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Postoperative Management in Patients Undergoing Major Pancreatic Resections

  • Alessandra Pulvirenti
  • Antonio Pea
  • Matteo De Pastena
  • Giovanni Marchegiani
  • Roberto Salvia
  • Claudio Bassi
Chapter

Abstract

Perioperative care following pancreatectomy in “high-volume” center is based on the application of standardized protocols. The clinical practice includes multimodal strategies that aim to limit postoperative complications, to improve recovery, and to reduce the length of hospital stay after surgery. This chapter discusses the perioperative care of patients undergoing pancreatic resections focusing on major topics such as fluid management, antimicrobial prophylaxis, feeding, drain management, administration of prophylactic somatostatin or its analogues, and radiological findings following surgery.

References

  1. 1.
    Balzano G, Zerbi A, Capretti G, Rocchetti S, Capitanio V, Di Carlo V. Effect of hospital volume on outcome of pancreaticoduodenectomy in Italy. Br J Surg. 2008;95(3):357–62.CrossRefPubMedGoogle Scholar
  2. 2.
    Pratt WB, Callery MP, Vollmer CM. Risk prediction for development of pancreatic fistula using the ISGPF classification scheme. World J Surg. 2008;32(3):419–28.CrossRefPubMedGoogle Scholar
  3. 3.
    Lassen K, Coolsen MME, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, et al. Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr. 2012;31(6):817–30.CrossRefPubMedGoogle Scholar
  4. 4.
    Futier E, Constantin J-M, Petit A, Chanques G, Kwiatkowski F, Flamein R, et al. Conservative vs restrictive individualized goal-directed fluid replacement strategy in major abdominal surgery: a prospective randomized trial. Arch Surg. 2010;145(12):1193–200.CrossRefPubMedGoogle Scholar
  5. 5.
    Lavu H, Sell NM, Carter TI, Winter JM, Maguire DP, Gratch DM, et al. The HYSLAR trial. Ann Surg. 2014;260(3):445–55.CrossRefGoogle Scholar
  6. 6.
    Fischer M, Matsuo K, Gonen M, Grant F, Dematteo RP, D’Angelica MI, et al. Relationship between intraoperative fluid administration and perioperative outcome after pancreaticoduodenectomy: results of a prospective randomized trial of acute normovolemic hemodilution compared with standard intraoperative management. Ann Surg. 2010;252(6):952–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Qureshi SH, Rizvi SI, Patel NN, Murphy GJ. Meta-analysis of colloids versus crystalloids in critically ill, trauma and surgical patients. Br J Surg. 2016;103(1):14–26.CrossRefPubMedGoogle Scholar
  8. 8.
    Shaw AD, Bagshaw SM, Goldstein SL, Scherer LA, Duan M, Schermer CR, et al. Major complications, mortality, and resource utilization after open abdominal surgery: 0.9% saline compared to Plasma-Lyte. Ann Surg. 2012;255(5):821–9.CrossRefGoogle Scholar
  9. 9.
    ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr. 26(1 Suppl):1SA–138SA.Google Scholar
  10. 10.
    Gerritsen A, Besselink MGH, Gouma DJ, Steenhagen E, Borel Rinkes IHM, Molenaar IQ. Systematic review of five feeding routes after pancreatoduodenectomy. Br J Surg. 2013;100(5):589–98. discussion 599CrossRefPubMedGoogle Scholar
  11. 11.
    Myers JG, Page CP, Stewart RM, Schwesinger WH, Sirinek KR, Aust JB. Complications of needle catheter jejunostomy in 2,022 consecutive applications. Am J Surg. 1995;170(6):547. -50-1CrossRefPubMedGoogle Scholar
  12. 12.
    O’Keefe SJD, Lee RB, Anderson FP, Gennings C, Abou-Assi S, Clore J, et al. Physiological effects of enteral and parenteral feeding on pancreaticobiliary secretion in humans. Am J Physiol Gastrointest Liver Physiol. 2003;284(1):G27–36.CrossRefPubMedGoogle Scholar
  13. 13.
    Bassi C, Malleo G. Pancreas: postoperative pancreatic fistula: use of enteral nutrition. Nat Rev Gastroenterol Hepatol. 2011;8(8):427–8.CrossRefPubMedGoogle Scholar
  14. 14.
    O’Keefe SJD. Physiological response of the human pancreas to enteral and parenteral feeding. Curr Opin Clin Nutr Metab Care. 2006;9(5):622–8.CrossRefPubMedGoogle Scholar
  15. 15.
    Xiong JJ, Altaf K, Mukherjee R, Huang W, Hu WM, Li A, et al. Systematic review and meta-analysis of outcomes after intraoperative pancreatic duct stent placement during pancreaticoduodenectomy. Br J Surg. 2012;99(8):1050–61.CrossRefPubMedGoogle Scholar
  16. 16.
    Klek S, Sierzega M, Turczynowski L, Szybinski P, Szczepanek K, Kulig J. Enteral and parenteral nutrition in the conservative treatment of pancreatic fistula: a randomized clinical trial. Gastroenterology. 2011;141(1):157–63, 163.e1CrossRefPubMedGoogle Scholar
  17. 17.
