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Are you a pancreatic surgeon managing pancreatic cancers & complex postop issues?
Or enroute to be one?
This thread is for you!
๐งต๐งต๐งต
Complications of the #Whipple operation & how best to manage them
#MedTwitter
#PancreaticCancerAwarenessMonth
@ISGPS_news
Are you a pancreatic surgeon managing pancreatic cancers & complex postop issues?
Or enroute to be one?
This thread is for you!
๐งต๐งต๐งต
Complications of the #Whipple operation & how best to manage them
#MedTwitter
#PancreaticCancerAwarenessMonth
@ISGPS_news
Relevance -
Whipple Surgery - most complex operation in Cancer surgery with myriad implications
Mortality - <5% (high vol centres) โฌ๏ธ frm ~30% in d 1900s -> We r managing postops much better nw
Morbidity still remains high @ 30-60% (!!) despite technical refinements. Why? ๐ค
Whipple Surgery - most complex operation in Cancer surgery with myriad implications
Mortality - <5% (high vol centres) โฌ๏ธ frm ~30% in d 1900s -> We r managing postops much better nw
Morbidity still remains high @ 30-60% (!!) despite technical refinements. Why? ๐ค
Major postoperative issues of a Whipple Sx influencing outcomes, hospital stay & quality of life as described in a concise and lucid presentation by @Manishbhandare4
YT - t.ly
Consensus statements by @IHPBA @ISGPS_news -
t.ly
YT - t.ly
Consensus statements by @IHPBA @ISGPS_news -
t.ly
๐งฟ Postop Pancreatic Fistula (POPF)- 22-26% (PD), >30% (DP), 20-60% (MP)
ISGPS Defn - Drain output (any vol) with amylase levels >3 times upper normal level
Grading by @ISGPS_news
Biochemical leak (Former Grade A)- No clinical implication; NOT a fistula ๐งจ
Grade B
Grade C
ISGPS Defn - Drain output (any vol) with amylase levels >3 times upper normal level
Grading by @ISGPS_news
Biochemical leak (Former Grade A)- No clinical implication; NOT a fistula ๐งจ
Grade B
Grade C
Can CR-POPF (clinically relevant Postop Pancreatic Fistula) risk be predicted?
๐งฉ Fistula Risk Score (FRS) Callery et al - t.ly
๐งฉ Alternative-FRS (a-FRS) Dutch Group - t.ly
Calculate the risk of POPF - pancreascalculator.com
๐งฉ Fistula Risk Score (FRS) Callery et al - t.ly
๐งฉ Alternative-FRS (a-FRS) Dutch Group - t.ly
Calculate the risk of POPF - pancreascalculator.com
pancreascalculator.com
Pancreascalculator | DPCG
Anatomische Classificatie Locally Advanced Pancreatic Cancer (LAPC) - PREOPANC-4-project Prediction...
t.ly/STTUl
A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy - PubMed
A simple 10-point Fistula Risk Score derived during pancreaticoduodenectomy accurately predicts subs...
t.ly/LSZkq
Alternative Fistula Risk Score for Pancreatoduodenectomy (a-FRS): Design and International External Validation - PubMed
The a-FRS predicts POPF after pancreatoduodenectomy based on 3 easily available variables (pancreati...
