The challenge of pancreatic anastomosis

"True" duct-to-mucosa pancreaticojejunostomy, with secure eversion of the enteric mucosa, in Whipple operation

BACKGROUND

Postoperative pancreatic fistula (POPF) due to anastomotic leak is often associated with significant morbidity and mortality. The aim of this study was to present an improved anastomotic technique for Whipple operation, which we call "true" duct-to-mucosa anastomosis (DMA)-pancreaticojejunostomy.

METHODS

A novel enteric mucosal eversion at the point of the jejunostomy is constructed prior to the anastomosis with the pancreatic duct in order to enhance sealing. This technique was tested in a series of 38 patients (study group) and compared to the technique used in the preceding 35 patients who served as controls.

RESULTS

The incidence of POPF was significantly lower in the study group compared to controls: 7.9 % (3/38) vs 34.3 % (12/35), respectively (P = 0.008, odds ratio 6.1). All POPFs in the study group were International Study Group on Pancreatic Fistula (ISGPF) grade A, while in the control group POPFs ISGPF grade B and C occurred in 17.1 %. Additionally, median (interquartile range) postoperative hospitalization was reduced in the study group [16 (14-21) days] compared to controls [20 (16-27) days, P = 0.005].

CONCLUSIONS

The "true" DMA technique appears to be one of the safest techniques reported to date. The modifications presented herein can easily be adopted by experienced surgeons already performing other techniques of duct-to-mucosa anastomosis.

Pancreaticogastrostomy is associated with significantly less pancreatic fistula than pancreaticojejunostomy reconstruction after pancreaticoduodenectomy: a meta-analysis of seven randomized controlled trials

OBJECTIVES

This study aimed to compare pancreaticojejunostomy (PJ) with pancreaticogastrostomy (PG) after pancreaticoduodenectomy (PD).

METHODS

A literature search of PubMed and the Cochrane Central Register of Controlled Trials for studies comparing PJ with PG after PD was conducted. The primary outcome for meta-analysis was pancreatic fistula. Secondary outcomes were morbidity, mortality, biliary fistula, intra-abdominal fluid collection, hospital length of stay (LoS), postoperative haemorrhage and reoperation. Outcome measures were odds ratios (ORs) and mean differences with 95% confidence intervals (CIs).

RESULTS

Seven recent RCTs encompassing 1121 patients (559 PJ and 562 PG cases) were involved in this meta-analysis. Incidences of pancreatic fistula (10.6% versus 18.5%; OR 0.52, 95% CI 0.37-0.74; P = 0.0002), biliary fistula (2.3% versus 5.7%; OR 0.42, 95% CI 0.03-3.15; P = 0.03) and intra-abdominal fluid collection (8.0% versus 14.7%; OR 0.50, 95% CI 0.34-0.74; P = 0.0005) were significantly lower in the PG than the PJ group, as was hospital LoS (weighted mean difference: -1.85, 95% CI -3.23 to -0.47; P = 0.008). Subgroup analysis indicated that severe pancreatic fistula (grades B or C) occurred less frequently in the PG than the PJ group (8.3% versus 20.5%; OR 0.37, 95% CI 0.23-0.59; P < 0.00001). However, there was no significant difference in morbidity (48.9% versus 51.0%; OR 0.90, 95% CI 0.70-1.16; P = 0.41), mortality (3.2% versus 3.5%; OR 0.82, 95% CI 0.43-1.58; P = 0.56), delayed gastric emptying (16.6% versus 14.7%; relative risk: 1.02, 95% CI 0.62-1.68; P = 0.94), postoperative haemorrhage (9.6% versus 11.1%; OR 0.82, 95% CI 0.54-1.24; P = 0.35) or reoperation (9.9% versus 9.8%; OR 0.93, 95% CI 0.60-1.43; P = 0.73).

CONCLUSIONS

Pancreaticogastrostomy provides benefits over PJ after PD, including in the incidences of pancreatic fistula, biliary fistula and intra-abdominal fluid collection and in hospital LoS. Therefore, PG is recommended as a safer and more reasonable alternative to PJ reconstruction after PD.

End-to-End Invaginated Pancreaticojejunostomy with Three Overlapping U-Sutures--A Safe and Simple Method of Pancreaticoenteric Anastomosis

BACKGROUND

Postoperative pancreatic fistula associated with mortality and morbidity remains an intractable problem after pancreaticoduodenectomy. To date it still carries a notable incidence of roughly 10% to 30% in large series in spite of numerous pharmacological and technical methods that have been proposed to achieve a leakproof pancreatic remnant.

