A new marker in post-pancreatectomy fistulas; hypophosphatemia

Year 2023, , 550 - 556, 30.09.2023

Özhan Çetindağ , Ali Ekrem Ünal

https://doi.org/10.18663/tjcl.1346797

Abstract

Aim: Postoperative hypophosphatemia is associated with morbidity after many gastrointestinal surgeries. In this study,
we aimed to investigate the relationship between hypophosphatemia and POPF, which is one of the morbidities after pancreatectomy.
Material and Methods: All adult patients who underwent pancreatectomy in our surgical oncology clinic from 2010 to 2020 were included in the patient data recording system to the Faculty of Medicine of Ankara University, Surgical Oncology clinic. Exclusions were made for those under 18, without postoperative Jackson-Pratt (jp) amylase levels, and with previous pancreatic surgery.
Results: Examination of a total of 185 patients showed that fistula occurred in 20% of cases. Statistical analysis revealed that postoperative 2nd and 3rd-day phosphorus levels are markers for pancreatic leak.
Conclusion: Decreased phosphate values after pancreatic surgery may be an indicator for pancreatic fistula, especially significant on the 2nd and 3rd postoperative days

Keywords

Pancreatectomy, Postoperative Fistula, Hypophosphatemia, Surgical Oncology, Pancreatic Leak, Phosphorus Levels

Post-pankreatektomi fistüllerinde yeni bir belirteç; hipofosfatemi

Abstract

Amaç: Postoperatif hipofosfatemi, birçok gastrointestinal cerrahi sonrası morbidite ile ilişkilidir. Bu çalışmada, hipofosfatemi ile pankreatektomi sonrası morbiditelerden biri olan POPF arasındaki ilişkiyi araştırmayı amaçladık.
Gereç ve Yöntemler: 2010 ile 2020 yılları arasında cerrahi onkoloji kliniğimizde pankreatektomi uygulanan tüm yetişkin hastalar, Ankara Üniversitesi Tıp Fakültesi, Cerrahi Onkoloji Kliniği hastaların veri kayıt sistemine dahil edildi. 18 yaşından küçük hastalar, postoperatif Jackson-Pratt (jp) amilaz seviyesi olmayan hastalar ve önceki pankreas cerrahisi olan hastalar bu çalışma dışı bırakıldı. Bulgular: Toplam 185 hastanın takibinde fistül gelişip gelişmediği kaydedildi ve vakaların %20'sinde fistül meydana geldi. Fistül ile BMI, yaş, cinsiyet, ca-19.9 seviyeleri ve ameliyat öncesi fosfor seviyeleri, pankreas cerrahisi türü ve ameliyat sonrası günlerdeki 0-1-2-3 fosfor seviyeleri arasındaki ilişki incelendi. POPF olmayan ve olan grup arasında POPL 0 değerleri arasında istatistiksel olarak anlamlı bir fark bulunmadı (p=0.422). POPF olmayan ve olan gruplardaki POPL 1 değerlerindeki fark önemli değil (p=0.296). POPF olmayan ve olan gruplardaki POPL 2 değerlerindeki fark anlamlı (p=0.002). POPF olmayan ve olan grup arasında POPL 3 değerlerindeki fark anlamlıydı (p=0.001). İstatistiksel analiz, ameliyat sonrası 0. gün fosfor seviyeleri ve ameliyat sonrası 1. gün fosfor seviyelerinin pankreas kaçağının bir göstergesi olmadığını, ameliyat sonrası 2. ve 3. gün fosfor seviyelerinin ise çalışma grubumuzda pankreas kaçağının belirleyicisi olduğunu gösterdi.
Sonuç: Pankreas cerrahisi sonrası azalan fosfat değerleri, pankreatik fistül için bir gösterge olabilir. Fosfor seviyeleri, özellikle ameliyat sonrası 2. ve 3. günlerde kaçak açısından anlamlı bulundu.

