Introduction
Pancreaticoduodenectomy ( PD ) is a complex surgical process. It has been established as a standard surgical operation for malignant and benign diseases in pancreatic caput and periampullary parts ( 1-3 ). Recently, the operative mortality rate after PD has dramatically decreased to less than 5 %, while the incidence of postoperative morbidity remains high, from 40 % to 50 % ( 1-5 ). In the bulk of instances, morbidity and mortality after PD are related to the surgical direction of the pancreatic stump ( 3-6 ).
Pancreatic escape remains the most of import cause of morbidity, and besides contributes significantly to drawn-out hospitalization, increased wellness attention costs, and mortality. It remains a challenge at high volume centers for pancreatic surgery ( 4,5 ). There is pronounced variableness in the incidence of pancreatic anastomotic escape after PD among different series, running from 5 to 30 % ( 5-9 ). This broad scope could be attributed to the deficiency of a universally recognized definition of the leak. Intra-abdominal abscess, intra-abdominal hemorrhage, and sepsis are common sequelae of pancreatic escape, which have been associated with a high mortality rate of 40 % or more ( 7, 8 ).
Recent surveys have suggested that many factors influence PF after PD, including age, sex, preoperative icterus, operative clip, intraoperative blood loss, type of pancreatic Reconstruction, anastomotic technique, consistency of pancreatic stump, pancreatic canal diameter, usage of somatostatin and sawbones experience ( 6-11 ). This job has been studied in many good designed tests addressed surgical techniques ( 9-11 ), modified drainage regimens ( 10-13 ), or disposal of somatostatin ( 13 ). The best technique in pancreatic inosculation is still debated (10-13).
The hazard factors for escape could non ever predict the badness and extent of the leak and could non exactly distinguish clinically relevant pancreatic fistulous withers from transeunt pancreatic fistulous withers. The purpose of the present survey was to analyze perioperative hazard factors for pancreatic escape after PD and measure the factors that may foretell the extent and badness of leak.
Patients and Methods
Study Design
We retrospectively studied all patients who underwent PD for malignant and benign diseases in pancreatic caput and periampullary part in our Gastroenterology Surgical Center, Mansoura University, Egypt, from January 2001 to June 2012. The medical records of patients were reviewed. We use a computerized pancreatic surgery sheet since 2000 which had all preoperative, intraoperative, and postoperative variables for each patient ( everyday pattern ). Informed consent for the surgical process was obtained from each patient. This survey was approved by the local ethical committee.
Preoperative Appraisal
Preoperative diagnostic workup included clinical appraisal ( age, sex, symptoms, and marks ), laboratory probes ( complete blood count, liver maps, creatinine, serum amylase, and tumor markers as CEA and CA19-9 ), radiological probes ( abdominal ultrasound, magnetic resonance cholangiopancreatography MRCP, and abdominal computerized imaging ). Preoperative bilious drainage was performed by endoscopic retrograde cholangiopancreatography ( ERCP ) in selected patients, with serum degrees of entire hematoid greater than 10 mg/dl or when bilious obstructor was associated with hepatic dysfunction ( aminotransferase: more than threefold than the normal i.e. more than 120 IU/ml ) were detected.
Surgical Process
Standard Whipple type operation was performed in 455 patients ( 96.7 % ) while the staying 16 patients ( 3.4 % ) underwent a pylorus continuing PD ( PPPD ). Pancreatic Reconstruction was done by either pancreaticogastrostomy ( PG ) or pancreaticojejunostomy ( PJ ) based on the sawbones penchant. Bilious drainage was achieved by terminal to side hepaticojejunostomy ( retro colic ). However, stomachic drainage was achieved by gastrojejunostomy ( GJ ) ( ante colic or retro colic ) ( manual or utilizing stapling machine ) in standard Whipple operation or dude no jejunostomy in PPPD ( terminal to the side or stop to stop ).
Postoperative Direction
All patients were managed in the intensive attention unit for at least one twenty-four hours before transportation to the ward. All patients received contraceptive antibiotics intraoperatively and for 4 years postoperatively. Contraceptive octreotide was given subcutaneously and continued postoperatively for 4 years, in patients considered a high hazard for pancreatic fistulous withers.