METHODS

In order to perform a safe anastomosis to pancreatic remnant with less sophisticated sutures and shorter operative duration, a fast and simple technique of end-to-end invaginated pancreaticojejunostomy with three overlapping U-sutures was devised in our institution.

RESULTS

Between April 2011 and July 2013, end-to-end invaginated pancreaticojejunostomy with three overlapping U-sutures technique was used in 23 consecutive cases that underwent pancreaticoduodenectomy in our institute. The median operative time for pancreaticojejunostomy was 12 min. The incidence of pancreatic fistula was 8.7% (n = 2) and both cases were grade A fistula with no clinical impact or delayed hospital discharge. Neither relaparotomy nor postoperative mortality was observed.

CONCLUSIONS

The technique of using three overlapping U-sutures in an end-to-end invaginated pancreaticojejunostomy represents a simple management of pancreaticoenteric anastomosis with reliability and applicability, and provides an alternative choice for pancreaticojejunostomy to senior pancreatic surgeons as well as those without experience.

Low mortality rate in 97 consecutive pancreaticoduodenectomies: the experience of a group

CONTEXT

Pancreaticoduodenectomy is the procedure of choice for resectable cancer of the periampullary region. These tumors account for 4% of deaths from cancer, being referred to as one of the lowest survival rates at 5 years. Surgery remains a complex procedure with substantial morbidity and mortality. Despite reports of up to 30% mortality rates, in centers of excellence it have been identified as less than 5%. Recent studies show that pancreaticojejunostomy represents the "Achilles' heel" of the procedure.

OBJECTIVE

To evaluate the post-operative 30 days morbidity and mortality rates.

METHODS

Retrospective analysis of 97 consecutive resected patients between July, 2000 and December, 2012. All patients were managed by the same group, and data were obtained from specific database service. The main objective was to evaluate the 30-day mortality rate, but we also studied data of surgical specimen, need for vascular resection and postoperative complications (gastric stasis, pancreatic fistula, pneumonia and reoperation rate).

RESULTS

Thirty-day mortality rate was 2.1% (two patients). Complete resection with no microscopic residual tumor was obtained in 93.8% of patients, and in 67.3% of cases pathology did not detected metastatic nodes. Among postoperative complications were reported 6% of prolonged gastric stasis, 10.3% of pneumonia, 10.3% of pancreatic fistula and 1% of infection in the drain pathway. Two patients underwent reoperation due to bleeding and infected hematoma caused by pancreatic fistula, and another for intestinal obstruction because of adhesions at postoperative day 12.

CONCLUSIONS

The pancreaticoduodenectomy as treatment procedure for periampullary cancers has a low morbidity and mortality rate in services with experience in Hepato-Pancreato-Biliary surgery, remaining as first-line treatment in resectable patients.

Techniques for prevention of pancreatic leak after pancreatectomy

Pancreatic resections are some of the most technically challenging operations performed by surgeons, and post-operative pancreatic fistula (POPF) are not uncommon, developing in approximately 13% of pancreaticoduodenectomies and 30% of distal pancreatectomies. Multiple trials of various operative techniques in the creation of the pancreatic ductal anastomosis have been conducted throughout the years, and herein we review the literature and outcomes data regarding these techniques, although no one technique of pancreatic ductal anastomosis has been shown to be superior in decreasing rate of POPF. Similarly, we review the literature regarding techniques of pancreatic closure after distal pancreatectomy. Again, no one technique has been shown to be superior in preventing POPF; however the use of buttressing material on the pancreatic staple line in the future may be a successful means of decreasing POPF. We review adjunctive techniques to decrease POPF such as pancreatic ductal stenting, the use of various topical biologic glues, and the use of somatostatin analogue medications. We conclude that future trials will need to be conducted to find optimal techniques to decrease POPF, and meticulous attention to intra-operative details and post-operative care by surgeons is necessary to prevent POPF and optimally care for patients undergoing pancreatic resection.

