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Several studies have looked into predictive patterns of occurrence, risk features and associated measures to prevent fistulas. A few recent studies, including conducted meta-analyses, have accumulated updated data. The aim of this review was to present the current knowledge on risk factors and preventive strategies for POPF in a collective synopsis.
Only studies published after were considered to allow for likely reporting according to the International Study Group on Pancreatic Fistula Definition issued that year. The final inclusion of papers to cite and refer was made at the discretion of the authors.
Where several reports exist, we prioritized the most recent or the one with highest evidence level. Case reports, single-center retrospective studies and editorials were excluded.
Specific management of POPF is a long and controversial chapter to cover in itself, and as such studies solely dealing with this aspect of POPF were excluded. Results Of a total of hits in the PubMed literature, we included 49 systematic reviews and meta-analyses,[ 10—58 ] all of which were conducted within the last 5 years — Three of these were Cochrane reviews.
Based on the identified and updated recent literature, we first present and discuss risk estimation of POPF based on surgery and surgical techniques including the type of anastomosis; second, we will discuss pancreas-specific factors including texture and the types of underlying pathology; third, we will discuss rossion situation based writing a cover of risk; further, we will present results from interventions, including use of drains, stents or products; finally, we will discuss the available clinical risk scores and their current role.
For example, pancreatic neuroendocrine tumors PNETs had a higher risk of POPF,[ 77 ] but this was largely attributed to the fact that these types of tumors more frequently underwent atypical resections and enucleations,[ 7778 ] thus posing a different risk for ductal injury.
In distal resections, tail resections appear to have higher risk than more central resections,[ 80 ] and a systematic review demonstrated superiority of stapler closure over suture closure in distal pancreatectomies.
Six meta-analyses [ 4345—4850 ] have investigated the effect of the two most commonly performed anastomotic techniques for creating continuity between the pancreas remnant and the gastrointestinal tract — pancreaticogastrostomy and pancreaticojejunostomy — and their effect on fistula rates, and found significantly different rates of POPF in all six meta-analyses.
The difference in the POPF rates is likely due to the variation in studies included, yet the risk reduction remains similar across studies odds ratio at about 0. The meta-analyses, although conducted and published within the same time-frame five published inone in include different number of trials and patients ranging from 4 to 8 randomized trials; and from to patients includedand also arrive at different conclusions concerning the additional effect on other outcomes, such as biliary fistula rates and intra-abdominal fluid collections.
Despite the slight difference in included material, the superiority of pancreaticogastrostomy appears consistent in all the meta-analyses, as all six studies conclude with an overall reduced risk for POPF. Notably, a recent small Canadian RCT found no difference between the two techniques, and the trial was stopped early.
The most frequently used technique for pancreaticojejunostomy is the end-to-side, duct-to-mucosa anastomosis.
However, these results were not confirmed in two French prospective case—control studies. The neck of the pancreas is a vascular watershed between the celiac and superior mesenteric arterial systems.
In a prospective, non-randomized study,[ 88 ] the blood supply at the cut surface of the pancreas was evaluated, and if found inadequate, the pancreas was cut back 1.
The technique resulted in a very low POPF rate. Others have investigated the effect of separating the pancreaticojejunostomy from the biliary anastomosis, but found no significant difference in fistula rates with single-loop over double-loop Roux-en-Y anastomosis.
Notably, these are highly selected patients and represent a situation where the pros and cons of total pancreatectomy must be carefully discussed with the patient prior to surgery. The combination of a soft gland and a small duct increases the risk for fistulae with several magnitudes.
Whether alternative techniques are warranted to specifically reduce POPF rates in soft glands with small ducts have yet to be demonstrated.
Biomarker and alternative detection techniques Metabolic profiling of predictive biomarkers has also been attempted. Currently, the use of a low albumin level may be the most consistent, widespread available and low cost alternative for prediction of fistula risk.
Also, several different measures of amylase in either serum or drain fluids have been proposed to correlate with fistula risk. Stents represent another controversial area for which evidence is conflicting.
One single-institution series found no protective effect of either internal or external stent use, and suggested even some adverse effects to be associated with the placement of stents.
In another meta-analysis of four trials comprising patients,[ 24 ] the use of external pancreatic duct stenting was found to reduce the incidence of both any grade POPF formation [OR 0.
The use of internal stents in pancreatic ducts anastomosis did not appear to reduce the rate of POPF in a second meta-analysis,[ 52 ] but the evidence is weak and based on limited level 1 evidence.
Post-operative drains Use of drains to prevent or to assess risk of fistula continues to be debated.
There were no significant differences in the rates of pancreatic fistula, intra-abdominal abscesses, post-pancreatectomy hemorrhage, biliary fistula, delayed gastric emptying, reoperation or radiologic-guided drains between the two groups.
Notably, this meta-analyses is highly skewed toward the trial results from the van Buren study,[ 64 ] questioning the validity of performing meta-analytic techniques to this question in the first place.Mercedes-Benz S-Class May 18, With the three engineering priorities "Intelligent Drive", "Efficient Technology" and "Essence of Luxury", the new Mercedes-Benz S-Class extends the boundaries of technology on many levels.
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Alain Méot of Université Clermont Auvergne, Clermont-Ferrand (Univ BPC) with expertise in: Cognitive Psychology. Read 60 publications, and contact Alain Méot on ResearchGate, the professional. Based on the identified and updated recent literature, we first present and discuss risk estimation of POPF based on surgery and surgical techniques including the type of anastomosis; second, we will discuss pancreas-specific factors including texture and the types of underlying pathology; third, we will discuss biomarkers of risk; further, we.