Fluorescence-based pancreas stump perfusion is associated with postoperative acute pancreatitis after pancreatoduodenectomy a prospective cohort study

Doussot, Alexandre; Decrock, Marc; Calame, Paul; Georges, Pauline; Turco, Célia; Lakkis, Zaher; Heyd, Bruno

doi:10.1016/j.pan.2021.05.009

Cited by 10 publications

(12 citation statements)

References 28 publications

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“…Previous prospective studies investigating nonsuture-related perfusion of the pancreatic stump during open pancreatoduodenectomy also reported that blood supply to the pancreatic stump was associated with the rate of POPF. 10 , 11 Unfortunately, multivariable logistic regression analysis to assess the value of hypoperfusion in relation to other known risk factors for POPF was not possible due to the low number of events.…”

Section: Discussionmentioning

confidence: 99%

Intraoperative Fluorescence Imaging During Robotic Pancreatoduodenectomy to Detect Suture-Induced Hypoperfusion of the Pancreatic Stump as a Predictor of Postoperative Pancreatic Fistula (FLUOPAN): Prospective Proof-of-concept Study

Chen,

Lof,

Zwart

et al. 2023

Annals of Surgery Open

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Background: A potential downside of robotic pancreatoduodenectomy (RPD) is the lack of tactile feedback when tying sutures, which could be especially perilous during pancreatic anastomosis. Near-infrared fluorescence imaging with indocyanine green (NIRF-ICG) could detect transpancreatic-suture-induced hypoperfusion of the pancreatic stump during RPD, which may be related to postoperative pancreatic fistula (POPF) grade B/C, but studies are lacking. Methods: This prospective study included 37 patients undergoing RPD to assess the relation between pancreatic stump hypoperfusion as objectified with NIRF-ICG using Firefly and the rate of POPF grade B/C. In 27 patients, NIRF-ICG was performed after tying down the transpancreatic U-sutures. In 10 ‘negative control’ patients, NIRF-ICG was performed before tying these sutures. Results: Pancreatic stump hypoperfusion was detected using NIRF-ICG in 9/27 patients (33%) during RPD. Hypoperfusion was associated with POPF grade B/C (67% [6/9 patients] versus 17% [3/18 patients], P = 0.026). No hypoperfusion was objectified in 10 ‘negative controls’. Conclusions: Transpancreatic-suture-induced pancreatic stump hypoperfusion can be detected using NIRF-ICG during RPD and was associated with POPF grade B/C. Surgeons could use NIRF-ICG to adapt their suturing approach during robotic pancreatico-jejunostomy. Further larger prospective studies are needed to validate the association between transpancreatic-suture-induced hypoperfusion and POPF.

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Section: Discussionmentioning

confidence: 99%

Intraoperative Fluorescence Imaging During Robotic Pancreatoduodenectomy to Detect Suture-Induced Hypoperfusion of the Pancreatic Stump as a Predictor of Postoperative Pancreatic Fistula (FLUOPAN): Prospective Proof-of-concept Study

Chen,

Lof,

Zwart

et al. 2023

Annals of Surgery Open

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“…The intraoperative appraisal of these or new parameters may implement the current dynamic framework. 49,50 Ultimately, while considering the variation of POPF risk over time, this study voluntarily includes only early postoperative parameters (ie, POH, DFA, CRP) appraised within the first 3 PODs-namely before a POPF can even be assigned by definition. 1 This analysis excluded the influence of other factors such as PPAP, 20 drain contamination and infections 43 or PPH 29 that usually occur later temporally and could be considered POPF indicators.…”

Section: Discussionmentioning

confidence: 99%

“…Moreover, although the first 3 PODs are an early postoperative timeframe, the earlier and more accurate the prediction of a fistula can be, the greater the benefits for patients. The intraoperative appraisal of these or new parameters may implement the current dynamic framework 49,50 . Ultimately, while considering the variation of POPF risk over time, this study voluntarily includes only early postoperative parameters (ie, POH, DFA, CRP) appraised within the first 3 PODs—namely before a POPF can even be assigned by definition 1 .…”

Section: Discussionmentioning

confidence: 99%

Postoperative Serum Hyperamylasemia Adds Sequential Value to the Fistula Risk Score in Predicting Pancreatic Fistula after Pancreatoduodenectomy

