Search Results (6)

Endoscopic management of benign pancreaticobiliary disorders encompasses a range of procedures designed to address complications in gallstone disease, choledocholithiasis, and pancreatic disorders. Acute cholecystitis is typically treated with cholecystectomy or percutaneous drainage (PT-GBD), but for high-risk or future surgical candidates, alternative decompression methods, such as endoscopic transpapillary gallbladder drainage (ETP-GBD), and endoscopic ultrasound (EUS)-guided gallbladder drainage (EUS-GBD), are effective. PT-GBD is associated with significant discomfort as well as variable adverse event rates. EUS-GBD leverages lumen-apposing metal stents (LAMS) for direct access to the gallbladder, providing the ability to treat an inflamed GB internally. Choledocholithiasis is primarily managed with ERCP, utilizing techniques to include balloon extraction, mechanical lithotripsy, or advanced methods such as electrohydraulic or laser lithotripsy in cases of complex stones. Altered anatomy from bariatric procedures like Roux-en-Y gastric bypass may necessitate specialized approaches, including balloon-assisted ERCP or EUS-directed transgastric ERCP (EDGE). Post-operative complications, including bile leaks and strictures, are managed endoscopically using sphincterotomy and stenting. Post-liver transplant anastomotic and non-anastomotic strictures often require repeated stent placements or advanced techniques like magnetic compression anastomosis in refractory cases. In chronic pancreatitis (CP), endoscopic approaches aim to relieve pain and address structural complications like pancreatic duct (PD) strictures and calculi. ERCP with sphincterotomy and stenting, along with extracorporeal shock wave lithotripsy (ESWL), achieves effective ductal clearance for PD stones. When traditional approaches are insufficient, direct visualization with peroral pancreatoscopy-assisted lithotripsy is utilized. EUS-guided interventions, such as cystgastrostomy, pancreaticogastrostomy, and celiac plexus blockade, offer alternative therapeutic options for pain management and drainage of peripancreatic fluid collections. EUS plays a diagnostic and therapeutic role in CP, with procedures tailored for high-risk patients or those with complex anatomy. As techniques evolve, endoscopic management provides minimally invasive alternatives for patients with complex benign pancreaticobiliary conditions, offering high clinical success and fewer complications. Full article

Background: Duodenal neuroendocrine tumors (NETs) are uncommon, accounting for less than 4% of all gastrointestinal neoplasms. Prognosis is related to tumoral staging and grading, as well as to the specific subtype. In this article, we retrospectively describe the clinical presentation and surgical treatment of two rare large duodenal NETs: a high-grade G3 NET and a Gangliocytic Paraganglioma (GP). Methods: Both patients presented with moderate-to-high-degree abdominal pain, without jaundice. Main vessel involvement and metastatic spread were excluded with imaging, while preoperative bioptic diagnosis was obtained via percutaneous needle citology and endoscopic ultrasound. Results: The presence of a sessile large lesion contraindicated any conservative approach in favor of a pancreaticoduodenectomy (PD). The detection of soft pancreatic tissue and a narrowed main pancreatic duct led us to perform a pancreaticogastrostomy to restore proper pancreatic drainage and to minimize the risk of postoperative leakage. Conclusion: PD may be a favorable choice in these cases; this procedure is challenging, but it results in a safer and more favorable clinical outcome for our patients. Pancreaticogastrostomy may guarantee lower rates of postoperative leak and appears to be preferred in this subset of patients. Full article

Background: After pancreatic surgery, the development of postoperative pancreatic fistula (POPF) is a serious concern. POPF involves the leakage of pancreatic fluids from the surgical site, which can lead to complications and even death. Preventing POPF is essential for enhancing patient recovery and lessening the impact on healthcare resources. This systematic review and meta-analysis evaluated medical methods and surgical techniques to prevent POPF. Methods: This study was registered under the International Prospective Register of Systematic Reviews (PROSPERO) with the registration number CRD42024500938. An electronic search was conducted through the PubMed, Google Scholar, Web of Science, and ScienceDirect databases for all relevant articles published in English from 2018 to 2023. The following search terms were used: ((Whipple procedure OR Pancreaticojejunal OR Pancreaticogastrostomy) AND (Prevention of postoperative pancreatic fistula) AND (Prevention OR Octreotide OR Sealant agent OR Stent OR Postoperative drain)). Results: Of 260 papers, 28 articles extracted through the database search were considered suitable for the systematic review. The included studies investigated a variety of surgical approaches for pancreatic resection. Pancreaticoduodenectomy (PD) was the most prevalent intervention. The incidence rates for POPF varied widely across the studies, ranging from as low as 11.6% to as high as 100%. The incidence rate of clinically relevant POPF (CR-POPF) ranged from 11.7% to 33.3%. The length of postoperative hospital stays also varied significantly. Discussion: Postoperative pancreatic fistula (POPF) affects 13–41% of patients post-pancreatic surgery. Despite its high incidence, mortality rates are low. Postoperative hospital stay varies, with higher rates in older patients and overweight individuals. Advancements in surgical techniques and perioperative management have reduced mortality rates to <5%. Conclusions: This study provides insights into the outcomes of pancreatectomy, including the incidence of POPF, postoperative hospital stays, and mortality rate. The findings suggest that the incidence of POPF is similar to that suggested in the literature and is influenced by various factors. Full article