End products from operatively placed drains were recorded daily. The drain was removed in all enrolled patients if no gall leak, pancreatic leak, or Pus. Outputs from nasogastric tubing were recorded daily, and it was removed if the patients passed fart, no dilatation, or the day-to-day end product less than 500 milliliters. The nasogastric tubing was reinserted after two episodes of purging. The patients resumed unwritten eating started by a fluid diet, followed by a regular diet once the intestine motion restarted and could be tolerated unwritten eating.
The amylase of serum and drainage fluid was measured on postoperative twenty-four hours ( POD ) 1, and POD 5. Liver maps were measured on POD1 and POD6. Abdominal ultrasound was done routinely for all patients and repeated if we suspect intraabdominal aggregation. US-guided tubal drainage was done if there is abdominal aggregation.
Definitions
Postoperative pancreatic fistulous withers was defined as proposed by International Study Group of Pancreatic Fistula ( ISGPF ) as any mensurable volume of fluid on or after POD 3 with amylase content greater than 3 times the serum amylase activity and classified into class A, B, C. ( 14-16 )
No fistulous withers group of patients deficiencies both elevated amylase degrees and any clinical sequelae of fistulous withers. Briefly, scaling of POPF is dependent on the clinical class: a class A POPF is transeunt and symptomless fistulous withers ( no clinical impact ), does non necessitate specific intervention and the abdominal drain is removed within 3 hebdomads. Grade B POPF is diagnostic, clinically evident that requires diagnostic rating and specific medical intervention or drawn-out drainage longer than 3 hebdomads. Grade C POPF is terrible, clinically important fistulous withers that requires major alterations in clinical direction or divergence from the normal clinical tract i.e. requires invasive therapy. Grade B and C were considered to represent clinically relevant postoperative pancreatic fistulous withers ( POPF ) ( 14-16 )
The biliary leak was defined as the presence of gall in the drainage fluid that persists to Pod 4. Delayed stomachic voidance was defined as end product from a nasogastric tubing of greater than 500 ml per twenty-four hours that persisted beyond POD 10, the failure to keep unwritten consumption by POD 14, or reinsertion of a nasogastric tubing ( 14, 15 ).
Data Collected
All patients had a baseline history and physical scrutiny records. Preoperative, intraoperative, and postoperative information was collected. Preoperative variables included patient demographics ( age, sex, and medical history ), patients symptoms ( icterus, abdominal hurting, emesis, diarrhea, loss of weight, diabetes ), physical marks ( icterus, abdominal mass, and organic structure weight ), laboratory trials ( preoperative sum hematoid, alkalic phosphatase, SGPT, albumen, amylase, complete blood image, tumor markers CEA, CA19-9 ) , preoperative image surveys, and preoperative bilious drainage by ERCP.
Intraoperative variables included liver position ( normal or cirrhotic ), tumor size, pancreatic canal diameter, a form of pancreatic stump and relation of the canal to its boundary lines, consistency of the pancreas ( soft, house ), techniques of pancreatic Reconstruction ( uninterrupted, interrupted or both ), type of sutures used ( absorbable, nonabsorbable or both ), operative clip, blood loss, and blood transfusion.
Postoperative variables included postoperative complications ( pancreatic leak, bile leak, delayed gastric emptying, bleeding, cardiorespiratory complications, aggregation, shed blooding PG, GJ, liver abuse, and wound infection ). Data of the drain including its end product, its nature, and POD of its remotion, the amylase of serum and drainage fluid, liver map at twenty-four hours 1 and at twenty-four hours 6, twenty-four hours of get downing unwritten, length of postoperative stay, re-exploration ( clip and causes ), hospital mortality ( twenty-four hours and cause ), all diseased specimens were reviewed to demo tumor size, tumor type, tumor distinction, lymph node position, surgical safety borders
Statistical Analysis
Statistical analysis of the information in this survey was performed utilizing the SPSS package, version 17. For uninterrupted variables, descriptive statistics were calculated and were reported as average ± criterion divergence ( SD ). Categorical variables were described utilizing frequency distributions. Independent sample t- trial was used to observe differences in the agencies of uninterrupted variables and a Chi-square trial was used in instances with low expected frequency. P values iˆ? 0.05 were considered to be important. Variables with P & A; lt; 0.05 were entered into a logistic arrested development theoretical account to find independent hazard factors of postoperative PF. The independent hazard factors of the variables were expressed as odds ratios ( OR ) with their 95 % assurance intervals ( CI ). The measuring of drain amylase degree on POD 1 and POD 5 has a major impact by enabling the development of PF to be predicted in the early period after PD. In fact, amylase degree in drains & A; gt; 4000 U/L have reported being an important prognostic factor for the incidence of all classes PF after PD ( 17,18 ). Therefore, the optimum cut-off degrees of the drain amylase degree on POD 1 and POD 5 for the distinction between no PF group and PF group was sought by receiving system operating features ( ROC ) curves, which were generated by ciphering sensitiveness and specificities of the drain amylase degree on POD 1 and POD 5 at the different predetermined cut off points. Line graphs were used for graphical visual images.