Keywords

Pankreatektomi, Postoperatif Fistül, Hipofosfatemi, Cerrahi Onkoloji, Pankreatik Sızıntı, Fosfor Seviyeleri

References

• W. Kimura, “Strategies for the treatment of invasive ductal carcinoma of the pancreas and how to achieve zero mortality for pancreaticoduodenectomy,” J. Hepatobiliary. Pancreat. Surg., vol. 15, no. 3, pp. 270–277, May 2008, doi: 10.1007/s00534-007-1305-7.
• W. S. HALSTED, “Contributions to the Surgery of the Bile Passages, Especially of the Common Bile-Duct,” Bost. Med. Surg. J., vol. 141, no. 26, pp. 645–654, Dec. 1899, doi: 10.1056/ nejm189912281412601.
• KAUSCH and W., “Die Resektion des Mittleren Duodenums-line Typische operation. Verlauzige Mitter-lung,” Zentralbl Chir., vol. 39, p. 1350, 1909, Accessed: Jun. 02, 2021. [Online]. Available: https://ci.nii.ac.jp/naid/10016079236.
• J. M. Howard, “Development and progress in resective surgery for pancreatic cancer,” in World Journal of Surgery, Sep. 1999, vol. 23, no. 9, pp. 901–906, doi: 10.1007/s002689900597.
• J. J. Monge’, E. S. Judd, and R. P. Gage, “Radical Pancreatoduodenectomy: A 22-Year Experience with the Complications, Mortality Rate, and Survival Rate *.” Accessed: Jun. 02, 2021. [Online]. Available: https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC1408901/.
• P.B.Lansing,J.B.Blalock,andJ.L.Ochsner,“Pancreatoduodenectomy: a retrospective review 1949 to 1969.,” Am. Surg., vol. 38, no. 2, pp. 79–86, Feb. 1972, Accessed: Jun. 02, 2021. [Online]. Available: https://europepmc.org/article/med/4333406.
• J. L. Cameron, T. S. Riall, J. Coleman, and K. A. Belcher, “One thousand consecutive pancreaticoduodenectomies,” Ann. Surg., vol. 244, no. 1, pp. 10–15, Jul. 2006, doi: 10.1097/01. sla.0000217673.04165.ea.
• C. Bassi, M. Falconi, R. Salvia, G. Mascetta, E. Molinari, and P. P. Pederzoli, “Management of complications after pancreaticoduodenectomy in a high volume centre: Results on 150 consecutive patients,” Dig. Surg., vol. 18, no. 6, pp. 453–457, 2001, doi: 10.1159/000050193.
• K. Søreide and K. J. Labori, “Risk factors and preventive strategies for post-operative pancreatic fistula after pancreatic surgery: a comprehensive review,”Scandinavian Journal of Gastroenterology, vol. 51, no. 10. Taylor and Francis Ltd, pp. 1147–1154, Oct. 02, 2016, doi: 10.3109/00365521.2016.1169317.
• “Butturini G, Daskalaki D, Molinari E et al (2008)... - Google Akademik.” https://scholar.google.com/scholar?hl=tr&as_sdt=0 %2C5&q=+Butturini+G%2C+Daskalaki+D%2C+Molinari+E+et+ al+%282008%29+Pancreatic+fistula%3A+definition+and+curr ent+problems.+J+Hepato+Biliary+Pancreat+Surg+15%3A247– 251&btnG= (accessed Jun. 02, 2021).
• C. Bassi, C. Dervenis, G. Butturini, A. Fingerhut, C. Y.- Surgery, and undefined 2005, “Postoperative pancreatic fistula: an international study group (ISGPF) definition,” Elsevier, Accessed: Jun. 02, 2021. [Online]. Available: https://www.sciencedirect. com/science/article/pii/S0039606005002291.
• Y. M. Yang, X. D. Tian, Y. Zhuang, W. M. Wang, Y. L. Wan, and Y. T. Huang, “Risk factors of pancreatic leakage after pancreaticoduodenectomy,” World J. Gastroenterol., vol. 11, no. 16, pp. 2456–2461, Apr. 2005, doi: 10.3748/wjg.v11.i16.2456.
• J. B. IV, D. Rattner, ... A. W.-A. of, and undefined 2001, “Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization,” jamanetwork.com, Accessed: Jun. 02, 2021. [Online]. Available: https:// jamanetwork.com/journals/jamasurgery/article-abstract/391232.
• T. Hackert, J. Werner, M. B.-T. Surgeon, and undefined 2011, “Postoperative pancreatic fistula,” Elsevier, Accessed: Jun. 02, 2021. [Online]. Available: https://www.sciencedirect.com/ science/article/pii/S1479666X10002738.
