Reinterventions belong to complications

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2 Reinterventions belong to complications Pancreatic surgery is the archetypus of complex abdominal surgery Mortality (1-4%) and morbidity (7-60%) rates are relevant even at high volume centres Reinterventions (5-20%) are the collateral damage of a demanding surgical procedures Reinterventions represent valuable measures of quality control

3 Complications after PD Pancreaticresectionshavearounda 50% morbidity 1,2 DGE: % CR-POPF: 9-40 % PPH: 1-8 % Abscess: 3-10% Woundinfection: 5-20% Others: 3-70% Conservative management, nasogastric tube aspiration Grade A does not change clinical management while grade B and C requires interventions It accounts for 11% to 38% of the overall mortality 1 - Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005; 138(1): Wente MN, Veit JA, Bassi C, et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 2007; 142(1):20-5.

4 Indications for reinterventions POPF PPH

5 Pancreatic Fistula the leading one Definition: Output via an operatively placed drain (or a subsequently placed, percutaneous drain) of any measurable volume of drain fluid on or after postoperative day 3, with an amylase content greater than 3 times the upper normal serum value Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005; 138(1):8-13.

6 Clinically Relevant POPF - management Grade B: requires a change in management or adjustment in the clinical pathway Grade C: major change in clinical management or deviation from the normal clinical pathway Operative intervention has to be considered in case of deteriorating general conditions despite maximal supporting care, septic intra-abdominal collections inaccessible to percutaneous or endoscopic drainage, suspected peritonitis by visceral perforation, and necrosis

7 Grade C fistula Operative reintervention Septic collections inaccesible to percutaneous or endoscopic dreinage Necrosis Operative intervention has to be considered in case of deteriorating general conditions despite maximal supporting care, Suspected septic intra-abdominal peritonitis collections inaccessible to percutaneous or endoscopic by drainage, perforation suspected peritonitis by visceral perforation, and necrosis 3 Deteriorating general conditions 3 - Malleo G, Pulvirenti A, Marchegiani G, et al. Diagnosis and management of postoperative pancreatic fistula. Langenbecks Arch Surg 2014; 399(7):

8 Grade C fistula How to operate? Septic collections inaccesible to percutaneous or endoscopic dreinage Necrosis Deteriorating general conditions Suspected peritonitis by perforation

9 Surgical strategies A) Pancreaticoduodenectomy with pancreaticojejunal reconstruction B) Conversion from pancreaticojejunostomy to pancreaticogastrostomy C) Bridge stenting anastomosis with external wirsungostomy D) Pancreatic remnant abandoning with main pancreatic duct external drainage by wirusungostomy E) Pancreatic remnant abandoning with main pancreatic duct closure by suturing F) Pancreatic remnant abandoning with subtotal resection G) Rescue completion pancretectomy

10 Pancreatic remnant preservation A) Pancreaticoduodenectomy with pancreaticojejunal reconstruction B) Conversion from pancreaticojejunostomy to pancreaticogastrostomy C) Bridge stenting anastomosis with external wirsungostomy

11 Pancreatic remnant abandoning D) Pancreatic remnant abandoning with main pancreatic duct external drainage by wirusungostomy E) Pancreatic remnant abandoning with main pancreatic duct closure by suturing F) Pancreatic remnant abandoning with subtotal resection G) Rescue completion pancreatectomy

12 Background: Background: Life-threatening postoperative pancreatic fistula (LTPOPF) is the most feared complication after pancreatoduodenectomy (PD).

13 Conservative Surgical Management of Life-threatening postoperative pancreatic fistula (LTPOPF)

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15 PPH Post pancreatectomy hemorrage Early hemorrage: technical failure of hemostasis or underlying perioperative coagulopathy Late hemorrage: from complications of the operation like intraabdominal abscess, erosion of a vessel by a POPF or intrabdominal drains 2 Loss of blood through abdominal drains or nasogastric tube Hematemesis or melena Lowering of the hemoglobin Clinical deterioration Unexplained hypotension or tachicardia 2 - Wente MN, Veit JA, Bassi C, et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 2007; 142(1):20-5.