Consequences
Features of Patients and Operative information:
A sum of 471 back-to-back patients ( 278 ( 59 % ) workforces and 193 ( 41 % ) adult females ) underwent PD in our Gastroenterology Surgical Center, Mansoura University, Egypt, from January 2001 to June 2012. The average age of patients was 52.58 ± 10.82 old ages. The most common initial symptoms included icterus in 431 ( 91 % ) patients, abdominal hurting in 339 ( 72 % ) and weight loss in 175 ( 37.2 % ) . Preoperative bilious stenting was done in 250 patients ( 53.1 % ).
Of the 471 patients, merely 16 patients ( 3.4 % ) underwent PPPD while the bulk 455 patients ( 96.7 % ) underwent authoritative PD. The average operative clip was 5.15± 1.04 hours ( scope, 2.5-9 hours ), and the average operative blood loss was 533.4 ± 427.36 milliliters ( range,50-3000 milliliters).
In all patients, intraoperative information consist of consistence of pancreatic parenchyma were documented. Of these patients, 307 ( 65.2 % ) had soft parenchyma and 164 ( 34.6 % ) had firm parenchyma.
Postoperative Information
Postoperatively, the average infirmary stay was 11.15 ± 8.2 years ( 4-71 years ), and the average ICU stay was 1.38 ± 1.65 years ( scope, 1-50 years ). The average clip to restart unwritten consumption was 7.05 ± 5.5 years ( scope, 0- 52 years ). The drain was removed after 10.16 ± 7.68 years postoperatively ( 4-71days ).
As respects, postoperative complications, 50 seven patients ( 12.1 % ) developed a POPF, 21 patients ( 4.5 % ) had a fistulous withers type A, 22 patients ( 4.7 % ) had a fistulous withers type B and the staying 14 patients ( 3 % ) had a POPF type C.
Other postoperative complications included delayed gastric emptying in 57 patients ( 12.1 % ) , intra-abdominal aggregation in 44 patients ( 9.3 % ) , wound infection in 33 patients ( 7 % ) , bilious escape in 27 patients ( 5.7 % ) , pneumonic complication in 25 patients ( 5.3 % ) , internal bleeding occurred in 13 patients ( 2.8 % ) ( 4/13 due to eroding of gastroduodenal arteria secondary to PF ) , shed blooding gastrojejunostomy in 13 patients ( 2.8 % ) , shed blooding PG in 8 patients ( 1.7 % ) , liver abuse in 7 patients ( 1.5 % ) , pancreatitis 7 patients ( 1.5 % ) , pneumonic intercalation in 3 patients ( 0.6 % ) , many of them occurred in combination with others.
Ultrasound-guided tubal drainage was required in 44 patients with intra-abdominal aggregation. Thirty-three patients required re-exploration because of internal bleeding ( 13 patients, 4/13 due to eroding of gastroduodenal arteria ), shed blooding gastrojejunostomy ( 10 patients ), shed blooding PG ( 8 patients ) or debridement and drainage ( 2 patients ). Completion splenic-pancreatectomy was required in one patient who had PF and complicated by internal bleeding due to the eroding of gastroduodenal arteria.
The infirmary mortality in this series was 11 patients ( 2.3 % ), and the mortality associated with pancreatic fistulous withers was 8 patients ( 8/57 ). The causes of decease were liver cell failure as a consequence attach to liver cirrhosis ( one patient ), pneumonic intercalation ( 3 patients ), infected daze as a sequence of PF ( 6 patients ), and secondary bleeding as a sequence of PF ( one patient ).
Postoperative pathological types were listed in.