• B. K. P. Goh, “Critical Appraisal of 232 Consecutive Distal Pancreatectomies With Emphasis on Risk Factors, Outcome, and Management of the Postoperative Pancreatic Fistula A 21-Year Experience at a Single Institution.” Accessed: Jun. 02, 2021. [Online]. Available: https://jamanetwork.com/journals/ jamasurgery/article-abstract/401940.
• B. Suc, S. Msika, A. Fingerhut, ... G. F.-A. of, and undefined 2003, “Temporary fibrin glue occlusion of the main pancreatic duct in the prevention of intra-abdominal complications after pancreatic resection: prospective,” ncbi.nlm.nih.gov, Accessed: Jun. 02, 2021. [Online]. Available: https://www.ncbi.nlm.nih.gov/ pmc/articles/pmc1513966/.
• A. El Nakeeb et al., “Pancreatic anastomotic leakage after pancreaticoduodenectomy. Risk factors, clinical predictors, and management (single center experience),” World J. Surg., vol. 37, no. 6, pp. 1405–1418, Jun. 2013, doi: 10.1007/s00268-013-1998-5.
• M. Shimoda, M. Katoh, I. Yukihiro, J. Kita, T. Sawada, and K. Kubota, “Body mass index is a risk factor of pancreatic fistula after pancreaticoduodenectomy,” Am. Surg., vol. 78, no. 2, pp. 190–194, Feb. 2012, doi: 10.1177/000313481207800237.
• J. L. Mueller et al., “Lower phosphate levels following pancreatectomy is associated with postoperative pancreatic fistula formation,” HPB, vol. 21, no. 7, pp. 834–840, Jul. 2019, doi: 10.1016/j.hpb.2018.10.017.
• J. McPhee, J. Hill, G. Whalen, ... M. Z.-A. of, and undefined 2007, “Perioperative mortality for pancreatectomy: a national perspective,” ncbi.nlm.nih.gov, Accessed: Jun. 02, 2021. [Online]. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC1933570/.
• M. Shimoda, M. Katoh, I. Yukihiro, J. Kita, T. Sawada, and K. Kubota, “Body mass index is a risk factor of pancreatic fistula after pancreaticoduodenectomy,” Am. Surg., vol. 78, no. 2, pp. 190–194, Feb. 2012, doi: 10.1177/000313481207800237.
• S. Gaujoux, A. Cortes, A. Couvelard, S. Noullet, L. C.- Surgery, and undefined 2010, “Fatty pancreas and increased body mass index are risk factors of pancreatic fistula after pancreaticoduodenectomy,” Elsevier, Accessed: Jun. 02, 2021. [Online]. Available: https://www.sciencedirect.com/science/ article/pii/S0039606009007971.
• A. Mckay et al., “Meta-analysis of pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy,” ingentaconnect.com, 2006, doi: 10.1002/bjs.5407.
• C. Bassi, M. Falconi, E. Molinari, ... R. S.-A. of, and undefined 2005, “Reconstruction by pancreaticojejunostomy versus pancreaticogastrostomy following pancreatectomy: results of a comparative study,” ncbi.nlm.nih.gov, Accessed: Jun. 02, 2021. [Online]. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC1409871/.
• M. K. Diener, H. P. Knaebel, S. T. Witte, I. Rossion, M. Kieser, and C. M. Seiler,“DISPACT trial: a randomized controlled trial to compare two different surgical techniques of DIStal PAnCreaTectomy- study rationale and design,” Clin. Trials, vol. 5, no. 5, pp. 534–545, 2008, doi: 10.1177/1740774508096140.
• M. Ridolfini, S. Alfieri, ... S. G.-W. journal of, and undefined 2007, “Risk factors associated with pancreatic fistula after distal pancreatectomy, which technique of pancreatic stump closure is more beneficial?,” ncbi.nlm.nih.gov, Accessed: Jun. 02, 2021. [Online]. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4434639/.
• I. G. Van Buren, ... M. B.-A. of, and undefined 2014, “A randomized prospective multicenter trial of pancreaticoduodenectomy with and without routine intraperitoneal drainage,” cdn.journals. lww.com, Accessed: Jun. 02, 2021. [Online]. Available: https:// cdn.journals.lww.com/annalsofsurgery/FullText/2014/04000/A_ Randomized_Prospective_Multicenter_Trial_of.1.aspx.
