Early recognition of clinically relevant postoperative pancreatic fistula: a systematic review

Smits, F. Jasmijn; Molenaar, I. Quintus; Besselink, Marc G.; Rinkes, Inne H.M. Borel; Eijck, Casper H.J. van; Busch, Olivier R.; Santvoort, Hjalmar C. van

doi:10.1016/j.hpb.2019.07.005

Cited by 41 publications

(26 citation statements)

References 56 publications

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“…In these patients, signs of inflammation are the only early signs of postoperative pancreatic fistula. These signs are, however, nonspecific and often not recognized as potential pancreatic leakage, especially in centers where only few patients with pancreatic fistula are seen annually [45]. We believe, however, that in these patients with a high risk of life threatening complications, early abdominal CT scan should be performed and peripancreatic fluid collections should be managed aggressively with percutaneous drainage in patients showing signs of systemic inflammation [9,48,49].…”

Section: Discussionmentioning

confidence: 99%

Care after pancreatic resection according to an algorithm for early detection and minimally invasive management of pancreatic fistula versus current practice (PORSCH-trial): design and rationale of a nationwide stepped-wedge cluster randomized trial

Smits

Henry

Eijck

et al. 2020

Preprint

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Background Pancreatic resection is a major abdominal operation with 50% risk of postoperative complications. A common complication is pancreatic fistula, which may have severe clinical consequences such as postoperative bleeding, organ-failure and death. The objective of this study is to investigate whether implementation of an algorithm for early detection and minimally invasive management of pancreatic fistula may improve outcomes after pancreatic resection. Methods This is a nationwide stepped-wedge, cluster randomized, superiority trial, designed in adherence to the CONSORT guidelines. During a period of 22 months, all Dutch centers performing pancreatic surgery will cross over in a randomized order from current practice to best practice according to the algorithm. This evidence- and consensus based algorithm will provide daily multilevel advice on the management of patients after pancreatic resection (i.e. indication for abdominal imaging, antibiotic treatment, percutaneous drainage and removal of abdominal drains). The algorithm is designed to aid early detection and minimally invasive step-up management of postoperative pancreatic fistula. Outcomes of current practice will be compared with outcomes after implementation of the algorithm. The primary outcome is a composite of major complications (i.e. postpancreatectomy bleeding, new-onset organ failure and death) and will be measured in a sample size of at least 1600 patients undergoing pancreatic resection. Secondary endpoints include the individual components of the primary endpoint and other clinical outcomes, healthcare resource utilization and costs analysis. Follow-up will be up to 90 days after pancreatic resection. Discussion It is hypothesized that a structured nationwide implementation of a dedicated algorithm for early detection and minimally invasive step-up management of postoperative pancreatic fistula will reduce the risk of major complications and death after pancreatic resection, as compared to current practice.

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Section: Discussionmentioning

confidence: 99%

Care after pancreatic resection according to an algorithm for early detection and minimally invasive management of pancreatic fistula versus current practice (PORSCH-trial): design and rationale of a nationwide stepped-wedge cluster randomized trial

Smits

Henry

Eijck

et al. 2020

Preprint

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“…1). [34,[41][42][43][44] In the "draining-tract-targeted" management of POPFs, treatment was started as soon as possible after diagnosing a POPF to reduce the risk of subsequent life-threatening complications (Fig. 1) [34].…”

Section: Discussionmentioning

confidence: 99%

“…[34,[41][42][43][44] In the "draining-tract-targeted" management of POPFs, treatment was started as soon as possible after diagnosing a POPF to reduce the risk of subsequent life-threatening complications (Fig. 1) [34]. "Draining-tract-targeted" management included three different approaches: (1) fistulography through the surgical drains with their subsequent replacement, or repositioning, over a wire [37]; (2) drain replacement with some pigtail or malecot 8-10 Fr one of which was inserted as soon as possible through the fistula into the gastrointestinal lumen [38,45,46]; (3) drain replacement under fluoroscopic control and closed lavage with 500 to 3000 mL of natural saline depending on the amylase level in the drained fluid [39].…”

Section: Discussionmentioning

confidence: 99%

“…An important advance for the purposes of assessing the efficacy of different mitigating procedures on the number and severity of POPFs came with the international classification of fistulae [32,33]. Early recognition of a POPF in its harmless state of biochemical leak might help to reduce the risk of subsequent life-threatening complications [34].…”

Section: Introductionmentioning

confidence: 99%

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Systematic review and meta-analysis of surgical drain management after the diagnosis of postoperative pancreatic fistula after pancreaticoduodenectomy: draining-tract-targeted works better than standard management