๐จ Biochemical Leak (former Gr A) -
No longer true POPF
No clinical impact
No prolongation of hospital stay
No deviation in expected post recovery
Patient clinically well, fed orally, adheres to ERAS
But needs close monitoring and early recognition of evolution to higher Gr
No longer true POPF
No clinical impact
No prolongation of hospital stay
No deviation in expected post recovery
Patient clinically well, fed orally, adheres to ERAS
But needs close monitoring and early recognition of evolution to higher Gr
๐จ Grade B POPF - Defined POPF
-Drains left in for extended period (3wks postop)/ -repositioning of drains by IR/percut/endoscopy (>85% success)
-Infec signs
Rx - NPO, EN>>PN, Abx,?Somatostatin?, ?ICU adm
Can cause POPF-related bleed/pseudoaneurysm - Transfusions / Angiography
-Drains left in for extended period (3wks postop)/ -repositioning of drains by IR/percut/endoscopy (>85% success)
-Infec signs
Rx - NPO, EN>>PN, Abx,?Somatostatin?, ?ICU adm
Can cause POPF-related bleed/pseudoaneurysm - Transfusions / Angiography
๐จ Grade C POPF ~2% Mort - ~35% ๐งจ
if Gr B POPF->
-Re-Sx
-Organ Failure
-Death
Organ Failure defn
๐งฉ need for reintubation (Resp)
๐งฉ hemodialysis (Renal)
๐งฉ use of inotropic agents for >24 hours (Cardiac)
Rx - Reoperation if conservative Rx fails / Inaccessible collections
if Gr B POPF->
-Re-Sx
-Organ Failure
-Death
Organ Failure defn
๐งฉ need for reintubation (Resp)
๐งฉ hemodialysis (Renal)
๐งฉ use of inotropic agents for >24 hours (Cardiac)
Rx - Reoperation if conservative Rx fails / Inaccessible collections
๐งฟ Post-pancreatectomy Hemorrhage (PPH) - 3-10%
@ISGPS_news Grading based on -
๐งฉ - Time of onset (Early <24hr v Late >24hr)
๐งฉ - Site (Intra v Extraluminal)
๐งฉ - Severity (Mild v severe)
MC cause of Late PPH (2-4 wks) - POPF B/C
Site - GDA
Source - t.ly
@ISGPS_news Grading based on -
๐งฉ - Time of onset (Early <24hr v Late >24hr)
๐งฉ - Site (Intra v Extraluminal)
๐งฉ - Severity (Mild v severe)
MC cause of Late PPH (2-4 wks) - POPF B/C
Site - GDA
Source - t.ly
๐งฟ Delayed Gastric Emptying - 20-60%
Inability to return to full oral diet by week 1, โฌ๏ธ NG tube need
๐ค- โฌ๏ธ Motilin d/t duod resection?, denerv of pylorus -> spasm?
โฌ๏ธ discomfort, hosp stay, Cost
โฌ๏ธ QoL
Classfn -
๐งฉ Duration of NG
๐งฉ NG reinsertion
๐งฉ Solid food tolerated
Inability to return to full oral diet by week 1, โฌ๏ธ NG tube need
๐ค- โฌ๏ธ Motilin d/t duod resection?, denerv of pylorus -> spasm?
โฌ๏ธ discomfort, hosp stay, Cost
โฌ๏ธ QoL
Classfn -
๐งฉ Duration of NG
๐งฉ NG reinsertion
๐งฉ Solid food tolerated
DGE Mx - Majority self-limiting
๐งฉ Assess cause ?POPF
๐งฉ PharmacoRx -
Erythromycin - Prokinetic -> triggers phase III gastric migratory motor complex
Somatostatin - No beneficial effect
๐งฉ Enteral Feed - Specific impact on DGE undefined
๐งฉ TPN - in refractory cases
๐งฉ Assess cause ?POPF
๐งฉ PharmacoRx -
Erythromycin - Prokinetic -> triggers phase III gastric migratory motor complex
Somatostatin - No beneficial effect
๐งฉ Enteral Feed - Specific impact on DGE undefined
๐งฉ TPN - in refractory cases
๐งฟ Chyle leak - 10 - 12.5%
Milky fluid from drain/wound on/after POD3; Triglyceride >=110mg/dl
๐งฉ Gr A - No clinical rel; Rx- Fat free diet, MCT
๐งฉ Gr B - Prolonged hosp stay, EN/TPN/Octreotide/surgical drains/placement of new drain
๐งฉ Gr C - Inv Rx (scleroRx, Shunt, Sx)
Milky fluid from drain/wound on/after POD3; Triglyceride >=110mg/dl
๐งฉ Gr A - No clinical rel; Rx- Fat free diet, MCT
๐งฉ Gr B - Prolonged hosp stay, EN/TPN/Octreotide/surgical drains/placement of new drain
๐งฉ Gr C - Inv Rx (scleroRx, Shunt, Sx)
๐งฟ Bile leak - (0.4-8%)
ISGLS Defn - bilirubin level in drain fluid 3 times above plasma levels on or after POD 3
MC Cause - HJ leak / BD injury
Sequelae -
intraabdominal abscesses
biliary peritonitis
โฌ๏ธ hospital stay
โฌ๏ธ mortality
Source - EBM Guidelines @TataMemorial
ISGLS Defn - bilirubin level in drain fluid 3 times above plasma levels on or after POD 3
MC Cause - HJ leak / BD injury
Sequelae -
intraabdominal abscesses
biliary peritonitis
โฌ๏ธ hospital stay
โฌ๏ธ mortality
Source - EBM Guidelines @TataMemorial
Should all PDs get a drain?
