title: Early intraperitoneal metabolic changes and protease activation as indicators of pancreatic fistula after pancreaticoduodenectomy.
abstract: BACKGROUND
  Ischaemia and local protease activation close to the pancreaticojejunal anastomosis (PJA) are potential mechanisms of postoperative pancreatic fistula (POPF) formation. To provide information on the pathophysiology of POPF, intraperitoneal microdialysis was used to monitor metabolic changes and protease activation close to the PJA after pancreaticoduodenectomy (PD).
  
  
  METHODS
  In patients who underwent PD, intraperitoneal metabolites (glycerol, lactate, pyruvate and glucose) were measured by microdialysis, and lactate and glucose in blood were monitored, every 4 h for 5 days, starting at 12.00 hours on the day after surgery. Trypsinogen activation peptide (TAP) was measured in microdialysates as a marker of protease activation.
  
  
  RESULTS
  Intraperitoneal glycerol levels and the ratio of lactate to pyruvate were higher after PD and glucose levels were lower in seven patients who later developed symptomatic POPF than in eight patients with other surgical complications (OSC) and 33 with no surgical complications (NSC) (all P < 0·050). TAP was detected at a concentration greater than 0·1 µg/l in six of seven patients with POPF, two of eight with OSC and two of 33 with NSC. Intraperitoneal lactate concentrations were higher than systemic levels in all patients on days 1 to 5 after surgery (P < 0·001). In patients with POPF, high intraperitoneal lactate concentrations were observed without systemic hyperlactataemia.
  
  
  CONCLUSIONS
  Early in the postoperative phase, patients who later developed clinically significant POPF had higher intraperitoneal glycerol concentrations and lactate/pyruvate ratios, and lower glucose concentrations in combination with a TAP level exceeding 0·1 µg/l close to the PJA, than patients who did not develop POPF.
authors: Division of Surgery, Department of Clinical Science, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden.
authors: C
authors: C
authors: Ansorge
authors: S
authors: S
authors: Regner
authors: R
authors: R
authors: Segersvärd
authors: L
authors: L
authors: Strömmer
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000681:Amylases / Q000097:blood; D015415:Biomarkers / Q000378:metabolism; D001786:Blood Glucose / Q000378:metabolism; D004789:Enzyme Activation; D005260:Female; D005947:Glucose / Q000378:metabolism; D005990:Glycerol / Q000378:metabolism; D006801:Humans; D019344:Lactic Acid / Q000097:blood / Q000378:metabolism; D008297:Male; D017551:Microdialysis; D008875:Middle Aged; D010185:Pancreatic Fistula / Q000201:enzymology / Q000209:etiology* / Q000378:metabolism* / Q000503:physiopathology; D016577:Pancreaticoduodenectomy / Q000009:adverse effects* / Q000401:mortality; D010447:Peptide Hydrolases / Q000378:metabolism*; D010529:Peritoneal Cavity; D011184:Postoperative Period; D019289:Pyruvic Acid / Q000378:metabolism; D013997:Time Factors; D014362:Trypsinogen / Q000378:metabolism
chemical_list: D015415:Biomarkers; D001786:Blood Glucose; D019344:Lactic Acid; D019289:Pyruvic Acid; D014362:Trypsinogen; D000681:Amylases; D010447:Peptide Hydrolases; D005947:Glucose; D005990:Glycerol