Pedrazzoli

Brazzale

2020

Langenbecks Arch Surg

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Purpose Drains’ role after pancreaticoduodenectomy (PD) is debated by proponents of no drain, draining selected cases, and early drain removal. The aim of the study was to assess the effect of “standard” and “draining-tract-targeted” management of abdominal drains still in situ after diagnosing a postoperative pancreatic fistula (POPF). Methods PubMed and Scopus were searched for “pancreaticoduodenectomy or pancreatoduodenectomy or duodenopancreatectomy,” “Whipple,” “proximal pancreatectomy,” “pylorus-preserving pancreatectomy,” and “postoperative pancreatic fistula or POPF.”. Main outcomes included clinically relevant (CR) POPF, grade-C POPF, overall mortality, POPF-related mortality, and CR-POPF-related mortality. Secondary outcomes were incidence of radiological and/or endoscopic interventions, reoperations, and completion pancreatectomies. Results Overall, 12,089 studies were retrieved by the search of the English literature (01/01/1990–31/12/2018). Three hundred and twenty-six studies (90,321 patients) reporting ≥ 100 PDs and ≥ 10 PD/year were finally included into the study. Average incidences were obtained by averaging the incidence rates reported in the single articles. Pooled incidences were calculated by combining the number of events and the total number of patients considered in the various studies. These were then meta-analyzed using DerSimonian and Laird’s (1986) method. Pearson’s chi-squared test was used to compare pooled incidences between groups. Post hoc testing was used to see which groups differed. The meta-analyzed incidences were compared using a fixed effect for moderators. “Draining-tract-targeted” management showed a significant advantage over “standard” management in four clinically relevant outcomes out of eight according to pool analysis and in one of them according to meta-analysis. Conclusion Clinically, “draining-targeted” management of POPF should be preferred to “standard” management.

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“…Many studies also recommend use of C-reactive Protein. (CRP) as a marker of infections in colorectal and pancreatic surgeries [29,30,31]. However, majority of studies showed that highest sensitivity and specificity of CRP in predicting infectious complications is at day 5 which may be too late particularly in Enhanced Recovery After Surgery or ERAS era and also as per survival sepsis guidelines PCT levels can also help in de-escalations of post-operative antibiotics.…”

Section: Discussionmentioning

confidence: 99%

Post-Operative Infectious Complications in Pancreatic Surgery – A Systemic Review and Updated Meta-analysis

Vasavada¹,

Patel²

2020

Preprint

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Aim of study:Aim of this meta-analysis is to evaluate post-operative procalcitonin as a marker to predict post- operative infectious complications after pancreatic surgeries.Material and Methods:Systemic literature search was performed using MEDLINE, EMBASE and to identify studies evaluating the diagnostic accuracy of Procalcitonin (PCT) as a predictor for detecting infectious complications on postoperative days (POD) 3 and 5 following pancreatic surgery. A meta-analysis was performed using random effect model and pooled predictive parameters for POD 3 and 5 were derived. Geometric means were calculated for PCT cut offs. Results:6 studies included day 3 PCT analysis, 2 studies included both day 3 and day 5 analysis. Total data of 471 patients were derived. 161 patients developed infectious complications. Pooled sensitivity, specificity, pooled area under curve, diagnostic odds ratio (DOR), positive and negative like hood ratio of day 3 PCT were 74%,79%,0.8453, 11.03,3.17 and 0.31 respectively. Pooled sensitivity, specificity, diagnostic odds ratio (DOR), positive and negative like hood ratio of day 5 PCT were 83%,70%,12.91,2.91 and 0.25 respectively. Geometric means for PCT cut off for day 3 and 5 were 0.80 and 0.43. Conclusion:Postoperative procalcitonin particularly day 3 procalcitonin levels predict post-operative infectious complications following pancreatic surgeries.

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Early recognition of clinically relevant postoperative pancreatic fistula: a systematic review

Cited by 41 publications

References 56 publications

Care after pancreatic resection according to an algorithm for early detection and minimally invasive management of pancreatic fistula versus current practice (PORSCH-trial): design and rationale of a nationwide stepped-wedge cluster randomized trial

Care after pancreatic resection according to an algorithm for early detection and minimally invasive management of pancreatic fistula versus current practice (PORSCH-trial): design and rationale of a nationwide stepped-wedge cluster randomized trial

Systematic review and meta-analysis of surgical drain management after the diagnosis of postoperative pancreatic fistula after pancreaticoduodenectomy: draining-tract-targeted works better than standard management

Post-Operative Infectious Complications in Pancreatic Surgery – A Systemic Review and Updated Meta-analysis

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