Isolated Roux loop pancreaticojejunostomy versus pancreaticogastrostomy after pancreaticoduodenectomy: a prospective randomized study

OBJECTIVES

The optimal strategy for the reconstruction of the pancreas following pancreaticoduodenectomy (PD) is still debated. The aim of this study was to compare the outcomes of isolated Roux loop pancreaticojejunostomy (IRPJ) with those of pancreaticogastrostomy (PG) after PD.

METHODS

Consecutive patients submitted to PD were randomized to either method of reconstruction. The primary outcome measure was the rate of postoperative pancreatic fistula (POPF). Secondary outcomes included operative time, day to resumption of oral feeding, postoperative morbidity and mortality, and exocrine and endocrine pancreatic functions.

RESULTS

Ninety patients treated by PD were included in the study. The median total operative time was significantly longer in the IRPJ group (320 min versus 300 min; P = 0.047). Postoperative pancreatic fistula developed in nine of 45 patients in the IRPJ group and 10 of 45 patients in the PG group (P = 0.796). Seven IRPJ patients and four PG patients had POPF of type B or C (P = 0.710). Time to resumption of oral feeding was shorter in the IRPJ group (P = 0.03). Steatorrhea at 1 year was reported in nine of 42 IRPJ patients and 18 of 41 PG patients (P = 0.029). Albumin levels at 1 year were 3.6 g/dl in the IRPJ group and 3.3 g/dl in the PG group (P = 0.001).

CONCLUSIONS

Isolated Roux loop PJ was not associated with a lower rate of POPF, but was associated with a decrease in the incidence of postoperative steatorrhea. The technique allowed for early oral feeding and the maintenance of oral feeding even if POPF developed.

Modified Blumgart anastomosis for pancreaticojejunostomy: technical improvement in matched historical control study

BACKGROUND

Postoperative pancreatic fistula (POPF) is the main cause of fatal complications after pancreatoduodenectomy. There is still no universally accepted technique for pancreaticoenterostomy, especially in patients with soft pancreas.

METHODS

Between July 2008 and June 2013, 240 patients who underwent pancreatoduodenectomy were enrolled in this single-institution matched historical control study. To approximate the pancreatic parenchyma to the jejunal seromuscular layer, 120 patients underwent anastomosis using the Kakita method (three or four interrupted penetrating sutures) and 120 underwent anastomosis using the modified Blumgart anastomosis (m-BA) method (one to three transpancreatic/jejunal seromuscular sutures to completely cover the pancreatic stump with jejunal serosa).

RESULTS

The rate of clinically relevant POPF formation was significantly lower in the m-BA group than that in the Kakita group (2.5 vs 36 %; p < 0.001). The duration of drain placement and the length of postoperative hospital stay were significantly shorter in the m-BA group. Multivariate analysis showed that m-BA was an independent predictor of non-formation of POPF (hazard ratio, 0.02; 95 % confidence interval, 0.01-0.08; p < 0.001).

CONCLUSION

The m-BA method is safe and simple and improves postoperative outcomes. We suggest that the m-BA is suitable for use as a standard method of pancreaticojejunostomy after pancreatoduodenectomy.

Evidence-based value of prophylactic intraperitoneal drainage following pancreatic resection: a meta-analysis

BACKGROUND AND OBJECTIVE

Prophylactic intraperitoneal drainage is usually indwelled after abdominal operation. This study assessed whether prophylactic intraperitoneal drainage was of value after pancreatic resection.

METHODS

A systematic literature search was performed to identify relevant articles. Data aggregation and analysis were performed using RevMan 5.0 software package.

RESULTS

A randomized controlled trial and seven observational cohort studies including a total of 2690 patients were eligible. The overall and major complication rates and the occurrence of pancreatic fistula in patients with drainage were higher than those without drainage. Prophylactic intraperitoneal drainage was not associated with a statistically significant reduction in the need for percutaneous drainage, reoperation and readmission, or with an increase in mortality.

CONCLUSION

The present meta-analysis demonstrated that prophylactic intraperitoneal drainage after pancreatic resection appears to be unable to improve the postoperative course, and may be associated with more severe and higher rate of complication and increased pancreatic fistula occurrence. There is a serious bias in the criteria to insert drain or not in these retrospective studies. Therefore these results should be confirmed by randomized controlled trial.