Hazard Factors for POPF
General hazard factors that were evaluated are shown in. The incidence of pancreatic fistulous withers was 14/74 ( 18.9 % ) in patients with cirrhotic liver compared to 43/397 ( 10.8 % ) patients holding non-cirrhotic liver ( P=0.05 ). The incidence of PF was 28/112 ( 25 % ) in patients with BMI greater than 25 kg/m2 and was 29/359 ( 8.07 % ) in those with BMI less than or equal 25 kg/m2 ( P= 0.0001 ).
Patients with soft pancreatic parenchyma or a pancreatic canal diameter & A; lt; 3mm had a significantly higher incidence of PF. The incidence of PF was 38/133 ( 28.6 % ) in patients with pancreatic canals less than or equal 3 millimeters and was 19/388 ( 4.9 % ) in those with canals more than 3 millimeters ( P=0.0001 ). The PF was 13/164 ( 7.9 % ) in patients with a house pancreas, and was 44/307 ( 14.3 % ) in those with a soft pancreas ( P=0.04 ). Patients with pancreatic canal near to the posterior border of the pancreatic stump were likely to develop PF, the incidence of PF was 35/224 ( 15.6 % ) in patients with pancreatic canal near to the posterior border less than or equal 3 millimeters and was 22/247 ( 8.9 % ) in those with canals off from the posterior border more than 3 millimeters ( P=0.02 ).
The average years of remotion of the drain in patients without PF ( 8.46 ± 3.9 scopes; 4-33 years ) was significantly earlier than in patients with PF ( 21 ± 11.5 scope; 4-71 years ).
Univariate analysis demonstrated five factors to be significantly associated with pancreatic fistulous withers ( BMI, cirrhotic liver position, parenchymal consistency, pancreatic canal diameter, location of the pancreatic canal from the posterior border ). These five hazard factors of PF identified in univariate analysis were farther analyzed in multivariate analysis. Both pancreatic canal diameter less than or equal 3 millimeters and BMI & A; gt; 25 kg/m2 were demonstrated to be independent hazard factors.
Predictive Factors for the Badness of PF
The average degree of amylase in a drain on POD 1, was 2416.3 ± 2027.2 U/L in instances with PF compared with 562.97± 1045.69 U/L in instances without complications ( P=0.0001 ) and on POD 5 was 10525.9 ± 11931.5 U/L in instances with PF compared with 455.09 ± 744.79 U/L in instances without complications ( P=0.0001 ). The average degree of amylase in drains tended to diminish from POD 1 to POD 5 in patients without PF but it tended to increase from POD 1 to POD 5 in patients with PF.
We recommended a cut off degree based on an amylase lift in the drainage fluid greater than 3 times the upper normal degree of serum amylase, which is 200U/L in our infirmary.
Sing the sensitiveness and specificity of the drain amylase on POD 1, a country under the ROC curve of 0.797 was obtained ( p & A; lt; 0.0001; 95 % assurance interval: 0.72-0.87 ) ( Fig 1 ). If Drain amylase degree & A; gt; 1000 U/L on POD 1 was suggested to be the best cut-off for the anticipation of the clinically relevant pancreatic fistulous withers. The sensitiveness, and specificity of drain amylase on POD 1 & A; gt; 1000 U/L were 71.9 % and 86.5 % severally. If Drain amylase degree & A; gt; 4000 U/L on POD 1 was suggested to be the best cut-off for the anticipation of the clinically relevant pancreatic fistulous withers. The sensitiveness, and specificity of drain amylase on POD 1 & A; gt; 4000 U/L were 28.1 % and 97.2 % severally.
With respect to the sensitiveness and specificity of the drain amylase on POD 5, a country under the ROC curve of 0.96 was obtained ( p & A; lt; 0.0001; 95 % assurance interval: 0.93-0.99 ) ( Fig 2 ). Drain amylase degree & A; gt; 4000 U/L on POD 5 was suggested to be the best cut-off for the anticipation of the clinically relevant pancreatic fistulous withers. The sensitiveness, and specificity of drain amylase on POD 5 & A; gt; 4000 U/L were 73.7 % and 99.3 % severally.
With the development of PF, male sex, BMI & A; gt; 25 kg/m2, cirrhotic liver, little pancreatic canal diameter less than or equal 3 millimeters, pancreatic canal located near to the posterior boundary line within a distance of 3mm, and soft pancreatic texture were a prognostic factor for the badness of PF. Leukocyte counts on POD 5 were significantly decreased compared to Pod 1 in PF type A group. In contrast to the class B and C group, leukocyte counts on POD 5 increased significantly compared to the POD 1 degree. The serum albumin degree on POD 5 decreased significantly in class B and C groups compared to the POD 1 degree.