๐งฉ Conlon et al - Ann Surg 2001 - 1๏ธโฃ centre RCT (n=139) Drain cohort โฌ๏ธ CR-POPF (12%) Mortality โฃ
๐งฉ PANDRA trial - 2๏ธโฃ centre RCT (n=395)
โฌ๏ธ CR-POPF with drain (12 v 6%)
๐งฉ van Buren et al - Multicentre RCT (n=137)
โฌ๏ธ mortality in NO drain cohort
๐งฉ Conlon et al - Ann Surg 2001 - 1๏ธโฃ centre RCT (n=139) Drain cohort โฌ๏ธ CR-POPF (12%) Mortality โฃ
๐งฉ PANDRA trial - 2๏ธโฃ centre RCT (n=395)
โฌ๏ธ CR-POPF with drain (12 v 6%)
๐งฉ van Buren et al - Multicentre RCT (n=137)
โฌ๏ธ mortality in NO drain cohort
McMillan et al - JOGS 2015 - Reappraisal of van Buren trial - Selective drain placement guided by the FRS Score !
Low FRS (0-2) - Can omit drain (CR-POPF risk without drain - 4.4%)
High FRS (3-10) - Better drained (CR-POPF risk without drain - 30%!!)
t.ly
Low FRS (0-2) - Can omit drain (CR-POPF risk without drain - 4.4%)
High FRS (3-10) - Better drained (CR-POPF risk without drain - 30%!!)
t.ly
Drain fluid Amylase POD1 (DFA-1) {Verona Group} -
Only DFA-1 predictive of CR-POPF on log regression analysis
Early drain removal based on DFA-1 cut off 5000 IU/L ->
โฌ๏ธ CR-POPF risk, Hosp stay, Complications
DFA1 + ฮ DFA - Better predictive model
t.ly
Only DFA-1 predictive of CR-POPF on log regression analysis
Early drain removal based on DFA-1 cut off 5000 IU/L ->
โฌ๏ธ CR-POPF risk, Hosp stay, Complications
DFA1 + ฮ DFA - Better predictive model
t.ly
Combining concepts -
๐งฉ Selective drains based on FRS Score
๐งฉ DFA1 with change in DFA over the postop course
๐งฉ Early drain removal (POD 3 if DFA1 <5000 IU/L)
Dynamic drain management protocol
t.ly
๐งฉ Selective drains based on FRS Score
๐งฉ DFA1 with change in DFA over the postop course
๐งฉ Early drain removal (POD 3 if DFA1 <5000 IU/L)
Dynamic drain management protocol
t.ly
Post Pancreatectomy Acute Pancreatitis (PPAP) -
Sustained โฌ๏ธ in serum amylase > inst. upper limit of normal persisting within atleast 1st 48 hrs postop
Needs to be-
๐งฉ Clinically relevant
๐งฉ Evident on Cross sectional imaging
If not, termed as Postop Hyperamylasemia (POH)
Sustained โฌ๏ธ in serum amylase > inst. upper limit of normal persisting within atleast 1st 48 hrs postop
Needs to be-
๐งฉ Clinically relevant
๐งฉ Evident on Cross sectional imaging
If not, termed as Postop Hyperamylasemia (POH)
PPAP Radiological abnormalities -
๐งฉ Diffuse/localised inflammation
๐งฉ Enlargement of pancreatic remnant
๐งฉ Inflm changes in peripancreatic fat / fluid collections
๐งฉ Parenchymal &/or peripancreatic necrosis
CT Severity index used for scoring
t.ly
๐งฉ Diffuse/localised inflammation
๐งฉ Enlargement of pancreatic remnant
๐งฉ Inflm changes in peripancreatic fat / fluid collections
๐งฉ Parenchymal &/or peripancreatic necrosis
CT Severity index used for scoring
t.ly
3 clinical scenarios -
๐จ - PPAP standalone
๐จ - POPF standalone
๐จ - PPAP โ> POPF; mutually interacting with adverse clinical outcome
Grade & severity requires the full clinical course of PPAP to evolve.
๐จ - PPAP standalone
๐จ - POPF standalone
๐จ - PPAP โ> POPF; mutually interacting with adverse clinical outcome
Grade & severity requires the full clinical course of PPAP to evolve.
@T4UGIS @WorldSurgical @modern_surgeon @aahpbs @OxfordHPB @sgeorgebarreto @dr_gilgson @SStattner @Giampaolo_Perri @IntuitiveSurg @PCNorthAmerica @aamirparray18 @docswapnil01 @raghurants @rohitomundhada @jeetrohila @SurgDiwakarP @sanket86024322 @sanketbankar1 @drsanket_shah Had the privilege and opportunity to participate in a panel discussion on the same topic at the recently concluded 3rd Indian Cancer Congress @icc_2023 moderated by @Shrikhande_SV who also gave a well-attended keynote address.
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