Postoperative acute necrotizing pancreatitis of the pancreatic remnant (POANP): a new definition of severe pancreatitis following pancreaticoduodenectomy

Abstract

Background: Recent studies have suggested acute pancreatitis as a separate pancreatic-specific complication following pancreaticoduodenectomy. However, data on necrotizing pancreatitis of the pancreatic remnant is limited. This study aimed to evaluate parameters of patients undergoing completion pancreatectomy (CP) after initial pancreaticoduodenectomy (PD) and compare those with or without necrosis of the pancreatic remanent. Methods: Patients who underwent CP following PD between January 2005 and December 2017 were identified from a prospectively collected database. Perioperative parameters were recorded, and patients were divided into those with or without histological evidence of necrosis of the pancreatic remnant. Results: Postoperative acute necrotizing pancreatitis (POANP) was histologically detected in 33 (41%) of 79 patients after CP. Serum CRP levels on POD 2 and the day of revision were significantly higher in the POANP group (p < 0.001 for each). POANP was reflected by higher APACHE II and SOFA scores after PD (P < 0.001 for each). Although patients with POANP had an earlier revision, length of ICU and total hospital stay was prolonged (p < 0.001 for each). POANP was associated with more major complications (Clavien-Dindo 3) and more often necessitated reoperations within 30 days (p < 0.001 for each). Conclusion: Patients requiring CP following PD for POANP have an increased risk of major complications, and longer hospital stay. CRP levels, APACHE II and SOFA score, seem to correlate with the severity and might predict POANP. Universally accepted definitions with a clinically validated grading system of severity for POAP and POANP are needed to facilitate appropriate treatment strategies and enable comparison of future studies.

Postpancreatectomy Acute Pancreatitis (PPAP)

“…The presence of an ischemic/inflammatory process of the pancreatic remnant was suggested as the etiology in several pathologic reports, particularly in series considering operative revisions for Grade C POPF 11,20,37 . These patients indeed represent the most severe and rare scenarios of PPAP (Fig.…”

“…2). The pathologic findings indicative of PPAP included in such cases acute necrotizing pancreatitis in 41% to 57% of surgical specimens of completion pancreatectomies for grade-C POPF 11,37 …”

“…For this reason, the current definition suggests this criterion for the POH definition. Nevertheless, some papers have also reported serum lipase as a diagnostic parameter 11,24,60 . As serum amylase may not be routinely available at all centers, serum lipase may be considered, but further detailed evaluations are requested.…”

“…The occurrence of an acute inflammatory process of the pancreatic parenchyma after pancreatic resections has been reported, 1–3 but the existence of clinically evident postpancreatectomy acute pancreatitis (PPAP) as a distinct complication has been challenged or, at least, considered to be a rare event 4–8 . Recently, emerging evidence defines PPAP as a local inflammatory/ischemic process of the pancreatic remnant, occurring more frequently than previously thought, which is able to trigger further postoperative morbidity 9–19 …”

Risk Factors and Clinical Impacts of Post-Pancreatectomy Acute Pancreatitis After Pancreaticoduodenectomy: A Single-Center Retrospective Analysis of 298 Patients Based on the ISGPS Definition and Grading System

“…This result provided a possible explanation for the polarization of PPAP incidence in the literature. Recent study ( 27 ) showed that necrotizing pancreatitis of the remnant pancreas confirmed by histological section was found in 33 out of 79 (41%) patients who underwent completion pancreatectomy after initial PD due to unfavorable complications. The postoperative pancreatitis not only occurred in the PD or other partial pancreatectomy but also was reported in scoliosis surgery ( 28 ), aortic dissection ( 29 ), renal transplantation ( 30 ), and gynecologic and obstetric surgery ( 31 ), and the incidence ranged from 0.29% to 5.9%.…”