Patients with POPF type C were significantly associated with vascular complications like eroding of gastroduodenal arteria taking to internal bleeding in 4/14 ( 28.6 % ), delayed gastric emptying in 11/14 ( 78.6 % ) and pleural gush in 3/14 ( 21.4 % ). Reoperation was required in 8/14 patients ( 57.1 % ). Mortality attributed to surgical complications after POPF type C was 7/14 ( 50 % ).
Outcome and Direction of PF
Patients were chiefly objected to the conservative direction without interventional process ( disposal of antibiotics, hypodermic octreotide, enteric or entire parenteral nutritionary support ). All patients who had PF type A were successfully managed by the conservative intervention. Ultrasound-guided tubal drainage was required in 26 patients holding intra-abdominal aggregation ( 19 patients had PF type B and 7 patients had PF type C. Ten patients required re-exploration the causes were internal bleeding in 5 patients, ( 4 patients due to eroding of gastroduodenal arteria and one due to secondary bleeding ), debridement and drainage ( 2 patients ) and shed blooding PG ( 3 patients ). Completion splenic-pancreatectomy was required in one patient who had PF and complicated by internal bleeding due to the eroding of gastroduodenal arteria.
No patients with a POPF type A developed other surgical complications and there was no mortality in that group. One patient with POPF type B died. In contrast, the development of POPF type C was associated with significantly increased mortality ( seven out of 14 patients ).
Discussion
Postoperative pancreatic fistulous withers ( POPF ) after PD remains a challenge even at high volume centers. It remains the major subscriber to morbidity after PD ( 5-9, 19 ). Many attempts have been made to extenuate this job including surgical techniques ( 13, 20-24 ), disposal of somatostatin, and usage of adhesive sealers ( 13 ).
In this survey, we found that PF in a series of 471 back-to-back PD was 50 seven patients ( 12.1 % ) which appears to be comparable to the PF rate of 5-14 % reported in other specialized centers ( 5-7, 25-30 ).
The hazard of PF formation appears to be multifactorial affecting preoperative, intraoperative, and postoperative factors. Many surveys reported that male sex was an important forecaster of PF ( 30, 31 ). Shmidt et Al ( 30 ) reported that male sex merely achieved significance as a univariate forecaster of PF formation in the overall group of patients undergoing PD. In our survey, no important difference between male and female. Some surveys found that old age was an important hazard factor of PF, this consequence was non found as a hazard factor in our survey.
In our survey, BMI, cirrhotic liver position, pancreatic parenchymal consistency, pancreatic canal diameter, location of the pancreatic canal within a distance of 3mm from the posterior boundary line of the pancreas were shown to be significantly associated with developing PF. Multivariate analysis revealed that the pancreatic canal diameter less than or equal 3 millimeters and BMI & A; gt; 25 kg/m2 were important independent hazard factors. In many series, patients undergoing PD have been categorized into two groups based on the character of pancreatic leftover: patients with a soft, delicate, little pancreatic canal, or pancreatic canal located near to the posterior boundary line within a distance of 3mm, who were considered at high hazard for PF, and patient with the house, fibrotic, dilated pancreatic canal, or pancreatic canal located far from the posterior boundary line, who are at low hazard ( 28, 31-36 ). Our consequences approved this reported information.
In our survey, Preoperative bilious drainage did non act upon the incidence of postoperative complications, and although it can be performed safely in icteric patients it should non be used routinely. Preoperative bilious drainage was performed by ERCP in selected patients, with serum degrees of entire hematoid greater than 10 mg/dl or when bilious obstructor was associated with hepatic dysfunction (aminotransferase: more than threefold than the normal i.e. more than 120 IU/ml ). There was no important difference in overall PF between patients with and without preoperative bilious drainage. Preoperative bilious drainage was introduced in an effort to better the general status and therefore cut down postoperative morbidity and mortality. Early surveys showed a decrease in morbidity ( 37-38 ). However, recent surveys found that preoperative bilious stenting has been associated with a high incidence of PF and other complications ( 30, 39-40 ). Therefore, the overall decision non to routinely execute preoperative bilious drainage seems apparent. Whether bilious drainage should ever be performed in icteric patients remains controversial ( 41-43 ).