Background and Aims: Pancreaticoduodenectomy (PD) is a complex and high-skill demanding procedure often associated with significant morbidity and mortality. However, the results have improved over the past two decades. However, there is a paucity of research concerning the learning curve for PD. Our aim was to report the outcomes of 100 consecutive PDs representing a single surgeon’s learning curve and to depict the factors that influenced the learning process. Methods: We reviewed the first 121 PDs performed at our academic center (2013–2019) by a single surgeon; 110 were PDs (5 laparoscopic and 105 open) and 11 were total PDs (1 laparoscopic and 10 open). Subsequent statistics was performed on the first 100 PDs, with attention paid to the learning curve and survival rate at 5 years. The data were analyzed comparing the first 50 cases (Group 1) to the last 50 cases (Group 2). Results: The most frequent histopathological tumor type was pancreatic ductal adenocarcinoma (50%). A total of 39% of patients had preoperative biliary drainage and 45% presented with positive biliary cultures. The preferred reconstruction technique included pancreaticogastrostomy (99%), in situ hepaticojejunostomy (70%), and precolic gastro-jejunal anastomosis (88%). Postoperative complications included biliary fistula (1%), pancreatic fistula (8%), pancreatic stump bleeding (4%), and delayed gastric emptying (13%). The mean operative time decreased after the first 50 cases (p < 0.001) and blood loss after 60 cases (p = 0.046). R1 resections lowered after 25 cases (p = 0.025). Vascular resections (17%) did not influence the rate of complications (p = 0.8). The survival rate at 5 years for pancreatic adenocarcinoma was 32.93%. Conclusions: Outcomes improve as surgeon experience increases, with proper training being the most important factor for minimizing the impact of the learning curve over the postoperative complications. Analyzing the learning curve from the perspective of a single surgeon is mandatory for accurate statistical results and interpretation. Full article

Despite the substantial decrease in mortality rates following a pancreaticoduodenectomy to less than 5%, morbidity rates remain significant, reaching even 73%. Postoperative pancreatic fistula is one of the most frequent major complications and is significantly associated with other complications, including patient death. Currently, there is no consensus regarding the ideal type of pancreatic anastomosis, as the question of the choice between a pancreaticogastrostomy and pancreaticojejunostomy is still open. Furthermore, worldwide implementation of an ideal pancreatic fistula risk prediction score is missing. Our study found several significant predictive factors for the postoperative occurrence of fistulas, such as the soft consistency of the pancreas, non-dilated Wirsung duct, important intraoperative blood loss, other perioperative complications, preoperative patient hypoalbuminemia, and patient weight loss. Our study also revealed that for patients who exhibit fistula risk factors, pancreaticogastrostomy demonstrates a significantly lower pancreatic fistula rate than pancreaticojejunostomy. The occurrence of pancreatic fistulas has been significantly associated with the development of other postoperative major complications, and patient death. As the current pancreatic fistula risk scores proposed by various authors have not been consensually validated, we propose a simple, easy-to-use, and sensitive score for the risk prediction of postoperative pancreatic fistula occurrence based on important predictors from statistical analyses that have also been found to be significant by most of the reported studies. The new pancreatic fistula risk score proposed by us could be extremely useful for improved therapeutic management of cephalic pancreaticoduodenectomy patients. Full article

Background: Different techniques of pancreatic anastomosis have been described, with inconclusive results in terms of pancreatic fistula reduction. Studies comparing robotic pancreaticogastrostomy (PG) and pancreaticojejunostomy (PJ) are scarcely reported. Methods: The present study analyzes the outcomes of two case-matched groups of patients who underwent PG (n = 20) or PJ (n = 40) after pancreaticoduodenectomy. The primary aim was to compare the rate of post-operative pancreatic fistula. Results: Operative time (375 vs. 315 min, p = 0.34), estimated blood loss (270 vs. 295 mL, p = 0.44), and rate of clinically relevant post-operative pancreatic fistula (12.5% vs. 10%, p = 0.82) were similar between the two groups. PJ was associated with a higher rate of intra-abdominal collections (7.5% vs. 0%, p = 0.002), but lower post-pancreatectomy hemorrhage (2.5% vs. 10%, p = 0.003). PG was associated with a lower rate of post-operative pancreatic fistula (POPF) (33.3% vs. 50%, p = 0.003) in the high-risk group of patients. Conclusions: The outcomes of post-operative pancreatic fistula are comparable between the two reconstruction techniques. PG may have a lower incidence of POPF in patients with high-risk of pancreatic fistula. Full article