Article

Postpancreatectomy hemorrhage (PPH) - An International Study Group of Pancreatic Surgery (ISGPS) definition

University of Verona, Verona, Veneto, Italy
Surgery (Impact Factor: 3.11). 08/2007; 142(1):20-5. DOI: 10.1016/j.surg.2007.02.001
Source: PubMed

ABSTRACT Postoperative hemorrhage is one of the most severe complications after pancreatic surgery. Due to the lack of an internationally accepted, universal definition of postpancreatectomy hemorrhage (PPH), the incidences reported in the literature vary considerably, even in reports from randomized controlled trials. Because of these variations in the definition of what constitutes a PPH, the incidences of its occurrence are not comparable.
The International Study Group of Pancreatic Surgery (ISGPS) developed an objective, generally applicable definition of PPH based on a literature review and consensus clinical experience.
Postpancreatectomy hemorrhage is defined by 3 parameters: onset, location, and severity. The onset is either early (< or =24 hours after the end of the index operation) or late (>24 hours). The location is either intraluminal or extraluminal. The severity of bleeding may be either mild or severe. Three different grades of PPH (grades A, B, and C) are defined according to the time of onset, site of bleeding, severity, and clinical impact.
An objective, universally accepted definition and clinical grading of PPH is important for the appropriate management and use of interventions in PPH. Such a definition also would allow comparisons of results from future clinical trials. Such standardized definitions are necessary to compare, in a nonpartisan manner, the outcomes of studies and the evaluation of novel operative treatment modalities in pancreatic surgery.

Download full-text

Full-text

Available from: Dirk J Gouma, Dec 08, 2014
2 Followers
 · 
236 Views
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: Pancreatic anastomotic leakаgе is one of the most serious complications following pancreaticoduodenectomy (PD). The most significant risk factors for pancreatic leakage are pan-creatic texture, main pancreatic duct (MPD) size and anastomotic technique. Herewith we des-cribe our technical modifications for single-layer pancreaticojejunostomy (PJ) with a soft pancreas and nondilated MPD for reconstruction after PD. Methods: We report our early experience using this technique in 52 patients who underwent PD between May 2009 and December 2012. Results: Overall postoperative mortality rate was 1.92%. Postoperative morbidity rate was 32.69%, with major complications occurring in three patients (5.77%). Pancreatic leak was diagnosed in six patients (11.54%). Three patients with pancreatic fistulae (PF) of Grades A and B were managed conservatively, whereas three other patients with PF of Grade C required relaparotomy. Con-clusions: According to our early experience with this modified technique for PJ, usage of hori-zontal mattress sutures, "everting" of MPD and incorporation of its wall into a single layer pan-creatic-enteric anastomosis result in a low pancreatic anastomotic leakage rate after PD. This technique for PJ with a soft pancreas and nondilated duct ensures ideal preconditions for anasto-mosis healing. They consist of an excellent blood supply, an anatomical position with tension-free approximation and unobstructed pancreatic juice flow from the pancreas into the jejunal loop.
    Surgical Science 10/2014; 5(5):444-453. DOI:10.4236/ss.2014.510069
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Abstract Objective. The first objective of the present study was to identify opportunities of improvement for clinical practice, assessed by local quality indicators, then to analyze possible reasons why we did not reach defined treatment quality measures. The second objective was to characterize patients, considered unresectable according to present criteria, for future arrangement of interventional studies with improved patient selection. Material and methods. Prospective observational cohort study from October 2008 to December 2010 of patients referred to the authors' institution with suspected pancreatic or periampullary neoplasm. Results. Of 330 patients, 135 underwent surgery, 195 did not, 129 due to unresectable malignancies. The rest had benign lesions. Perioperative morbidity rate was 32.6%, mortality 0.7%. Radical resection (R0) was obtained in 23 (41.8%) of 55 patients operated for pancreatic adenocarcinoma and 6.3% underwent reconstructive vascular surgery. Diagnostic failure/delay resulted in unresectable carcinoma, primarily misconceived as serous cystic adenoma in two patients. One resected lesion turned out to be focal autoimmune pancreatitis. One case with misdiagnosed cancer was revised to be a pseudoaneurysm. Palliative treatment was offered to 144 patients with malignant tumors, 62 due to locally advanced disease and all pancreatic adenocarcinomas. Conclusions. Quality improvement opportunities were identified for patient selection and surgical technique: Too few patients underwent reconstructive vascular surgery. The most important quality indicators are those securing resectional, radical (R0) surgery. Altogether 143 patients (57.9%) of those with malignant tumors were found unresectable, most of these patients are eligible for inclusion in future interventional studies with curative and/or palliative intention.
    Scandinavian Journal of Gastroenterology 05/2013; 48(5):617-625. DOI:10.3109/00365521.2013.781218 · 2.33 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: OBJECTIVE: To evaluate Peng's binding pancreaticojejunostomy as a safe technique which avoids anastomotic leakage after a pancreaticoduodenectomy. METHODS: Prospective, observational, dual-institutional study, of patients who underwent a Peng's binding pancreaticojejunostomy was conducted. It was compared with an historical control group of patients who underwent duct to mucosa pancreaticojejunostomy. Overall postoperative mortality, morbidity, postoperative pancreatic fistulas, postpancreatectomy hemorrhage, reoperation, length and costs of hospital stay were collected. Factors related with pancreatic fistula were: sex, age, co-morbidities, body mass index, American Society of Anesthesiologists score, type of resection, extension of resection, characteristics of the pancreatic remnant, pathological diagnosis and surgeons. Univariate and multivariate analyzes were carried out. RESULTS: Sixty-nine patients who underwent binding pancreaticojejunostomy were reported. The control group consisted of 52 patients. The mean length of hospital stay was significantly shorter in the control group than in binding group (p = 0.003). Multivariate analyzes showed that soft pancreatic remnant was significantly related to an increasing rate of postoperative pancreatic fistula (OR 3.7-CI 1.1-12.8-P = 0.034) while the type of pancreatic anastomosis was not significantly related with the occurrence of postoperative pancreatic fistula. CONCLUSIONS: In the European population, the binding pancreaticojejunostomy according to Peng did not preclude or reduce the postoperative pancreatic fistula rate.
    Pancreatology 05/2013; 13(3):305-309. DOI:10.1016/j.pan.2013.03.003 · 2.50 Impact Factor