et al. 2022

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Objective: To evaluate whether postoperative serum hyperamylasemia (POH), with drain fluid amylase (DFA) and C-reactive protein (CRP), improves the Fistula Risk Score (FRS) accuracy in assessing the risk of a postoperative pancreatic fistula (POPF). Summary Background Data: The FRS predicts POPF occurrence using intraoperative predictors with good accuracy but intrinsic limits. Methods: Outcomes of patients who underwent pancreaticoduodenectomies between 2016 and 2021 were evaluated across FRS-risk zones and POH occurrence. POH consists of serum amylase activity greater than the upper limit of normal (52 U/l), persisting within the first 48 hours postoperatively (postoperative day –POD– 1 and 2). Results: Out of 905 pancreaticoduodenectomies, some FRS elements, namely soft pancreatic texture (odds ratio (OR) 11.6), pancreatic duct diameter (OR 0.80), high-risk pathologic diagnosis (OR 1.54), but not higher blood loss (OR 0.99), were associated with POH. POH was an independent predictor of POPF, which occurred in 46.8% of POH cases (P<0.001). Once POH occurs, POPF incidence rises from 3.8% to 42.9%, 22.9% to 41.7%, and 48.9% to 59.2% in patients intraoperatively classified at low, moderate and high FRS risk, respectively. The predictive ability of multivariable models adding POD 1 drain fluid amylase, POD 1-2 POH and POD 3 C-reactive protein to the FRS showed progressively and significantly higher accuracy (AUC FRS=0.82, AUC FRS-DFA=0.85, AUC FRS-DFA-POH=0.87, AUC FRS-DFA-POH-CRP=0.90, DeLong always P<0.05). Conclusions: POPF risk assessment should follow a dynamic process. The stepwise retrieval of early, postoperative biological markers improves clinical risk stratification by increasing the granularity of POPF risk estimates and affords a possible therapeutic window before the actual morbidity of POPF occurs.

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“…As ICG administered intravenously remains within the intravascular space because it binds to plasma lipoprotein, ICG fluorescence represents a reliable tool for assessing microperfusion of the organ. The assessment of microperfusion using ICG fluorescence allows evaluation of the risks associated with anastomosis in colorectal, esophageal, and pancreatic surgeries [ 5 , 22 , 23 ]. With regard to pancreatic surgery, pancreas perfusion was investigated using ICG fluorescence for assessment of surgical risk after pancreaticoduodenectomy and was mostly detected within 30 s [ 23 ].…”

Section: Discussionmentioning

confidence: 99%

“…The assessment of microperfusion using ICG fluorescence allows evaluation of the risks associated with anastomosis in colorectal, esophageal, and pancreatic surgeries [ 5 , 22 , 23 ]. With regard to pancreatic surgery, pancreas perfusion was investigated using ICG fluorescence for assessment of surgical risk after pancreaticoduodenectomy and was mostly detected within 30 s [ 23 ]. In the current study, the DPA was preserved by avoiding dissection around the proximal SpA and exposure of the DPA, therefore, perfusion to the pancreatic remnant could be confirmed immediately using intravenous injection of ICG dose of 0.2 mg/kg as previously reported [ 24 ].…”

Section: Discussionmentioning

confidence: 99%

Indocyanine green fluorescence to ensure perfusion in middle segment-preserving pancreatectomy: a case report

et al. 2021

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Background Middle segment-preserving pancreatectomy (MSPP) is an alternative to total pancreatectomy that allows for the preservation of the endocrine and exocrine functions of the pancreas. However, maintaining perfusion to the pancreatic remnant is of critical importance. We describe the first case to our knowledge in which indocyanine green (ICG) fluorescence was used to confirm perfusion to the pancreatic remnant during MSPP. Case presentation A 79-year-old man with diabetes mellitus was referred to our hospital for treatment of a pancreatic tumor. Computed tomography revealed a hypovascular mass in the uncus of the pancreas and dilatation of the main pancreatic duct, measuring 13 mm in the tail of the pancreas. He was diagnosed with cancer of the pancreatic uncus via endoscopic ultrasound and fine-needle aspiration revealed a mixed-type intraductal papillary mucinous neoplasm (IPMN), along with high-risk stigmata in the tail of the pancreas. We performed MSPP and the length of the pancreatic remnant was 4.6 cm. The dorsal pancreatic artery was preserved and perfusion to the pancreatic remnant was confirmed by ICG fluorescence. Histopathological examination showed a pancreatic ductal adenocarcinoma in the uncus (pT1cN1M0, pStage 2B) and IPMN in the tail of the pancreas. The postoperative course was complicated by a grade B pancreatic fistula, but this was successfully treated with conservative management. The patient was transferred to a hospital 33 days after surgery. Insulin administration was necessary, but C-peptide was detectable and blood glucose was relatively well-controlled. He did not exhibit any exocrine dysfunction when pancreatic enzyme supplementation was administered. Conclusion ICG fluorescence can be used to evaluate perfusion to the pancreatic remnant during MSPP.

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Fluorescence-based pancreas stump perfusion is associated with postoperative acute pancreatitis after pancreatoduodenectomy a prospective cohort study

Cited by 10 publications

References 28 publications

Intraoperative Fluorescence Imaging During Robotic Pancreatoduodenectomy to Detect Suture-Induced Hypoperfusion of the Pancreatic Stump as a Predictor of Postoperative Pancreatic Fistula (FLUOPAN): Prospective Proof-of-concept Study

Intraoperative Fluorescence Imaging During Robotic Pancreatoduodenectomy to Detect Suture-Induced Hypoperfusion of the Pancreatic Stump as a Predictor of Postoperative Pancreatic Fistula (FLUOPAN): Prospective Proof-of-concept Study

Postoperative Serum Hyperamylasemia Adds Sequential Value to the Fistula Risk Score in Predicting Pancreatic Fistula after Pancreatoduodenectomy

Indocyanine green fluorescence to ensure perfusion in middle segment-preserving pancreatectomy: a case report

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