Preventing Delayed Gastric Emptying After Whipple's Procedure-Isolated Roux Loop Reconstruction With Pancreaticogastrostomy

Although delayed gastric emptying (DGE) after Whipple's pancreaticoduodenectomy is not life-threatening and can be treated conservatively, it results in discomfort and significant prolongation of the hospital stay and adds on to the hospital costs. To overcome this problem, we started using the isolated loop technique of reconstruction along with pancreaticogastrostomy and we present our series using this technique. All consecutive patients undergoing Whipple's pancreaticoduodenectomy in a single surgical unit from January 2009 until December 2012 were included. In the absence of hepatic and peritoneal metastasis, resection (Whipple's procedure) with curative intent was done using isolated loop technique with pancreaticogastrostomy. Delayed gastric emptying was assessed clinically and on oral gastrograffin study. Bile reflux was also assessed on clinical parameters and evidence of beefy friable gastric mucosa on upper GI endoscopy and presence of reflux on hepatobiliary scintigraphy. A total of 52 patients were operated using this technique from January 2009 to October 2012. The mean operative time was 260.8 ± 50.3, and the mean operative blood loss was 1,068.0 ± 606.1 ml. Mean gastric emptying time 106.0 ± 6.1 min (89-258 min). Three out of the 52(5.7 %) patients had persistent vomiting in the post-operative period requiring reinsertion of NG tube. A HIDA scan done on POD7 for all patients did not show any evidence of bile reflux in any of the patients. Pancreatogastrostomy with isolated loop in pancreaticoduodenal resection markedly reduces the post-operative incidence of alkaline reflux gastritis and DGE.

Middle-preserving pancreatectomy with reversed pancreaticogastrostomy: report of a case

Parenchyma-sparing pancreatic resections have been reported increasingly in recent years; however, for multifocal diseases involving the head and the tail of the pancreas, total pancreatectomy is still the preferred procedure. The possible consequence of this procedure is loss of normal pancreatic parenchyma, resulting in insufficiency of pancreatic exocrine and endocrine functions. Various types of limited resection have been introduced for isolated or multiple pancreatic lesions, depending on the location of the tumor. Even for multifocal diseases, if the pancreatic body is spared, a middle-preserving pancreatectomy (MPP) can be performed to assure maximal pancreatic function and uncompromised quality of life. Yet, few papers have introduced the feasibility of MPP for a better outcome. This report describes a new surgical technique for MPP using an alternative approach for the remnant pancreas anastomosis. We used this technique successfully to remove a bifocal neoplasm: adenocarcinoma of the distal bile duct and mucinous cyst adenoma in the tail of the pancreas.

Triple-layer duct-to-mucosa pancreaticojejunostomy with resection of jejunal serosa decreased pancreatic fistula after pancreaticoduodenectomy

BACKGROUND

Pancreatic fistula (PF) is one of the most common complications after pancreaticoduodenectomy (PD). We described a new method of pancreaticojejunostomy (PJ) developed by combining triple-layer duct-to-mucosa PJ with resection of jejunal serosa, which was named as modified layer-to-layer PJ (MLLPJ). The aim of the present study was to observe whether the new technique would effectively reduce the PF rate in comparison with two-layer duct-to-mucosa PJ (TLPJ).

METHODS

Data on 184 consecutive patients who underwent the two methods of PJ after standard PD between January 1, 2010 and January 31, 2013 were collected retrospectively from a prospective database. The primary endpoint was the PF rate. The risk factors of PF were investigated by using univariate and multivariate analyses.

RESULTS

A total of 88 patients received TLPJ and 96 underwent MLLPJ. Rate of PF for the entire cohort was 8.2%. There were 11 fistulas (12.5%) in the TLPJ group and four fistulas (4.2%) in the MLLPJ group (P = 0.039). Body mass index, pancreatic texture, pancreatic duct diameter, and methods of PJ anastomosis had significant effects on the formation of PF on univariate analysis. Multivariate analysis showed that pancreatic duct diameter ≤3 mm and TLPJ were the significant risk factors of PF.

CONCLUSIONS

MLLPJ effectively reduces the PF rate after PD in comparison with TLPJ. Results confirm increased PF rates in patients with pancreatic duct diameter ≤3 mm compared with pancreatic duct diameter >3 mm.

