Efficacy of Amniotic Membrane Over Pancreatic Anastomosis After Pancreaticoduodenenctomy to Preventing Pancreatic Fistula

Pancreatic Resection Clinical Trial

— POPF  

Official title:

Efficacy of Amniotic Membrane Implantation Over Pancreo-jejunal Anastomosis After Pancreaticoduodenectomy in Reducing Post-operative Pancreatic Fistula POPF.

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT03891225
• Other study ID #: 2039CESC
• Status: Completed
• Phase: Phase 1
• Start date: March 25, 2019
• Est. completion date: December 20, 2020

Study information

• Verified date: January 2021
• Source: Casa di Cura Dott. Pederzoli
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Post-operative pancreatic fistula (POPF) after pancreatic resection is a potentially life-threatening complication occuring in up to 27% of patients undergoing a pancreatic resection. Despite several strategies have been proposed further improvements are needed. Many studies suggest that amniotic membrane(AM) implantation is effective in tissue regeneration and prevention of fluid leakage at many surgical sites. However,the implantation of AM has never been used in pancreatic surgery. After having completed the first case of implantation of AM we proceed with this pilot study to determine in 20 consecutive patients undergone to pancreaticoduodenectomy (PD) with high risk of POPF, the efficacy of AM in reducing this event and the related morbidity.

Description:

Twenty consecutive patients candidated to PD regardless the diagnosis will be enrolled if presenting an high Fistula Risk Score. Enrollement will be done in O.R. after frozen section of the pancreas. The AM is provided by Fondazione Banca dei Tessuti di Treviso Onlus. The placenta is sourced from donors undergoing caesarean sections and processed shortly after retrieval, donors are evaluated according to Italian requirements. The AM is carefully detached from the chorion and rinsed with sterile saline solution, flattened on a nitrocellulose membrane filter (Merck Millipore), with its stromal side facing down, in contact with the filter. The AM is then immersed in a cocktail of antibiotics then cut into patches and immersed in cryopreservant solution. Cryopreservation was achieved using a programmable cryogenic freezer (Planer KryoSave Integra, 750-30), which triggers a controlled cooling rate. The AM patches were stored in vapor-phase liquid nitrogen. Thirty minutes before its use, the AM was defrozen and washed with saline. A 10x15cm MA patch was placed around the pancreatic anastomoses starting from the posterior surface. The caudal and the cranial flap were overlapped on the anterior surface to wrap the anastomosis. The membrane was than fixed with 4-0 Monocryl sutures at the jejunal surface and at the peri-pancreatic tissue. Then an end-to-side bilio-enteric anastomosis was carried out. The reconstruction was completed by an end-to-side antecolic duodenojejunostomy. At the end of the procedure, two drains were placed ventral and dorsal to the PJ, without friction with the AM. In the postoperative period will be evaluated: morbidity according to Clavien Dindo classification with attention to clinical relevant pancreatic fistula, bleeding, need of reintervention, surgical site infection, multi drug resistant infection and mortality. Costs and postoperative staying will be monitored as well. Student t test, Mann Whitney and Chi square will be used for statistical analysis.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 20
• Est. completion date: December 20, 2020
• Est. primary completion date: September 30, 2020
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years to 85 Years

Eligibility

Inclusion Criteria:

• Age between 18 and 85 years
• Undergone to Pancreatico-duodenectomy with high FRS (>=5)
• Adeguate consent

Exclusion Criteria:

• Total pancreatectomy
• Pancreatic anastomosis different from pancreo-jejunal anastomosis

Related Conditions & MeSH terms

• Biological Dressing
• Fistula
• Pancreatic Fistula
• Pancreatic Resection
• Post Operative Pancreatic Fistula

Intervention

Procedure:
• Amniotic Membrane implantation
Surgical procedure will be performed with Longemire Traverso technique. At the end of all pancreatic, biliary and duodenal anastomosis, the AM will be implanted.

Locations

Country	Name	City	State
Italy	Pederzoli Hospital	Peschiera Del Garda	Verona

Sponsors (2)

Lead Sponsor	Collaborator
Casa di Cura Dott. Pederzoli	Fondazione Banca dei Tessuti di Treviso onlus

Country where clinical trial is conducted

Italy, 

References & Publications (8)

Barski D, Gerullis H, Ecke T, Varga G, Boros M, Pintelon I, Timmermans JP, Winter A, Bagner JW, Otto T. Repair of a vesico-vaginal fistula with amniotic membrane - Step 1 of the IDEAL recommendations of surgical innovation. Cent European J Urol. 2015;68(4):459-61. doi: 10.5173/ceju.2015.683. Epub 2015 Nov 13. — View Citation

Callery MP, Pratt WB, Kent TS, Chaikof EL, Vollmer CM Jr. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg. 2013 Jan;216(1):1-14. doi: 10.1016/j.jamcollsurg.2012.09.002. Epub 2012 Nov 2. — View Citation

Knight BC, Kausar A, Manu M, Ammori BA, Sherlock DJ, O'Reilly DA. Evaluation of surgical outcome scores according to ISGPS definitions in patients undergoing pancreatic resection. Dig Surg. 2010;27(5):367-74. doi: 10.1159/000313693. Epub 2010 Oct 13. — View Citation

Lin SD, Lai CS, Hou MF, Yang CC. Amnion overlay meshed skin autograft. Burns Incl Therm Inj. 1985 Jun;11(5):374-8. — View Citation

McMillan MT, Vollmer CM Jr, Asbun HJ, Ball CG, Bassi C, Beane JD, Berger AC, Bloomston M, Callery MP, Christein JD, Dixon E, Drebin JA, Castillo CF, Fisher WE, Fong ZV, Haverick E, House MG, Hughes SJ, Kent TS, Kunstman JW, Malleo G, McElhany AL, Salem RR, Soares K, Sprys MH, Valero V 3rd, Watkins AA, Wolfgang CL, Behrman SW. The Characterization and Prediction of ISGPF Grade C Fistulas Following Pancreatoduodenectomy. J Gastrointest Surg. 2016 Feb;20(2):262-76. doi: 10.1007/s11605-015-2884-2. Epub 2015 Jul 11. — View Citation

Patel K, Teta A, Sukharamwala P, Thoens J, Szuchmacher M, DeVito P. External pancreatic duct stent reduces pancreatic fistula: a meta-analysis and systematic review. Int J Surg. 2014;12(8):827-32. doi: 10.1016/j.ijsu.2014.06.008. Epub 2014 Jul 6. Review. — View Citation

Pulvirenti A, Marchegiani G, Pea A, Allegrini V, Esposito A, Casetti L, Landoni L, Malleo G, Salvia R, Bassi C. Clinical Implications of the 2016 International Study Group on Pancreatic Surgery Definition and Grading of Postoperative Pancreatic Fistula on 775 Consecutive Pancreatic Resections. Ann Surg. 2018 Dec;268(6):1069-1075. doi: 10.1097/SLA.0000000000002362. — View Citation

Talmi YP, Sigler L, Inge E, Finkelstein Y, Zohar Y. Antibacterial properties of human amniotic membranes. Placenta. 1991 May-Jun;12(3):285-8. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	postoperative complications	clinical relevant pancreatic fistula, intra-abdominal collection, acute pancreatitis, SSI, need for reintervention, mortality	up to 90 days after surgery
Secondary	correlation between microscopic pancreatic fibrosis and CR POPF	the absence of microscopic fibrosis in a macroscopically soft pancreas may be related to higher risk of CR POPF and therefore may suggest implementation of anastomotic protecion (ie. the AM)	90 days from surgery