16 PPH surgical approach Mild bleeding: < 3 g/dl Hb drop, with none or minimal clinical impairment Severe bleeding: 3 g/dl Hb drop with clinical impairment with hypotension tachicardia and/or oliguria Conservative management: fluid resuscitation and blood transfusion of 2-3 PRBC Blood transfusion with > 3 PRBC and invasive treatment Reoperation or interventional angiography

17 PPH Post pancreatectomy hemorrage 2 - Wente MN, Veit JA, Bassi C, et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery 2007; 142(1):20-5.

18 PPH Post pancreatectomy hemorrage

19 PPH Post pancreatectomy hemorrage

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21 Abdominal Abscess Antibiotic therapy Drainage Surgery Especially if small, with the patient not particularly ill and the abscess difficult to reach with drain If patient do not respond to noninvasive treatment, surgery may be required (eg peritoneal lavage, placement of sufficient drains)

22 Pancreatic Resections Resections2015 N (%) DCP PP 161 (46,4) DCP sec Whipple 26 (7,4) splenopancreasectomia distale 106 (30,6) pancreasectomia distale spleen preserving 8 (2,5) splenopancreasectomia totale 28 (8,0) pancreasectomia totale spleen preserving 2 (0,5) pancreasectomia intermedia 3 (0,8) enucleazione 11 (3,1) duodeno-digiunectomia 2 (0,5) asportazione locale di lesione duodenale 1 (0,2) TOTALE 348 Patient s characteristics Sex n (%) F=171 (49,1) M=177 (50,9) Age (median range) 64 (63-66) ASA n (%) 1 27 (7,8) (74,7) 3 59 (17,0) 4 2 (0,6)

23 Complications Complications N (%) Complications 191 (55) Pancreatic fistula 82 (24) PPH 40 (12) Pulmonar and cardiac complications 90 (26) 82 POPF: POPF A 19 (5%) POPF B 54 (15%) POPF C 9 (2%) 9 POPF C: Of which 8 reintervention

24 Reinterventions on 348 patients 29 (8,3%) Reinterventions N (%) PPH 14 (48) POPF alone 2 (8) Other anastomosis disruption 5 (17) Perforation 3 (10) Other 5 (17) Total 29 9 POPF C: Of which 8 reintervention POPF reinterventions indications 8POPF -C POPF alone 2 Late PPH 2 Right colon perforation DD and GE anastomosis leakage peritonitis 1 Total 8 N 1 2

25 Reinterventions CR-POPF (n=63) Hospital stay (days) Conservative management (n=48) Surgical Management (n=15) N median (CI 95%) 24 (16-29) 44 (34-57) CR-POPF (n=63) N (%) Mortality Conservative management (n=48) Surgical Management (n=15) 0 2(13) Mann-Whitney U test: P < 0,001 PPH (n=40) Hospital stay (days) Conservative management (n=24) Surgical Management (n=16) N median (CI 95%) 13 (10-21) 35 (12-45) PPH (n=40) N (%) Mortality Conservative management (n=24) Surgical Management (n=16) 0 2 (12) Mann-Whitney U test: P < 0,001

26 The worst case of yrs 2cm BD-IPMN + 6 mm MPD + mural nodule PD with Child reconstruction 1-6 POD Good clinical course Drains removed Solid diet Return of Bowel function 7 POD t 38 Pain upper righ abd No oral food intake -Antibiotic therapy -TPN -CT-SCAN 7 POD -Peripancreatic collection with bubbles -PJ deiscence with complete disconnection percutaneous drainage 1

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28 The worst case of yrs 2cm BD-IPMN + 6 mm MPD + mural nodule PD with Child reconstruction 1-6 POD Good clinical course Drains removed Solid diet Return of Bowel function 7 POD t 38 Pain upper righ abd No oral food intake -Antibiotic therapy -TPN -CT-SCAN 7 POD -Peripancreatic collection with bubbles -PJ deiscence with complete disconnection percutaneous drainage 16 POD Sudden pain upper quadrants BP 140/65 HR 134 SO2 96% CT SCAN Intraabdominal air 8-15 POD No fever Naso jejunal & EN Drain output 200 cc/die and purulent 1