Modified technique of pancreaticogastrostomy for soft pancreas with two continuous hemstitch sutures: a single-center prospective study

Postoperative pancreatic fistula (POPF) remains a persistent problem after pancreaticoduodenectomy (PD), especially in the presence of a soft, nonfibrotic pancreas. To reduce the risk of POPF, pancreaticogastrostomy (PG) is an optional reconstruction technique for surgeons after PD. This study presents a new technique of PG for a soft, nonfibrotic pancreas with double-binding continuous hemstitch sutures and evaluates its safety and reliability. From January 2011 to June 2012, 92 cases of patients with periampullary malignancy with a soft pancreas underwent this technique. A modified technique of PG was performed with two continuous hemstitch sutures placed in the mucosal and seromuscular layers of the posterior gastric wall, respectively. Then the morbidity and mortality was calculated. This technique was applied in 92 patients after PD all with soft pancreas. The median time for the anastomosis was 12 min (range, 8-24). Operative mortality was zero, and morbidity was 16.3 % (n = 15), including hemorrhage (n = 2), biliary fistula (n = 2), pulmonary infection (n = 1), delayed gastric emptying (DGE; n = 5, 5.4 %), abdominal abscess (n = 3, one caused by PF), and POPF (n = 2, 2.2 %). Two patients developed a pancreatic fistula (one type A and one type B) classified according to the International Study Group on Pancreatic Fistula. The described technique is a simple and safe reconstruction procedure after PD, especially for patients with a soft and fragile pancreas.

To drain or not to drain: a cumulative meta-analysis of the use of routine abdominal drains after pancreatic resection

BACKGROUND

To warrant the adoption or rejection of health care interventions in daily practice, it is important to establish the point at which the available evidence is considered sufficiently conclusive. This process must avoid bias resulting from multiple testing and take account of heterogeneity across studies. The present paper addresses the issue of whether the available evidence may be considered sufficiently conclusive to continue or discontinue the current practice of postoperative abdominal drainage after pancreatic resection.

METHODS

A systematic review was conducted of randomized and non-randomized studies comparing outcomes after routine intra-abdominal drainage with those after no drainage after pancreatic resection. Studies were retrieved from the PubMed, Cochrane Central Trial Register and EMBASE databases and meta-analysed cumulatively, adjusting for multiple testing and heterogeneity using the iterated logarithm method.

RESULTS

Three reports, describing, respectively, one randomized and two non-randomized studies with a comparative design, met the inclusion criteria predefined for primary studies reporting on drain management and complications after pancreatic resection. These studies included 89, 179 and 226 patients, respectively. The absolute differences in rates of postoperative complications in these studies were -6.4%, -9.5% and -6.3%, respectively, in favour of the no-drain groups. The cumulative risk difference in major complications, adjusted for multiple testing and heterogeneity, was -7.8%, with a 95% confidence interval of -20.2% to 4.7% (P = 0.214).

CONCLUSIONS

The routine use of abdominal drains after pancreatic resection may result in a higher risk for major complications, but the evidence is inconclusive.

A prospective, randomized trial of Roux-en-Y reconstruction with isolated pancreatic drainage versus conventional loop reconstruction after pancreaticoduodenectomy

BACKGROUND

Postoperative pancreatic fistula (POPF) is a major and serious complication after pancreaticoduodenectomy (PD). There have been no prospective randomized trials evaluating POPF rates in Roux-en-Y reconstruction (RYR) with isolated pancreatic drainage versus conventional loop reconstruction (CLR). The authors hypothesized that RYR decreases the incidence and severity of POPF in patients after PD.

METHODS

Between January 2006 and April 2012, the findings for 216 patients were analyzed in this multicenter, prospective trial in China. After providing appropriate preoperative informed consent, patients were randomly assigned to either RYR or CLR after completion of pancreaticoduodenal resection. We referred to the Johns Hopkins fistula definition and classified POPF as grade A, B, or C according to the International Study Group of Pancreatic Fistula classification.

RESULTS

The incidence of POPF was similar in the RYR (15.7%, 17/107) and CLR (17.6%, 19/109) groups. Both univariate and multivariate logistic regression analyses revealed that the factor most highly associated with POPF was ampullary or duodenal disease (P < .05). The incidence of type B POPF was higher in the CLR than in the RYR group. Furthermore, patients with POPF in the CLR group had a significantly longer postoperative hospital stay (31.9 ± 6.9 days) and higher total hospital costs than did the patients in the RYR group (P < .05).

