The Beneficial Effects of Minimizing Blood Loss in Pancreatoduodenectomy

Seykora, Thomas; Ecker, Brett L.; McMillan, Matthew T.; Maggino, Laura; Beane, Joal D.; Fong, Zhi Ven; Hollis, Robert H.; Jamieson, Nigel B.; Javed, Ammar A.; Kowalsky, Stacy J.; Kunstman, John W.; Malleo, Giuseppe; Poruk, Katherine E.; Soares, Kevin C.; Valero, Vicente; Velu, Lavanniya Kumar Palani; Watkins, Ammara A.; Vollmer, Charles M.

doi:10.1097/sla.0000000000002714

Cited by 53 publications

(31 citation statements)

References 43 publications

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“…First, we defined massive IBL as more than 20% of the estimated circulating blood volume, based on the model of Lundsgaard-Hansen [ 27 ]. This definition of massive IBL is stricter than that of previous studies [ 32 , 33 ]. If we define massive IBL as bleeding of over 1000 ml, 60 patients (34.3%) would be included in the massive IBL group.…”

Section: Discussionmentioning

confidence: 94%

“…The negative impact of IBL on outcomes after pancreatic surgery has long been suspected [ 29 – 34 ]; however, there have been few reports demonstrating risk factors for IBL [ 32 , 33 ]. Rystedt et al retrospectively analyzed 1864 patients who had undergone a PD in the Swedish National Pancreatic and Periampullary Cancer Registry.…”

Section: Discussionmentioning

confidence: 99%

“…The national study on resectable periampullary tumors shows that the preoperative independent risk factors associated with major IBL (≥1000 mL) were male sex, body mass index ≥25 kg/m 2 , preoperative biliary drainage, C-reactive protein ≥12 mg/L, and neo-adjuvant chemotherapy treatment [ 32 ]. Seykora et al conducted a multi-institutional retrospective study and precisely evaluated 5323 PD patients who had been treated for either benign or malignant disease by 62 surgeons from 17 institutions [ 33 ]. They demonstrated that factors significantly associated with increased IBL (>1300 mL) were trans-anastomotic stent placement, neoadjuvant chemotherapy, pancreaticogastrostomy reconstruction, multiorgan or vascular resection, and elevated operative time (>435 min).…”

Section: Discussionmentioning

confidence: 99%

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Prediction of massive bleeding in pancreatic surgery based on preoperative patient characteristics using a decision tree

et al. 2021

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Massive intraoperative blood loss (IBL) negatively influence outcomes after surgery for pancreatic ductal adenocarcinoma (PDAC). However, few data or predictive models are available for the identification of patients with a high risk for massive IBL. This study aimed to build a model for massive IBL prediction using a decision tree algorithm, which is one machine learning method. One hundred and seventy-five patients undergoing curative surgery for resectable PDAC at our facility between January 2007 and October 2020 were allocated to training (n = 128) and testing (n = 47) sets. Using the preoperatively available data of the patients (34 variables), we built a decision tree classification algorithm. Of the 175 patients, massive IBL occurred in 88 patients (50.3%). Binary logistic regression analysis indicated that alanine aminotransferase and distal pancreatectomy were significant predictors of massive IBL occurrence with an overall correct prediction rate of 70.3%. Decision tree analysis automatically selected 14 predictive variables. The best predictor was the surgical procedure. Though massive IBL was not common, the outcome of patients with distal pancreatectomy was secondarily split by glutamyl transpeptidase. Among patients who underwent PD (n = 83), diabetes mellitus (DM) was selected as the variable in the second split. Of the 21 patients with DM, massive IBL occurred in 85.7%. Decision tree sensitivity was 98.5% in the training data set and 100% in the testing data set. Our findings suggested that a decision tree can provide a new potential approach to predict massive IBL in surgery for resectable PDAC.

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Section: Discussionmentioning

confidence: 94%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Prediction of massive bleeding in pancreatic surgery based on preoperative patient characteristics using a decision tree

et al. 2021

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“…Pancreatic invasive ductal adenocarcinoma was selected as a stratification factor because some previous studies have reported that vascular resection, hard pancreas and neoadjuvant therapy, which are associated with pancreatic invasive ductal adenocarcinoma, were associated with major blood loss during PD. 5–7 However, requirement for vascular resection and texture of pancreas are often uncertain before surgery, and whether performing neoadjuvant therapy largely depends on institution policy. Therefore, our pragmatic protocol includes preoperative clinical diagnosis as a stratification factor.…”

Section: Discussionmentioning

confidence: 99%

Tranexamic ACid during PancereaticoDuodenectomy (TAC-PD): study protocol for a multicentre randomised, blind, placebo-controlled trial