    Moore FA, Feliciano DV, Andrassy RJ, McArdle AH, Booth FV, Morgenstein-Wagner TB, et al. Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results of a meta-analysis. Ann Surg. 1992;216(2):172–83.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Gianotti L, Braga M, Gentilini O, Balzano G, Zerbi A, Di Carlo V. Artificial nutrition after pancreaticoduodenectomy. Pancreas. 2000;21(4):344–51.CrossRefPubMedGoogle Scholar
  19. 19.
    Nelson Richard L, Gladman E, Barbateskovic M. Antimicrobial prophylaxis for colorectal surgery. Cochrane Database Syst Rev. 2014;5:CD001181.Google Scholar
  20. 20.
    Bratzler DW, Hunt DR. The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery. Clin Infect Dis. 2006;43:322–30.CrossRefPubMedGoogle Scholar
  21. 21.
    Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183(6):630–41.CrossRefPubMedGoogle Scholar
  22. 22.
    Povoski SP, Karpeh MS, Conlon KC, Blumgart LH, Brennan MF. Association of preoperative biliary drainage with postoperative outcome following pancreaticoduodenectomy. Ann Surg. 1999;230(2):131–42.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Kondo K, Chijiiwa K, Ohuchida J, Kai M, Fujii Y, Otani K, et al. Selection of prophylactic antibiotics according to the microorganisms isolated from surgical site infections (SSIs) in a previous series of surgeries reduces SSI incidence after pancreaticoduodenectomy. J Hepatobiliary Pancreat Sci. 2013;20(3):286–93.CrossRefPubMedGoogle Scholar
  24. 24.
    Fong ZV, McMillan MT, Marchegiani G, Sahora K, Malleo G, De Pastena M, et al. Discordance between perioperative antibiotic prophylaxis and wound infection cultures in patients undergoing pancreaticoduodenectomy. JAMA Surg. 2015;2114:1–8.Google Scholar
  25. 25.
    Sudo T, Murakami Y, Uemura K, Hayashidani Y, Hashimoto Y, Ohge H, et al. Specific antibiotic prophylaxis based on bile cultures is required to prevent postoperative infectious complications in pancreatoduodenectomy patients who have undergone preoperative biliary drainage. World J Surg. 2007;31(11):2230–5.CrossRefPubMedGoogle Scholar
  26. 26.
    Donald GW, Sunjaya D, Lu X, Chen F, Clerkin B, Eibl G, et al. Perioperative antibiotics for surgical site infection in pancreaticoduodenectomy: does the SCIP-approved regimen provide adequate coverage? Surgery. 2013;154(2):190–6.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Sourrouille I, Gaujoux S, Lacave G, Bert F, Dokmak S, Belghiti J, et al. Five days of postoperative antimicrobial therapy decreases infectious complications following pancreaticoduodenectomy in patients at risk for bile contamination. HPB. 2013;15(6):473–80.CrossRefPubMedGoogle Scholar
  28. 28.
    Samama CM, Geerts W-H. Prevention of intraoperative venous thromboembolism: what are the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition)? Ann Fr Anesth Reanim. 2009;28(9 Suppl):S23–8.CrossRefPubMedGoogle Scholar
  29. 29.
    Sweetland S, Green J, Liu B, Berrington de González A, Canonico M, Reeves G, et al. Duration and magnitude of the postoperative risk of venous thromboembolism in middle aged women: prospective cohort study. BMJ. 2009;339:b4583.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Mandalà M, Falanga A, Roila F, ESMO Guidelines Working Group. Management of venous thromboembolism (VTE) in cancer patients: ESMO Clinical Practice Guidelines. Ann Oncol Off J Eur Soc Med Oncol. 2011;22 Suppl 6(3):vi85–92.Google Scholar
  31. 31.
    Gould MK, Garcia DA, Wren SM, Karanicolas PJ, Arcelus JI, Heit JA, et al. Prevention of VTE in nonorthopedic surgical patients. Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 SUPPL):227–77.CrossRefGoogle Scholar
  32. 32.
    Harris AG. Somatostatin and somatostatin analogues: pharmacokinetics and pharmacodynamic effects. Gut. 1994;35:S1–4.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Allen PJ, Gönen M, Brennan MF, Bucknor AA, Robinson LM, Pappas MM, et al. Pasireotide for postoperative pancreatic fistula. N Engl J Med. 2014;370(21):2014–22.CrossRefPubMedGoogle Scholar
  34. 34.
    McMillan MT, Christein JD, Callery MP, Behrman SW, Drebin JA, Kent TS, et al. Prophylactic octreotide for pancreatoduodenectomy: more harm than good? HPB (Oxford). 2014;16(10):954–62.CrossRefGoogle Scholar
  35. 35.
    Gurusamy KS, Koti R, Fusai G, Davidson BR. Somatostatin analogues for pancreatic surgery. Cochrane Database Syst Rev. 2013;(4):CD008370.Google Scholar
  36. 36.
    Fiore JF, Castelino T, Pecorelli N, Niculiseanu P, Balvardi S, Hershorn O, et al. Ensuring early mobilization within an enhanced recovery program for colorectal surgery. Ann Surg. 2017;266(2):223–31.CrossRefPubMedGoogle Scholar