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30 The worst case of yrs 2cm BD-IPMN + 6 mm MPD + mural nodule PD with Child reconstruction 1-6 POD Good clinical course Drains removed Solid diet Return of Bowel function 7 POD t 38 Pain upper righ abd No oral food intake -Antibiotic therapy -TPN -CT-SCAN 7 POD -Peripancreatic collection with bubbles -PJ deiscence with complete disconnection percutaneous drainage 16 POD Sudden pain upper quadrants BP 140/65 HR 134 SO2 96% CT SCAN 16 POD: REOPERATION PJ dehiscence + pancreatitis of the stump Intraabdominal air = PJ reperformed after short resection + external MPD stenting on roux jejunal loop 8-15 POD No fever Naso jejunal & EN Drain output 200 cc/die and purulent 1 2

31 The worst case of POD Percutaneous drainage 16 POD REOPERATION 18 POD persistent pain dyspnea BP 130/100 SatO2 91% drain purulent effluent CT SCAN suspected intestinal infarction 18 POD: REOPERATION GJ dehiscence Abdominal lavage Direct repair of gastrojejunostomy Nutritional jejunostomy performed Drainage 4 Drains left POD Sepsis Pseudomonas MDR Jejunostomy dehiscence High output POPF evisceration 58 POD: REOPERATION pancreatic remnant abandoning wth external wirsungostomy repair GJ Drainage into the jejunal perforation Drainage of the colonic perforation Vacuum dressing therapy

32 Gastrojejunostomy Pancreatic stump Jejunal drainage Wirsungostomy

33 The worst case of POD Percutaneous drainage 16 POD REOPERATION 18 POD persistent pain dyspnea BP 130/100 SatO2 91% drain purulent effluent CT SCAN suspected intestinal infarction 18 POD: REOPERATION GJ dehiscence Abdominal lavage Direct repair of gastrojejunostomy Nutritional jejunostomy performed Drainage 4 Drains left POD Sepsis Pseudomonas MDR Jejunostomy dehiscence High output POPF evisceration 109 POD: REOPERATION 58 POD: REOPERATION POD critical pulmonary condition, intubated Heart failure, FE 25% High output POPF Enterocutaneous fistula Jejunal perforation Bleeding without certain source Isolation and resection of the Roux jejunal loop (ex pancreatic pancreaticojejunostomy) remnant abandoning and Petzer s drain placement wth external Repair wirsungostomy gastrojejunostomy repair Isolation GJ and resection of the jejunal loop downstream Drainage the gastrojejunal into the jejunal anastomosis up to the last jejunal tract perforation with enteric anastomosis Drainage Pancreatic of the colonic remnant abandoned with main pancreatic perforation duct external drainage by wirusungostomy Vacuum Drainage dressing of therapy colonic perforation Packing

34 The worst case of st REOPERATION 3 rd REOPERATION 5 th REOPERATION Percutaneous drainage Peripancreatic collection 2 nd REOPERATION PJ dehiscence GJ dehiscence BD-IPMN with low grade dysplasia 4 th REOPERATION - Jejunostomy dehiscence - High output POPF - Evisceration - POPF - enterocutaneous fistula - Jejunal perforation - Bleeding DEATH on 116 POD 7 POD 16 POD 18 POD 58 POD 109 POD

35 Surgical Reinterventions in Pancreatic Surgery #TakeHomeMessage Less is More!

36 Grazie per l attenzione! If you would be a real seeker after truth, it is necessary that at least once in your life you doubt, as far as possible, all things. René Descartes

37 Conclusion Several types of pancreas-preserving surgical management for LTPOPF have been described in the literature, and these managements might address to different types of patients. The published data testify to acceptable morbidity and mortality rates in this life-threatening setting, when compared to CP. A pancreassparing policy also reduces the incidence of postoperative endocrine insufficiency. Simple drainage of the dehiscent anastomosis should be probably abandoned when another option is possible. Although a CP might be of benefit in a subgroup of patients, this review suggests that it should no longer be considered as the standard of care when reintervention for LTPOPF is required.