Pancreaticojejunostomy Versus Pancreaticogastrostomy After Pancreaticoduodenectomy: An Up-to-date Meta-analysis of RCTs Applying the ISGPS (2016) Criteria
Abstract:The goal of our study was to compare the impact of pancreaticogastrostomy (PG) versus pancreaticojejunostomy (PJ) on the incidence of complications after pancreaticoduodenectomy. A systematic search was performed using RevMan 5.3 software. A meta-analysis showed that PG was not superior to PJ in terms of postoperative pancreatic fistula (POPF). In multicenter randomized controlled trials, the incidence of POPF was lower in patients undergoing PG than in those undergoing PJ. However, PG was associated with an i… Show more
“…Of the several available techniques, pancreaticogastrostomy (PG) and pancreatojejunostomy (PJ) are the most commonly performed. Some RCTs[28-35] and meta-analyses[36-44] have compared PG and PJ. Topal et al[32] reported comparative results of the occurrences of POPFs (grade B or C) in an RCT with 329 patients.…”
Section: Pancreaticoduodenectomymentioning
confidence: 99%
“…Several meta-analysis results on this issue have been reported and demonstrated the apparent superiority of PG in the risk for POPF despite the slight difference in the included studies[36-44]. However, PJ was found to have physiological advantages compared to PG although the follow-up periods were relatively short[34,45-48].…”
Postoperative pancreatic fistula (POPF) is one of the most severe complications after pancreatic surgeries. POPF develops as a consequence of pancreatic juice leakage from a surgically exfoliated surface and/or anastomotic stump, which sometimes cause intraperitoneal abscesses and subsequent lethal hemorrhage. In recent years, various surgical and perioperative attempts have been examined to reduce the incidence of POPF. We reviewed several well-designed studies addressing POPF-related factors, such as reconstruction methods, anastomotic techniques, stent usage, prophylactic intra-abdominal drainage, and somatostatin analogs, after pancreaticoduodenectomy and distal pancreatectomy, and we assessed the current status of POPF. In addition, we also discussed the current status of POPF in minimally invasive surgeries, laparoscopic surgeries, and robotic surgeries.
“…Of the several available techniques, pancreaticogastrostomy (PG) and pancreatojejunostomy (PJ) are the most commonly performed. Some RCTs[28-35] and meta-analyses[36-44] have compared PG and PJ. Topal et al[32] reported comparative results of the occurrences of POPFs (grade B or C) in an RCT with 329 patients.…”
Section: Pancreaticoduodenectomymentioning
confidence: 99%
“…Several meta-analysis results on this issue have been reported and demonstrated the apparent superiority of PG in the risk for POPF despite the slight difference in the included studies[36-44]. However, PJ was found to have physiological advantages compared to PG although the follow-up periods were relatively short[34,45-48].…”
Postoperative pancreatic fistula (POPF) is one of the most severe complications after pancreatic surgeries. POPF develops as a consequence of pancreatic juice leakage from a surgically exfoliated surface and/or anastomotic stump, which sometimes cause intraperitoneal abscesses and subsequent lethal hemorrhage. In recent years, various surgical and perioperative attempts have been examined to reduce the incidence of POPF. We reviewed several well-designed studies addressing POPF-related factors, such as reconstruction methods, anastomotic techniques, stent usage, prophylactic intra-abdominal drainage, and somatostatin analogs, after pancreaticoduodenectomy and distal pancreatectomy, and we assessed the current status of POPF. In addition, we also discussed the current status of POPF in minimally invasive surgeries, laparoscopic surgeries, and robotic surgeries.