CONCLUSION

These data do not support the hypothesis that RYR is associated with a lower incidence of POPF than is CLR. However, they do indicate that RYR may contribute to decreasing fistula severity, duration of stay, and hospital expense.

Laparoscopic pancreaticoduodenectomy: experience of 22 cases

BACKGROUND

Laparoscopic pancreatic surgery has gradually expanded its applications to include pancreaticoduodenectomy. However, the benefits of the laparoscopic approach are still debated. This article aims to present data regarding the efficacy of laparoscopic pancreaticoduodenectomy in a single center.

METHODS

From March 2003 to June 2010, a total of 22 patients underwent pancreaticoduodenectomy with a totally laparoscopic approach, using a five-trocar technique. Reconstruction of the digestive tract was adapted to the aspect of the pancreatic stump, with 6 patients having Wirsung duct occlusion and 16 patients pancreaticodigestive anastomosis. Patient selection, short-term outcomes, oncologic results, and technical issues were retrospectively reviewed.

RESULTS

Mean operative time was 392 (range, 327-570) min. Conversion was required in 2 patients (9.1 %) as a result of bleeding and difficult dissection. Major intraoperative complications included an injury to the right hepatic artery (4.5 %). Postoperative mortality was 4.5 %. Surgery-related morbidity occurred in 14 patients (63.6 %) and included bleeding (n = 5), pancreatic fistula (n = 6), biliary fistula (n = 2), and dumping syndrome (n = 1). Pancreatic fistulas occurred in 4 patients with duct occlusion and in 2 patients with pancreaticojejunostomy, and they all healed with conservative treatment. Mean hospital stay was 23 (range, 12-35) days. Pathologic diagnoses were pancreatic ductal adenocarcinoma (n = 11), ampullary adenocarcinoma (n = 8), and duodenal adenocarcinoma (n = 3). The resection margins were all free from disease; the mean number of collected lymph nodes was 15 (range, 14-20).

CONCLUSIONS

The complexity of pancreaticoduodenectomy entails some issues, including patient selection and management of the pancreatic stump, that are not related to the approach used. Laparoscopic pancreaticoduodenectomy is feasible, safe, and oncologically adequate, but only if performed in selected cases by highly skilled laparoscopic surgeons. Laparoscopy does not provide any significant advantage over traditional surgery, but it may improve postoperative outcomes in the so-called excellence centers, once the learning curve has been overcome. Multicenter randomized trials are needed.

Options and limitations in applying the fistula classification by the International Study Group for Pancreatic Fistula

BACKGROUND

Because of its retrospective character, the classification system of the International Study Group of Pancreatic Fistula (ISGPF) lacks prognostic capacity regarding fistula-related complications. This study aimed to evaluate the options and limitations of the ISGPF classification system and to identify risk factors with respect to clinical decision making.

METHODS

Between 1992 and 2009, 1966 patients underwent surgery of the pancreas. All patient data were entered into a prospective clinical data management system.

RESULTS

After surgery, 276 patients (14%) developed postoperative pancreatic fistula (POPF). ISGPF type A fistula was seen in 69 patients (25%), type B in 110 (39.9%), and type C in 97 (34.1%). Solely due to their death, 16 patients had to be classified as type C fistula, even though they suffered only type A or B. Compared to genuine C fistulas, we were not able to detect any significant predictors, which may allow to distinguish the development in their further clinical course. The level of drainage amylase is of no use, whereas univariate analysis identified underlying disease, type of operation, and high levels of serum amylase or bilirubin on the day of onset of POPF to be prognostic parameters for reoperation. Multivariate analysis found elevated serum C-reactive protein to be an independent factor for increased in-hospital mortality.

CONCLUSIONS

The ISGPF classification system has its limitations in clinical decision making, because it does not adequately describe a large subgroup of patients. To improve clinical decision making about management of patients, it is crucial that the ISGPF classification system is merged with newer clinical data.

An easy and secure pancreaticogastrostomy after pancreaticoduodenectomy: transpancreatic suture with a buttress method through an anterior gastrotomy

PURPOSE

The aim of this report was to describe a new reconstructive technique of pancreaticogastrostomy and to also discuss this procedure's effectiveness for reducing the incidence of postoperative complications.

METHODS

We retrospectively analyzed early surgical outcomes in 21 consecutive patients who underwent this novel pancreaticogastrostomy after pancreaticoduodenectomy. Pancreaticogastrostomy was completed with 2 transpancreatic sutures with buttresses on both the upper and lower edges of the implanted pancreas through the retracted anterior gastrotomy.