This survey showed that the type of inosculation had no important impact on the incidence of PF. This determination is matched with the consequence of Bassi et Al ( 11 ). Yeo et Al ( 35 ) found that the incidence of pancreatic fistulous withers was about similar for the PG ( 12.3 % ) and PJ ( 11.1 % ) groups with no important difference. McKay et Al ( 44 ) concluded in meta-analysis survey that current literature suggests that the safer agencies of pancreatic Reconstruction after PD is PG, but much of the grounds come from experimental cohort survey information.
It remains ill-defined what hazard factors can exactly foretell which type of POPF ( clinical relevant ( POPF type B and C ) or transeunt pancreatic fistulous withers ( POPF type A ) will happen when naming pancreatic fistulous withers on POD3 by ISGPF standards. We have evaluated the factors that may foretell the extent and badness of leak. In our analysis, we found that soft consistency of pancreas, lift of amylase in drainage fluid on POD 1 and 5, a lift of WBC on POD 1 and 5, little pancreatic canal diameter, its relation to the posterior boundary line of the pancreas, cirrhotic liver, and fleshiness significantly increase the hazard for the development of a type B and C fistulous withers
It is of importance to foretell the development of clinically relevant pancreatic fistulous withers in the early period after PD. In many surveys, soft pancreatic parenchyma has been widely recognized as the most important hazard factor of PF ( 45-48 ). Kawai M et Al found that soft parenchyma was non-prognostic of pancreatic leak type B and C, although it was an independent hazard factor sing incidence of pancreatic fistulous withers ( 15 ).
In the literature, there are few surveys that have tried to measure the prognostic value of amylase in drains with the hazard of developing PF, despite the fact that amylase values significantly affect postoperative direction ( 17,49-50 ). Sutcliffe RP et Al ( 51 ) reported that the average drain amylase degree on POD1 in patients with PF ( 6205; run 357-23391 ) was significantly higher than in patients without a PF ( 69; run 5-2180; P=0.01 ), and found that no patients with a PF had drain unstable amylase degree on POD1 & A; lt; 350 U/L, compared to 48/61 ( 79 % ) without a PF. Using 350 U/L as a cut-off, a low drain amylase on POD1 excluded a PF with sensitiveness, specificity, positive and negative prognostic values 100, 79, 41, and 100 % severally ( 51 ). Molinari et Al concluded that a drainage amylase value on POD 1 greater than 5,000 U/l was an important prognostic factor of PF with a sensitiveness, specificity, positive and negative prognostic values 93, 84, 59, and 98 % severally. ( 17 ) . The retrospective survey by Shinchi et Al ( 50 ) on 207 PD defined PF as an end product & A; gt; 30 ml/24h with amylase values on POD5 that were more than 5 times the serum value. Hashimoto N and Ohyanagi H ( 52 ) reported that an average degree of amylase in a drain on POD 1, 10878 ± 14800 U/L in instances with PF compared with 1482 ± 1615 U/L in instances without complications. Some surveys reported that an amylase degree in drainage fluid after PD has no clinical impact ( 19, 49 ). Kawai M et al reported that there was no important difference in amylase degree in drainage fluid on POD 1 and POD 4 between transeunt pancreatic fistulous withers and clinically important pancreatic fistulous withers, although the addition was significantly greater in instances of pancreatic fistulous withers as compared to those with no pancreatic fistulous withers. Therefore, mensurating day-to-day degrees of amylase in drainage fluid may non reflect the badness of pancreatic fistulous withers ( 15 ). In the other manus, Reido-Lombardo et Al have suggested that the ability to observe clinical PF by drain information entirely is imperfect ( 19 ). In our survey, we found that the average degree of amylase in a drain on POD 1, was 2416.3 ± 2027.2 U/L in instances with PF compared with 562.97± 1045.69 U/L in instances without complications ( P=0.0001 ) and on POD 5 was 10525.9 ± 11931.5 U/L in instances with PF compared with 455.09 ± 744.79 U/L in instances without complications ( P=0.0001 ). The degree of amylase in a drain on POD1 and POD 5 has prognostic value for the visual aspect of PF, and in peculiar when the degree of amylase is greater than 4000 U/L.
