Conventional versus binding pancreaticojejunostomy after pancreaticoduodenectomy: a prospective randomized trial

OBJECTIVE

This study compared the postoperative pancreatic anastomosis leakage rate of a new binding technique with the conventional technique of pancreaticojejunostomy after pancreaticoduodenectomy.

SUMMARY BACKGROUND DATA

Leakage from pancreatic anastomoses remains the single most important morbidity after pancreaticoduodenectomy and contributes to prolonged hospitalization and mortality. The reported incidence after conventional pancreaticojejunostomy ranged from 10% to 29%. We previously reported a new binding pancreaticojejunostomy technique with a leakage of 0%.

METHODS

We conducted a prospective randomized study on 217 patients who underwent pancreaticoduodenectomy for benign and malignant diseases of the pancreatic head and the periampullary region comparing the 2 techniques of pancreaticojejunostomy.

RESULTS

Of the 111 patients randomized to the conventional group, pancreaticojejunostomy leakage occurred in 8 patients, while no patient in the 106 patients randomized to the binding group developed leakage (chi test, P = 0.014). The overall postoperative complications developed in 41 patients (36.9%) in the conventional group compared with 26 patients (24.5%) in the binding group (chi test, P = 0.048). Seven patients (6.3%) died in the perioperative period in the conventional group compared with 3 patients (2.8%) in the binding group (chi test, P = 0.37). The postoperative hospital stay (mean +/- SD) for the conventional group was 22.4 +/- 10.9 days, which was significantly longer than the binding group (18.4 +/- 4.7 days) (Mann-Whitney U test, P < 0.001).

CONCLUSIONS

Binding pancreaticojejunostomy after panceaticoduodenectomy significantly decreased postoperative complication and pancreaticojejunostomy leakage rates and shortened hospital stay when compared with conventional pancreaticojejunostomy.

Surgical treatment of hepatocellular carcinoma originating from caudate lobe--a report of 39 cases

The study objective was to study the therapeutic effect of surgical treatment for hepatocellular carcinoma (HCC) originating from the caudate lobe. From 1995 to 2003, caudate lobe resection was carried out for 97 cases; among them 39 were for HCC, who were divided into two groups. Group A consisted of 19 cases undergoing isolated caudatectomy, and group B consisted of 20 cases undergoing caudatectomy combined with other liver resections. The factors that might influence postoperative recovery were compared between the two groups. A special instrument, Peng's Multifunctional Operative Dissector, was used for surgical dissection. All tumors were resected successfully. One patient died of postoperative renal failure. Hydrothorax occurred in three patients, ascites occurred in four patients, and bile leakage occurred in one patient. Thirty cases received long-term follow-up with survival rates at 1, 3, and 5 years of 53%, 50%, and 39%, respectively. Caudate lobectomy is an effective therapeutic method for HCC originating in the caudate lobe. Isolated caudatectomy should be performed as the first choice whenever possible. Anterior transhepatic approach is appropriate in some cases. Peng's Multifunctional Operative Dissector is a very useful instrument for surgical dissection.

[Retrograde caudate lobectomy in 7 cases]

OBJECTIVE

To explore the clinical value and significance of retrograde caudate lobectomy.

METHODS

From December 2003 to January 2005, 7 patients underwent retrograde caudate lobectomy in which division and ligation of short hepatic veins were carried out at the final stage of the procedure in stead of at the initial stage.

RESULTS

The procedures were carried out smoothly with no operative death in all the 7 cases including isolated complete caudate lobectomy in 4 cases, isolated partial caudate lobectomy in 1 case, combined right half liver resection in 2 case. The average operation time, blood loss and length of stay after operation was (273 +/- 44) min, (1114 +/- 241) ml (800-1500 ml) and 16 days respectively. Complications including pleural effusion and ascites in 1 case respectively were fully recovered. During the follow-up, 1 patient died at 6 months for tumor recurrence in lung and the remaining 6 patients are alive at the follow-up of 5 to 16 months.

CONCLUSIONS

Retrograde caudate lobectomy is a new procedure suitable for those caudate neoplasms which are adhering to or infiltrating to IVC or too big to move side by side. The application of this technique can converse certain kind of caudate lobe tumor from non-resectable to resectable resulting in widening the indication.

[Surgical treatment of hepatocellular carcinoma originating from caudate lobe]

OBJECTIVE

To explore the significance of surgical treatment of HCC originating from caudate lobe.

METHODS

From 1995 to 2003, caudate lobectomy, including 19 cases of isolated lobectomy and 20 cases of combined lobectomy, were performed in 39 patients with HCC originating from caudate lobe, and the factors that might influence postoperative liver function were compared between the two groups.

RESULTS

All tumors were resected successfully. One patient died of postoperative renal failure. Hydrothorax occurred in 3 patients, ascites in 4 patients, and bile leakage in 1 patient. The survival rates of 1, 3, 5 year were 53%, 50%, 39% respectively.

CONCLUSIONS

Caudate lobectomy is a effective method for HCC originating from caudate lobe.

Binding pancreaticojejunostomy--a safe and reliable anastomosis procedure

BACKGROUND

Over the past one hundred years, the development of pancreaticoduodenectomy (PD) has always involved the struggle against pancreatic leakage. Until now, leakage of the pancreatic anastomosis has remained a common and serious complication after PD. Various methods of dealing with the pancreatic stump for prevention of pancreatic anastomotic leakage have been described. No matter which method is used, however, pancreatic anastomotic leakage is still most likely to occur when anastomosis involves a normal and soft pancreas.

METHODS

To perform a safe and reliable pancreaticoenteric anastomosis, we investigated the risk factors and potential mechanisms of occurrence of pancreatic leakage, including leakage from the needle hole and from the seam between two anastomosed structures, blood supply to the anastomosis and tension at the anastomosis. Based on these findings, we established a new pancreaticoenteric anastomosis procedure - binding pancreaticojejunostomy. The unique aspects of this procedure are as follows. The sero-muscular sheath of jejunum is bound to the invaginated pancreatic stump, so as to seal the gap between them; mucosa of the segment of jejunum that would eventually be in contact with the pancreatic stump is destroyed either chemically or by electric coagulation to promote healing. There is no needle hole on the jejunal surface of the anastomotic site.

RESULTS

From 1996 to 2003, a total of 227 consecutive patients were treated with this type of pancreaticojejunostomy in this institution. None of the patients developed a pancreatic anastomotic leak.

DISCUSSION

Binding pancreaticojejunostomy is a safe and reliable anastomotic procedure to effectively minimize leakage even when the texture of the pancreas is soft and normal.