  37. 37.
    Conlon KC, Labow D, Leung D, Smith A, Jarnagin W, Coit DG, et al. Prospective randomized clinical trial of the value of intraperitoneal drainage after pancreatic resection. Ann Surg. 2001;234(4):487–93; discussion 493-4CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Bassi C, Molinari E, Malleo G, Crippa S, Butturini G, Salvia R, et al. Early versus late drain removal after standard pancreatic resections: results of a prospective randomized trial. Ann Surg. 2010;252(2):207–14.CrossRefPubMedGoogle Scholar
  39. 39.
    Van Buren G, Bloomston M, Hughes SJ, Winter J, Behrman SW, Zyromski NJ, et al. A randomized prospective multicenter trial of pancreaticoduodenectomy with and without routine intraperitoneal drainage. Ann Surg. 2014;259(4):605–12.CrossRefPubMedGoogle Scholar
  40. 40.
    Callery MP, Pratt WB, Kent TS, Chaikof EL, Vollmer CM. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg. 2013;216(1):1–14.CrossRefPubMedGoogle Scholar
  41. 41.
    McMillan MT, Fisher WE, Van Buren G, McElhany A, Bloomston M, Hughes SJ, et al. The value of drains as a fistula mitigation strategy for pancreatoduodenectomy: something for everyone? Results of a randomized prospective multi-institutional study. J Gastrointest Surg. 2015;19(1):21–31.CrossRefPubMedGoogle Scholar
  42. 42.
    McMillan MT, Malleo G, Bassi C, Allegrini V, Casetti L, Drebin JA, et al. Multicenter, prospective trial of selective drain management for pancreatoduodenectomy using risk stratification. Ann Surg. 2017;265(6):1209–18.CrossRefPubMedGoogle Scholar
  43. 43.
    Molinari E, Bassi C, Salvia R, Butturini G, Crippa S, Talamini G, et al. Amylase value in drains after pancreatic resection as predictive factor of postoperative pancreatic fistula: results of a prospective study in 137 patients. Ann Surg. 2007;246(2):281–7.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Fong ZV, Correa-Gallego C, Ferrone CR, Veillette GR, Warshaw AL, Lillemoe KD, et al. Early drain removal-the middle ground between the drain versus no drain debate in patients undergoing pancreaticoduodenectomy: a prospective validation study. Ann Surg. 2015;262(2):378–83.CrossRefGoogle Scholar
  45. 45.
    Partelli S, Tamburrino D, Crippa S, Facci E, Zardini C, Falconi M. Evaluation of a predictive model for pancreatic fistula based on amylase value in drains after pancreatic resection. Am J Surg. 2014;208(4):634–9.CrossRefPubMedGoogle Scholar
  46. 46.
    Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery. 2005;138(1):8–13.CrossRefPubMedGoogle Scholar
  47. 47.
    Malleo G, Salvia R, Butturini G, D’Onofrio M, Martone E, Marchegiani G, et al. Is routine imaging necessary after pancreatic resection? An appraisal of postoperative ultrasonography for the detection of pancreatic fistula. Pancreas. 2014;43(2):319–23.CrossRefPubMedGoogle Scholar
  48. 48.
    Bruno O, Brancatelli G, Sauvanet A, Vullierme MP, Barrau V, Vilgrain V. Utility of CT in the diagnosis of pancreatic fistula after pancreaticoduodenectomy in patients with soft pancreas. AJR Am J Roentgenol. 2009;193(3):W175–80.CrossRefPubMedGoogle Scholar
  49. 49.
    Sierzega M, Kulig P, Kolodziejczyk P, Kulig J. Natural history of intra-abdominal fluid collections following pancreatic surgery. J Gastrointest Surg. 2013;17(8):1406–13.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Gervais DA, Fernandez-del Castillo C, O’Neill MJ, Hahn PF, Mueller PR. Complications after pancreatoduodenectomy: imaging and imaging-guided interventional procedures. Radiographics. 2001;21:673–90.CrossRefPubMedGoogle Scholar
  51. 51.
    Faccioli N, Foti G, Molinari E, Hermans JJ, Comai A, Talamini G, et al. Role of fistulography in evaluating pancreatic fistula after pancreaticoduodenectomy. Br J Radiol. 2012;85(1011):219–24.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Mcmillan MT, Malleo G, Bassi C, Butturini G, Salvia R, Roses RE, et al. Drain management after pancreatoduodenectomy: reappraisal of a prospective randomized trial using risk stratification. J Am Coll Surg. 2015;221(4):798–809.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2018

Authors and Affiliations

  • Alessandra Pulvirenti
    • 1
  • Antonio Pea
    • 1
  • Matteo De Pastena
    • 1
  • Giovanni Marchegiani
    • 1
  • Roberto Salvia
    • 1
  • Claudio Bassi
    • 1
  1. 1.Department of Surgery, Pancreas InstituteUniversity and Hospital Trust of VeronaVeronaItaly

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