Kawai M et Al found that white blood counts ( WBC ) on POD 4 were significantly decreased compared to Pod 1 in both the no pancreatic fistulous withers group and the class A group. However, in the POPF type B and C WBC on POD 4 did non diminish significantly compared to Pod 1 degrees ( 15 ). In our survey, Leukocyte counts on POD 5 were significantly decreased compared to Pod 1 in PF type A group. In contrast to the class B and C group, leukocyte counts on POD 5 increased significantly compared to the POD 1 degree
Our survey proved that patients with POPF type C are significantly associated with vascular complications like eroding of gastroduodenal arteria taking to internal bleeding in 4/14 ( 28.6 % ). Reoperation was required in 8/14 patients ( 57.1 % ). Mortality attributed to surgical complications after POPF C was 7/14 ( 50 % ). Pratt et Al ( 14 ) reported that POPF C is associated with higher rates of complications, surgical or radiological intercessions, ICU, and overall infirmary stay, and overall cost. Frymerman AS et Al ( 45 ) found that patients who developed POPF had significantly more vascular but nonother surgical complications than patients without POPF. Patients with POPF A had no vascular or surgical complications. Twenty-one of the 29 patients with POPF C had surgical complications ( 17 vascular complications ). Mortality attributed to surgical complications after POPF C was 5/29. A soft pancreatic consistency ( OR 8.5 ; P & A; lt; 0.008 ) and a high drain lipase activity on postoperative twenty-four hours 3 ( OR 4.4 ; P = 0,065 ) were forecasters for the development of POPF C.
The function of the surgically placed contraceptive intra-abdominal drain after pancreatic resection and their consequence on morbidity rate and optimum timing for their remotion remains controversial ( 53-57 ). In our survey, the average years of remotion of the drain in patients without PF ( 8.46 ± 3.9 scopes; 4-33 years ) was significantly earlier than in patients with PF ( 21 ± 11.5 scope; 4-71 years ). Bassi et al after a randomized controlled survey on 114 patients who underwent pancreatic resection reported that in patients at the low hazard of PF, the intraabdominal drain can safely be removed on POD3 after standard pancreatic resection. A delayed drain remotion is associated with a higher rate of postoperative PF ( P=0.0001 ) with increased infirmary stay and costs ( 53 ). Kawai M et Al concluded that early remotion of an intra-abdominal drain on POD 4 cut downing intra-abdominal infection and significantly decreased the rate of PF ( 54 ). Although early drain remotion is considered desirable, in some instances this may be followed by intra-abdominal aggregation or sepsis. Yeo et Al and Yamaguchi M et Al reported that contraceptive drains after PD allow monitoring of the happening of intraabdominal hemorrhage, every bit good as the sensing and drainage of PF ( 55,56 ). Most of the high volume centers insert a contraceptive drains and normally removed around POD 7 ( 3, 17, 51,55, 57 ).
There are several restrictions to our survey because of the retrospective nature of information aggregation and the surgical process such as PG or PJ or usage of pancreatic stent were non-randomized but depended on sawbones penchant. Therefore, farther surveys are necessary to prospectively formalize these prognostic hazard factors to corroborate the possible relationship between these factors and the development of PF.
Indecision, This survey demonstrates five factors to be significantly associated with pancreatic fistulous withers after PD, BMI & A; gt; 25 kg/m2, cirrhotic liver position, soft parenchymal consistency, little pancreatic canal diameter, and location of the pancreatic canal within 3 millimeters distance from the posterior border. Amylase value & A ; gt ; 4000 U/L in drain, serum albumen & A ; lt ; 3 g/dl and leucocyte counts & A ; gt ; 10,000 on POD1 and POD 5 can foretell clinically relevant PF ( class B and C ) before it becomes terrible. Management of PF depends on the grade of PF; hence, the designation of these prognostic hazard factors can supply utile information to help the sawbones in doing a determination about pancreatic Reconstruction technique intraoperative and to orient the postoperative direction for patients who are at an increased hazard of developing PF. To forestall the development of PF we introduce somatostatin parallel intervention and antibiotic therapy for high hazard groups and hold remotion of the drain with near follow up by abdominal ultrasound. The intraoperative placed drain is left in topographic point until leakage halt. However, in instances of terrible PF farther direction depends on rapid determination for re-exploration, particularly in instances of vascular complication or uncontrolled sepsis. Surgeons should go on to look into to cut down the incidence of PF after PD.