RESULTS

Operative mortality was zero and morbidity was 23.8%. A significant pancreatic fistula occurred in 1 patient (4.7%; grade B).

CONCLUSION

This technique is very easy to perform, less traumatic to the pancreatic stump, can be performed through a mini-laparotomy due to good vision and straight sutures, and it is secure owing to anchoring of the invaginated pancreatic stump to the stomach's posterior wall with buttresses. The results of this pilot study indicate that the technique may provide a favorable outcome and could be an alternative method of pancreatoenteric anastomosis. However, to determine its superiority over the conventional procedures, this operative technique should be evaluated more comprehensively in a larger series.

Management and outcomes of haemorrhage after pancreatogastrostomy versus pancreatojejunostomy

Background

Postpancreatectomy haemorrhage (PPH) is a major cause of morbidity and mortality after pancreaticoduodenectomy (PD). It remains unclear whether performance of a pancreatogastrostomy (PG) instead of a pancreatojejunostomy (PJ) improves outcomes owing to better endoscopic accessibility.

Methods

A large retrospective analysis was undertaken to compare outcomes of PPH, depending on whether a PG or PJ was performed. The primary outcome was the rate of successful endoscopy. A secondary outcome was the therapeutic success after adding surgery.

Results

Of 944 patients who had a PD, 8·4 per cent developed PPH. Endoscopy was the primary intervention in 21 (81 per cent) of 26 patients with a PG and 34 (64 per cent) of 53 with a PJ; it identified the bleeding site in 35 and 25 per cent respectively (P = 0·347). Successful endoscopic treatment was more common in the PG group (31 versus 9 per cent; P = 0·026). Surgery was performed for PPH in 15 patients (58 per cent) with a PG and 35 (66 per cent) with a PJ (P = 0·470). The majority of haemorrhages that required surgery were non-anastomotic intra-abdominal haemorrhages (12 of 15 versus 21 of 35; P = 0·171). Endoscopic or conservative treatment for PPH was successful in 42 per cent of patients with a PG and 32 per cent with a PJ (P = 0·520). The success rate increased to 85 and 91 per cent respectively when surgery was included in the algorithm (P = 0·467).

Conclusion

The type of pancreatic anastomosis and its inherent effect on endoscopic accessibility had very little impact on the outcome of PPH. This was because haemorrhage frequently occurred from intra-abdominal or non-anastomotic intraluminal lesions.

Does external pancreatic duct stent decrease pancreatic fistula rate after pancreatic resection?: a meta-analysis

OBJECTIVES

The use of an external pancreatic duct stent to prevent fistula formation of pancreatic anastomosis remains a matter of debate. This study is a meta-analysis of the available evidence.

METHODS

Articles published until the end of March 2011 comparing external stenting and non-stenting in pancreatic anastomosis were included. Pooled odds ratios (ORs) and weighted mean differences (WMDs) with 95% confidence intervals (95% CI) were calculated using either the fixed effects model or random effects model.

RESULTS

Six articles were identified for inclusion: 3 randomized controlled trials and 3 observational clinical studies. The meta-analysis revealed that the use of an external pancreatic duct stent was associated with a statistically significant reduction in overall postoperative morbidity (OR 0.56; 95% CI 0.39-0.81; p = 0.002), pancreatic fistula (OR 0.34; 95% CI 0.23-0.15; p < 0.001), severity of pancreatic fistula (OR 0.70; 95% CI 0.32-1.57; p = 0.04), delayed gastric emptying (OR 0.44; 95% CI 0.25-0.80; p = 0.007), and length of hospital stay (WMD -3.95; 95% CI -6.38 to -1.52; p = 0.001).

CONCLUSIONS

The current literature suggests that the use of an external pancreatic duct stent reduced the leakage rate of pancreatic anastomosis after pancreatic resection. and IAP.

Improving outcome for patients with pancreatic cancer through centralization

BACKGROUND

High-volume institutions are associated with improved clinical outcomes for pancreatic cancer. This study investigated the impact of centralizing pancreatic cancer surgery in the south of the Netherlands.

