Abstract
Background
In 2005, the International Study Group of Pancreatic Fistula (ISGPF) developed a definition and grading system for postoperative pancreatic fistula (POPF). The authors sought to determine the rate of POPF after enucleation and/or resection of pancreatic neuroendocrine tumors (PNET) and to identify clinical, surgical, or pathologic factors associated with POPF.
Methods
A retrospective analysis of pancreatic enucleations and resections performed from March 1998 to April 2010. We defined a clinically significant POPF as a grade B that required nonoperative intervention and grade C.
Results
One hundred twenty-two patients were identified; 62 patients had enucleations and 60 patients had resections of PNET. The rate of clinically significant POPF was 23.7 % (29/122). For pancreatic enucleation, the POPF rate was 27.4 % (17/62, 14 grade B, 3 grade C). The pancreatic resection group had a POPF rate of 20 % (12/60, 10 grade B, 2 grade C). This difference was not significant (p = 0.4). In univariate analyses, patients in the enucleation group with hereditary syndromes (p = 0.02) and non-insulinoma tumors (p = 0.02) had a higher POPF rate. Patients in the resection group with body mass index (BMI) > 25 (p < 0.01), multiple endocrine neoplasia type 1 (MEN-1; p < 0.01) and those who underwent simultaneous multiple procedures (p = 0.02) had a higher POPF rate. Multivariate analyses revealed that hereditary syndromes were able to predict POPF in the enucleation group, while having BMI > 25 and increasing lesion size were also associated with POPF in the group undergoing resection.
Conclusions
We found a clinically significant POPF rate after surgery in PNET to be 23.7 % with no difference by the type of operation. Our POPF rate is comparable to that reported in the literature for pancreatic resection for other types of tumors. Certain inherited genetic diseases—von Hippel–Lindau disease (VHL) and MEN-1—were associated with higher POPF rates.
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References
Cameron JL, Pitt HA, Yeo CJ et al (1993) One hundred forty-five consecutive pancreaticoduodenectomies without mortality. Ann Surg 217:430–435 (discussion 435–438)
Yeo CJ, Cameron JL, Sohn TA et al (1997) Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg 226:248–257 (discussion 257–260)
Bassi C, Dervenis C, Butturini G et al (2005) Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 138:8–13
Buchler MW, Friess H, Wagner M et al (2000) Pancreatic fistula after pancreatic head resection. Br J Surg 87:883–889
Kazanjian KK, Hines OJ, Eibl G et al (2005) Management of pancreatic fistulas after pancreaticoduodenectomy: results in 437 consecutive patients. Arch Surg 140:849–854 (discussion 846–854)
Gouma DJ, van Geenen RC, van Gulik TM et al (2000) Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume. Ann Surg 232:786–795
Phan GQ, Yeo CJ, Hruban RH et al (1998) Surgical experience with pancreatic and peripancreatic neuroendocrine tumors: review of 125 patients. J Gastrointest Surg 2:473–482
Dong X, Zhang B, Kang MX et al (2011) Analysis of pancreatic fistula according to the International Study Group on Pancreatic Fistula classification scheme for 294 patients who underwent pancreaticoduodenectomy in a single center. Pancreas 40:222–228
Tan WJ, Kow AW, Liau KH (2011) Moving towards the New International Study Group for Pancreatic Surgery (ISGPS) definitions in pancreaticoduodenectomy: a comparison between the old and new. HPB (Oxf) 13:566–572
Fendrich V, Merz MK, Waldmann J et al (2011) Neuroendocrine pancreatic tumors are risk factors for pancreatic fistula after pancreatic surgery. Dig Surg 28:263–269
Hackert T, Werner J, Buchler MW (2011) Postoperative pancreatic fistula. Surgeon 9:211–217
Pitt SC, Pitt HA, Baker MS et al (2009) Small pancreatic and periampullary neuroendocrine tumors: resect or enucleate? J Gastrointest Surg 13:1692–1698
Halfdanarson TR, Rabe KG, Rubin J et al (2008) Pancreatic neuroendocrine tumors (PNETs): incidence, prognosis and recent trend toward improved survival. Ann Oncol 19:1727–1733
Wang DS, Zhang DS, Qiu MZ et al (2011) Prognostic factors and survival in patients with neuroendocrine tumors of the pancreas. Tumour Biol 32:697–705
Kloppel G (2007) Tumour biology and histopathology of neuroendocrine tumours. Best Pract Res Clin Endocrinol Metab 21:15–31