• R. Poon, S. Fan, C. Lo, K. Ng, ... W. Y.-A. of, and undefined 2007, “External drainage of pancreatic duct with a stent to reduce leakage rate of pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized,” ncbi. nlm.nih.gov, Accessed: Jun. 02, 2021. [Online]. Available: https:// www.ncbi.nlm.nih.gov/pmc/articles/pmc1959348/.
• P. J. Allen et al., “Pasireotide for Postoperative Pancreatic Fistula,” N. Engl. J. Med., vol. 370, no. 21, pp. 2014–2022, May 2014, doi: 10.1056/nejmoa1313688.
• J. J. Pomposelli et al., “Life-Threatening Hypophosphatemia After Right Hepatic Lobectomy for Live Donor Adult Liver Transplantation,” Elsevier, vol. 7, no. 7, pp. 637–642, 2001, doi: 10.1053/jlts.2001.26287.
• I. Hessov, N. G. Jensen, and A. Rasmussen, “Prevention of hypophosphatemia during postoperative routine glucose administration,” Acta Chir. Scand., vol. 146, no. 2, pp. 109–114, Jan. 1980, Accessed: Jun. 02, 2021. [Online]. Available: https:// europepmc.org/article/med/6774541.
• A. Rasmussen, H. H. Kimose, and I. Hessov, “Severity of postoperative hypophosphatemia in relation to glucose administration and renal handling of phosphate,” Acta Chir. Scand., vol. 154, no. 11–12, pp. 617–621, Nov. 1988, Accessed: Jun. 02, 2021. [Online]. Available: https://europepmc.org/article/ med/3232477.
• I. Giovannini, C. Chiarla, and G. Nuzzo, “Pathophysiologic and clinical correlates of hypophosphatemia and the relationship with sepsis and outcome in postoperative patients after hepatectomy,” Shock, vol. 18, no. 2, pp. 111–115, 2002, doi: 10.1097/00024382-200208000-00003.
• “Early post-operative hypophosphatemia as a novel... - Google Akademik.” https://scholar.google.com/scholar?q=Early post-operative hypophosphatemia as a novel predictor of anastomotic failure after pancreatic resection: a risk-prediction tool. Oral Presentation (accessed Jun. 02, 2021).
• E. Sadot et al., “Hypophosphatemia as a Predictor of Organ- Specific Complications Following Gastrointestinal Surgery: Analysis of 8034 Patients,” World J. Surg., vol. 43, pp. 385–394, 2019, doi: 10.1007/s00268-018-4726-3.
• “Hypophosphataemia after major hepatectomy and the risk of post-operative hepatic insufficiency and mortality: an analysis of 719 patients | Elsevier Enhanced Reader.” https://reader.elsevier. com/reader/sd/pii/S1365182X15314957?token=A7012E1AF0214 66A68DB899D844311933107C9B23C7438303FB6403E7D8E5B71 0CE57BF839AE0C3F19F55673917A5588&originRegion=eu-west- 1&originCreation=20210913163841 (accessed Sep. 13, 2021).
• D. Kooby, K. Zakian, S. Challa, C. Matei, H. P.-C. research, and undefined 2000, “Use of phosphorous-31 nuclear magnetic resonance spectroscopy to determine safe timing of chemotherapy after hepatic resection,” AACR, vol. 60, pp. 3800– 3806, 2000, Accessed: Sep. 13, 2021. [Online]. Available: https:// cancerres.aacrjournals.org/content/60/14/3800.short.
• R. R. Salem and K. Tray, “Hepatic Resection-Related Hypophosphatemia Is of Renal Origin as Manifested by Isolated Hyperphosphaturia,” Ann. Surg., vol. 241, no. 2, p. 343, Feb. 2005, doi: 10.1097/01.SLA.0000152093.43468.C0.
• K. Nomura et al., “Hepatectomy-Related Hypophosphatemia: A Novel Phosphaturic Factor in the Liver-Kidney Axis,” J. Am. Soc. Nephrol., vol. 25, no. 4, pp. 761–772, Apr. 2014, doi: 10.1681/ ASN.2013060569.
• J. Zheng et al., “Hypophosphatemia after Hepatectomy or Pancreatectomy: Role of the Nicotinamide Phosphoribosyltransferase,” J. Am. Coll. Surg., vol. 225, no. 4, pp. 488-497.e2, Oct. 2017, doi: 10.1016/J.JAMCOLLSURG.2017.06.012.
• V. Barak, A. Schwartz, I. Kalickman, B. Nisman, G. Gurman, and Y. Shoenfeld, “Prevalence of Hypophosphatemia in Sepsis and Infection: The Role of Cytokines,” Am. J. Med., vol. 104, no. 1, pp. 40–47, Jan. 1998, doi: 10.1016/S0002-9343(97)00275-1.