2020

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IntroductionPancreaticoduodenectomy (PD) is a major gastroenterological surgery that results in a substantial amount of blood loss. Several studies have demonstrated that major blood loss during PD is associated with both short-term and long-term poor outcomes. Administration of perioperative tranexamic acid (TXA) has been reported to reduce intraoperative blood loss in various surgeries, including cardiovascular surgery and orthopaedic surgery. Nevertheless, the effect of perioperative TXA use in patients undergoing PD has not been investigated. This study aims to investigate the effect of TXA on blood loss during PD.Methods and analysisA multicentre (six hospitals), randomised, blind (patient-blinded, surgeon-blinded, anaesthesiologist-blinded, monitor-blinded), placebo-controlled trial of TXA during PD was started in September 2019. Patients undergoing PD for biliary, duodenal or pancreatic diseases are randomly assigned to the TXA or placebo group. The stratification factors are the institutions and preoperative clinical diagnosis. Before skin incision, the participants in TXA group are administrated 1 g TXA as a loading infusion followed by a maintenance infusion of 125 mg/hour TXA until the end of surgery or 8 hours from the incision. Participants in the placebo group are administrated the same volume of saline that is indistinguishable from the TXA. The primary outcome is blood loss during PD. The secondary outcomes are intraoperative and postoperative (up to day 2) blood transfusions, operation time, anaesthesia time, postoperative laboratory variables, length of hospital stay, in-hospital and 90-day mortality and postoperative complications occurring within 28 days of surgery or requiring readmission. To date, 115 patients of a planned 220 have been enrolled in the study.Ethics and disseminationThis protocol was approved by the Nagoya University Clinical Research Review Board and is registered with Japan Registry of Clinical Trials on 15 August 2019. The results of this trial will be disseminated through peer-reviewed journals.Trial registration numberjRCTs041190062.

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“…Considerable physiologic changes secondary to fluid shifts, blood loss, prolonged operation and multiple anastomoses during PD contribute to high incidence of postoperative infectious complications [24]. Despite several factors such as BMI objectively existing independently of surgical intervention, others such as intraoperative blood loss/transfusion and prolonged operation are changeable, the effects of which on surgical outcomes in PD has been recognized [29,30]. Although intraoperative transfusion is necessary for severe blood loss, strict criteria for blood transfusion should be defined based on assessment of its appropriateness.…”

Section: Discussionmentioning

confidence: 99%

Clinical significance of drain fluid culture after pancreaticoduodenectomy

Yang

Jin

et al. 2018

J Hepato Biliary Pancreat

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Background The mechanism of infected postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy (PD) is undefined. Drain amylase has been used to predict POPF, whereas little data are available about the value of drain fluid culture. The aim was to investigate the incidence, risk factors and association with surgical outcomes of positive drainage culture (PDC) after PD. Methods A single‐center retrospective analysis was conducted of prospectively collected data from patients who underwent PD between January 2005 and December 2015. Drain fluid samples were obtained for microbiological analysis after surgery. Risk factors for PDC were evaluated, and its influence on surgical outcomes was explored. Results Of 768 patients, 261 (34%) had PDC during the postoperative period. Among them, a total of 434 isolates were yielded. One hundred and seven (24.7%) were Gram‐positive, 283 (65.2%) Gram‐negative, and 44 (10.1%) fungi. Multivariate analysis revealed that body mass index (BMI) ≥25 kg/m2, preoperative chemoradiation and intra‐operative red blood cell transfusion were independent risk factors for PDC. PDC was associated with higher incidences of complications including POPF, major complications and reoperation, but with no correlation between the day of PDC and complications. BMI ≥25 kg/m2, early PDC (≤3 days), main pancreatic duct <3 mm, and soft pancreas were revealed as independent predictors for POPF. There was a correlation between type of microorganisms and complications. Conclusion Considering the correlation between PDC and postoperative complications, preventive measures are crucial to improve outcomes after PD. Whether antibiotic treatment for early PDC will alter the clinical course of POPF needs further evaluation.

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The Beneficial Effects of Minimizing Blood Loss in Pancreatoduodenectomy

Abstract: Minimizing blood loss contributes to fewer intraoperative transfusions and better perioperative outcomes for PD. Improvements might be achieved by targeting modifiable factors that influence EBL.

Cited by 53 publications

References 43 publications

Prediction of massive bleeding in pancreatic surgery based on preoperative patient characteristics using a decision tree

Prediction of massive bleeding in pancreatic surgery based on preoperative patient characteristics using a decision tree

Tranexamic ACid during PancereaticoDuodenectomy (TAC-PD): study protocol for a multicentre randomised, blind, placebo-controlled trial

Clinical significance of drain fluid culture after pancreaticoduodenectomy

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