“…Surgical mortality rates have declined following advances in surgical techniques and the perioperative care associated with PD. However, the complexity of the surgical procedure leads to considerable morbidity after PD 2,3. With the increase in life expectancy in the fast-growing population of elderly patients, pancreatic procedures are increasingly being performed in this patient population.…”
Background/AimsWe investigated the effect of preoperative malnutrition on postoperative surgical outcomes in elderly patients undergoing pancreatoduodenectomy for periampullary neoplasms.MethodsThis prospective cohort study enrolled 154 patients aged ≥65 years with periampullary neoplasms. Using the Mini Nutritional Assessment tool, patients were categorized into three groups according to their preoperative nutritional status: well-nourished (13.0%), at-risk-of-malnutrition (59.7%), and malnourished (27.3%).ResultsSignificant intergroup differences were observed in preoperative body mass index (25.6±2.4 kg/m2 [well-nourished] vs 23.4±2.6 kg/m2 [at-risk-of-malnutrition] vs 21.1±2.8 kg/m2 [malnourished], p<0.001). The overall morbidity significantly differed between the well-nourished and malnourished groups (20% vs 50.0%, p=0.024). The rates of clinically significant postoperative pancreatic fistula were significantly different among groups (p=0.035). Univariate and multivariate analyses showed that the at-risk-of-malnutrition or malnourished status (hazard ratio [HR], 3.45; p=0.037) and intraoperative blood loss (HR, 1.01; p=0.040) significantly affected the overall postoperative morbidity in elderly patients.ConclusionsBefore surgery, 87.0% of patients were classified into the at-risk-of-malnutrition or malnourished group. Compared with well-nourished patients, patients with nutritional issues showed a higher overall surgical morbidity. Improved preoperative nutritional status leads to favorable surgical outcomes in elderly patients.
“…These risk factors can be categorized into 3 groups: The technically demanding group, intraoperative volume status–related group, and poor general condition group (Figure 2 ). The risk factors in the technically demanding group (soft pancreas[ 2 , 5 , 6 , 9 ], small pancreatic duct[ 6 , 9 , 29 ], extrapancreatic lesion[ 6 ], absence of preoperative pancreatitis or low lipase level[ 30 ], absence of preoperative endoscopic biliary decompression, absence of neoadjuvant radiotherapy, and high BMI[ 7 ]) indicate potential difficulty in reconstructing the pancreatic-enteric anastomosis, which could cause POPF. Patients with pancreatic cancer, chronic pancreatitis, or neoadjuvant treatment have increased pancreatic fibrosis and a lower incidence of POPF than other PD patients[ 30 , 31 ].…”
Section: Discussionmentioning
confidence: 99%
“…In this way, we expect our platform to help select patients who need more intense therapy and establish effective (and cost-effective) treatment strategies for POPF. Various mitigation strategies have been proposed to reduce the occurrence and morbidity of POPF, including technical variations, such as, pancreaticogastrostomy reconstruction[ 2 , 42 ], dunking/invaginating anastomosis[ 1 , 43 , 44 ], absorbable mesh patches[ 45 , 46 ], and the use of intraperitoneal drains[ 29 ], anastomotic stents[ 47 ], and prophylactic somatostatin analogues[ 4 , 48 , 49 ]. As a part of those efforts, we have an ongoing trial of this risk score wherein we are applying a somatostatin analogue during postoperative days 0–3 in high-risk patients.…”
BACKGROUND
Despite advancements in operative technique and improvements in postoperative managements, postoperative pancreatic fistula (POPF) is a life-threatening complication following pancreatoduodenectomy (PD). There are some reports to predict POPF preoperatively or intraoperatively, but the accuracy of those is questionable. Artificial intelligence (AI) technology is being actively used in the medical field, but few studies have reported applying it to outcomes after PD.
AIM
To develop a risk prediction platform for POPF using an AI model.
METHODS
Medical records were reviewed from 1769 patients at Samsung Medical Center who underwent PD from 2007 to 2016. A total of 38 variables were inserted into AI-driven algorithms. The algorithms tested to make the risk prediction platform were random forest (RF) and a neural network (NN) with or without recursive feature elimination (RFE). The median imputation method was used for missing values. The area under the curve (AUC) was calculated to examine the discriminative power of algorithm for POPF prediction.
RESULTS
The number of POPFs was 221 (12.5%) according to the International Study Group of Pancreatic Fistula definition 2016. After median imputation, AUCs using 38 variables were 0.68 ± 0.02 with RF and 0.71 ± 0.02 with NN. The maximal AUC using NN with RFE was 0.74. Sixteen risk factors for POPF were identified by AI algorithm: Pancreatic duct diameter, body mass index, preoperative serum albumin, lipase level, amount of intraoperative fluid infusion, age, platelet count, extrapancreatic location of tumor, combined venous resection, co-existing pancreatitis, neoadjuvant radiotherapy, American Society of Anesthesiologists’ score, sex, soft texture of the pancreas, underlying heart disease, and preoperative endoscopic biliary decompression. We developed a web-based POPF prediction platform, and this application is freely available at
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CONCLUSION
This study is the first to predict POPF with multiple risk factors using AI. This platform is reliable (AUC 0.74), so it could be used to select patients who need especially intense therapy and to preoperatively establish an effective treatment strategy.
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