Kloppel G, Anlauf M, Perren A (2007) Endocrine precursor lesions of gastroenteropancreatic neuroendocrine tumors. Endocr Pathol 18:150–155
Pour PM, Schmied B (1999) The link between exocrine pancreatic cancer and the endocrine pancreas. Int J Pancreatol 25:77–87
Oberg K, Eriksson B (2005) Endocrine tumours of the pancreas. Best Pract Res Clin Gastroenterol 19:753–781
Blansfield JA, Choyke L, Morita SY et al (2007) Clinical, genetic and radiographic analysis of 108 patients with von Hippel–Lindau disease (VHL) manifested by pancreatic neuroendocrine neoplasms (PNETs). Surgery 142:814–818 (discussion 818, e811–e812)
Binkovitz LA, Johnson CD, Stephens DH (1990) Islet cell tumors in von Hippel–Lindau disease: increased prevalence and relationship to the multiple endocrine neoplasias. Am J Roentgenol 155:501–505
Goudet P, Murat A, Binquet C et al (2010) Risk factors and causes of death in MEN1 disease. A GTE (Groupe d’Etude des Tumeurs Endocrines) cohort study among 758 patients. World J Surg 34:249–255. doi:10.1007/s00268-009-0290-1
DiNorcia J, Lee MK, Reavey PL et al (2010) One hundred thirty resections for pancreatic neuroendocrine tumor: evaluating the impact of minimally invasive and parenchyma-sparing techniques. J Gastrointest Surg 14:1536–1546
Kulke MH, Bendell J, Kvols L et al (2011) Evolving diagnostic and treatment strategies for pancreatic neuroendocrine tumors. J Hematol Oncol 4:29
Roth E, Muhlbacher F, Karner J et al (1987) Free amino acid levels in muscle and liver of a patient with glucagonoma syndrome. Metabolism 36:7–13
Whipple AO, Frantz VK (1935) Adenoma of islet cells with hyperinsulinism: a review. Ann Surg 101:1299–1335
Jensen RT (1996) Gastrointestinal endocrine tumours. Gastrinoma. Baillieres Clin Gastroenterol 10:603–643
Jensen RT, Niederle B, Mitry E et al (2006) Gastrinoma (duodenal and pancreatic). Neuroendocrinology 84:173–182
Zollinger RM (1971) Islet cell tumors: a diarrheogenic syndrome. Prensa Med Argent 58:1458–1462
Zollinger RM, Ellison EH (1955) Primary peptic ulcerations of the jejunum associated with islet cell tumors of the pancreas. Ann Surg 142:709–723 (discussion 708–724)
Batcher E, Madaj P, Gianoukakis AG (2011) Pancreatic neuroendocrine tumors. Endocr Res 36:35–43
Pratt WB, Maithel SK, Vanounou T et al (2007) Clinical and economic validation of the International Study Group of Pancreatic Fistula (ISGPF) classification scheme. Ann Surg 245:443–451
Imamura M (2010) Recent standardization of treatment strategy for pancreatic neuroendocrine tumors. World J Gastroenterol 16:4519–4525
Oberg K (2005) Neuroendocrine tumors of the gastrointestinal tract: recent advances in molecular genetics, diagnosis, and treatment. Curr Opin Oncol 17:386–391
House MG, Fong Y, Arnaoutakis DJ et al (2008) Preoperative predictors for complications after pancreaticoduodenectomy: impact of BMI and body fat distribution. J Gastrointest Surg 12:270–278
Vanounou T, Pratt WB, Callery MP et al (2007) Selective administration of prophylactic octreotide during pancreaticoduodenectomy: a clinical and cost–benefit analysis in low- and high-risk glands. J Am Coll Surg 205:546–557
Wagner M, Gloor B, Ambuhl M et al (2007) Roux-en-Y drainage of the pancreatic stump decreases pancreatic fistula after distal pancreatic resection. J Gastrointest Surg 11:303–308
Berger AC, Howard TJ, Kennedy EP et al (2009) Does type of pancreaticojejunostomy after pancreaticoduodenectomy decrease rate of pancreatic fistula? A randomized, prospective, dual-institution trial. J Am Coll Surg 208:738–747 (discussion 737–739)
DeOliveira ML, Winter JM, Schafer M et al (2006) Assessment of complications after pancreatic surgery: a novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann Surg 244:931–937 (discussion 937–939)
Lin JW, Cameron JL, Yeo CJ et al (2004) Risk factors and outcomes in postpancreaticoduodenectomy pancreaticocutaneous fistula. J Gastrointest Surg 8:951–959
Zhu B, Geng L, Ma YG et al (2011) Combined invagination and duct-to-mucosa techniques with modifications: a new method of pancreaticojejunal anastomosis. Hepatobiliary Pancreatic Dis Int 10:422–427
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Inchauste, S.M., Lanier, B.J., Libutti, S.K. et al. Rate of Clinically Significant Postoperative Pancreatic Fistula in Pancreatic Neuroendocrine Tumors. World J Surg 36, 1517–1526 (2012). https://doi.org/10.1007/s00268-012-1598-9
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DOI: https://doi.org/10.1007/s00268-012-1598-9