas. Higher incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) after CP than after pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) has been reported, but no nomogram for prediction of CR-POPF after open CP has been previously established.MethodsPatients undergoing open CP for benign or low-grade malignant pancreatic neoplasms in the department of Hepatobiliary and Pancreatic (HBP) surgery of Shanghai Changhai Hospital affiliated to Naval Medical University between January 01, 2009 and December 31,2020 were enrolled. Pre-, intra- and post-operative parameters were analyzed retrospectively.ResultsA total of 194 patients, including 60 men and 134 women, were enrolled with median age of 52 years (21~85 years). 84 patients (43.3%) were overweight (BMI>23.0 Kg/m2) and 14 (7.2%) were obese (BMI>28.0 Kg/m2). Pathological diagnoses ranged from serous cystic neoplasm (32.5%), solid pseudopapillary neoplasm (22.2%), pancreatic neuroendocrine tumor (20.1%), intraductal papillary mucinous neoplasm (18.0%) to mucinous cystic neoplasm (5.2%). All patients had soft pancreatic texture. Main pancreatic duct diameters were ≤0.3cm for 158 patients (81.4%) and were ≥0.5cm in only 12 patients (6.2%). A stapler (57.7%) or hand-sewn closure (42.3%) were used to close the pancreatic remnant. The pancreatic anastomosis techniques used were duct to mucosa pancreaticojejunostomy (PJ)-interrupted suture (47.4%), duct to mucosa PJ-continuous suture (43.3%), duct to mucosa “HO” half-purse binding PJ (5.2%) and invaginating pancreaticogastrostomy (4.1%). Post-surgical incidences of CR-POPF of 45.9%, surgical site infection of 28.9%, postpancreatectomy hemorrhage of 7.7% and delayed gastric emptying of 2.1% were found. Obesity and pancreatic anastomosis technique were independent risk factors of CR-POPF, with a concordance index of 0.675 and an Area Under the Curve of 0.678.DiscussionThis novel nomogram constructed according to obesity and pancreatic anastomosis technique showed moderate predictive performance of CR-POPF after open CP.

The standard deviation of CT value may become a new way to predict pancreatic fistula: a single-center large sample data study

“…In the present study, higher BMI was an independent predictor of CR-POPF after LPD. The possible reason for this is that the common complications of peripancreatic uid collection in overweight/obese patients after surgery may be attributed to wider resection area, more tissue damage, larger dead space, more frequent drainage dysfunction, and delayed mobilization [23] compared with patients with normal BMI [22] . Obese patients also have a stronger in ammatory response to surgical invasion [24] , and high levels of in ammatory factors have also been found in patients with high BMI [25] .…”

Outcomes of Duct-to-Mucosa vs. Invagination Pancreatojejunostomy: Toward a Personalized Approach for Distal Pancreatic Stump Anastomosis in Central Pancreatectomy?

“…However, a CP is associated with high morbidity rates (higher than distal pancreatectomies) [ 5 , 6 , 7 , 9 ] and exceptionally high rates of postoperative pancreatic fistulae (POPF) [ 2 , 3 ]. Thus, even in large series of patients from high-volume centers, the POPF rates after CP are around 45.3–63% [ 10 , 11 , 12 ]. A potential explanation for the high rates of POPF is the presence of two remaining pancreatic stumps (proximal and distal) [ 11 , 13 ] and the fact that the indications for CP are mainly represented by benign cystic or neuroendocrine pancreatic tumors [ 7 , 11 ], a situation widely considered to be associated with increased rates of POPF [ 14 , 15 ].…”

“…Thus, even in large series of patients from high-volume centers, the POPF rates after CP are around 45.3–63% [ 10 , 11 , 12 ]. A potential explanation for the high rates of POPF is the presence of two remaining pancreatic stumps (proximal and distal) [ 11 , 13 ] and the fact that the indications for CP are mainly represented by benign cystic or neuroendocrine pancreatic tumors [ 7 , 11 ], a situation widely considered to be associated with increased rates of POPF [ 14 , 15 ]. Furthermore, most patients with CP have soft pancreas texture and small Wirsung ducts [ 11 ], two determinant risk factors for POPF development [ 14 , 15 ].…”

“…A potential explanation for the high rates of POPF is the presence of two remaining pancreatic stumps (proximal and distal) [ 11 , 13 ] and the fact that the indications for CP are mainly represented by benign cystic or neuroendocrine pancreatic tumors [ 7 , 11 ], a situation widely considered to be associated with increased rates of POPF [ 14 , 15 ]. Furthermore, most patients with CP have soft pancreas texture and small Wirsung ducts [ 11 ], two determinant risk factors for POPF development [ 14 , 15 ]. Nevertheless, the distal pancreatic stump anastomosis after CP remains a significant source of postoperative complications, namely POPF.…”

“…The jejunum is primarily used for distal pancreatic stump anastomoses after CP [ 1 , 4 , 8 , 11 , 12 , 16 ]. However, in a few centers, an anastomosis with the stomach is preferred for the distal pancreatic stump after CP [ 10 , 17 , 18 ], especially in a minimally invasive approach [ 19 , 20 ].…”