METHODS

All patients diagnosed in the Eindhoven Cancer Registry area in 1995-2000 (precentralization) and 2005-2008 (implementation of centralization agreements) with primary cancer of the pancreatic head, extrahepatic bile ducts, ampulla of Vater or duodenum were included. Resection rates, in-hospital mortality, 2-year survival and changes in treatment patterns were analysed. Multivariable regression analyses were used to identify independent risk factors for death.

RESULTS

Some 2129 patients were identified. Resection rates increased from 19·0 to 30·0 per cent (P < 0·001). The number of hospitals performing resections decreased from eight to three, and the annual number of resections per hospital increased from two to 16. The in-hospital mortality rate dropped from 24·4 to 3·6 per cent (P < 0·001) and was zero in 2008. The 2-year survival rate after surgery increased from 38·1 to 49·4 per cent (P = 0·001), and the rate irrespective of treatment increased from 10·3 to 16·0 per cent (P < 0·001). There was no improvement in 2-year survival in non-operated patients. After adjustment for relevant patient and tumour factors, those undergoing surgery more recently had a lower risk of death (hazard ratio 0·70, 95 per cent confidence interval 0·51 to 0·97). Changes in surgical patterns seemed largely to explain the improvements.

CONCLUSION

High-quality care can be achieved in regional hospitals through collaboration. Centralization should no longer be regarded as a threat by general hospitals but as a chance to improve outcomes in pancreatic cancer.

Systematic review of delayed postoperative hemorrhage after pancreatic resection

INTRODUCTION

This review assesses the presentation, management, and outcome of delayed postpancreatectomy hemorrhage (PPH) and suggests a novel algorithm as possible standard of care.

METHODS

An electronic search of Medline and Embase databases from January 1990 to February 2010 was undertaken. A random-effect meta-analysis for success rate and mortality of laparotomy vs. interventional radiology after delayed PPH was performed.

RESULTS

Fifteen studies comprising of 248 patients with delayed PPH were included. Its incidence was of 3.3%. A sentinel bleed heralding a delayed PPH was observed in 45% of cases. Pancreatic leaks or intraabdominal abscesses were found in 62%. Interventional radiology was attempted in 41%, and laparotomy was undertaken in 49%. On meta-analysis comparing laparotomy vs. interventional radiology, no significant difference could be found in terms of complete hemostasis (76% vs. 80%; P = 0.35). A statistically significant difference favored interventional radiology vs. laparotomy in term of mortality (22% vs. 47%; P = 0.02).

CONCLUSIONS

Proper management of postoperative complications, such as pancreatic leak and intraabdominal abscess, minimizes the risk of delayed PPH. Sentinel bleeding needs to be thoroughly investigated. If a pseudoaneurysm is detected, it has to be treated by interventional angiography, in order to prevent a further delayed PPH. Early angiography and embolization or stenting is safe and should be the procedure of choice. Surgery remains a therapeutic option if no interventional radiology is available, or patients cannot be resuscitated for an interventional treatment.

Risk-adapted anastomosis for partial pancreaticoduodenectomy reduces the risk of pancreatic fistula: a pilot study

BACKGROUND

Pancreatic fistula (PF) is the main cause of postoperative morbidity and mortality after pancreatectomy. Two reasons for PF are a "soft" pancreatic texture and a narrow pancreatic duct (high-risk gland). Pancreaticojejunostomy (PJ) may lead to a higher fistula rate in such glands. In the literature there are no data available on risk-adapted assignment of pancreatogastrostomy (PG) in a high-risk gland. Therefore, an observational pilot study was conducted to address this issue.

METHODS

Since January 2007 the concept of a "risk-adapted pancreatic anastomosis" (RAP) was introduced (PG for high-risk glands). The PF rate, morbidity, and mortality during this period (January 2007 to December 2008, n = 74) were compared to those between January 2004 and December 2006 (n = 119, only PJ). PF was defined according to the International Study Group on Pancreatic Surgery.

RESULTS

Through RAP the PF rate was reduced from 22 to 11% (P = 0.0503). Grade C PF rate was reduced from 6.7 to 1.4% (P = 0.1569) and grade A PF from 6 to 1.4% (P = 0.2537). The PF-associated mortality was reduced from 3.4 to 1.4%. PG revealed a PF rate of 7% and PJ accounted for 19% of PFs (P = 0.1765). There was no incidence of grade C PF following PG. The incidence of intraluminal hemorrhage (P = 0.0422) and delayed gastric emptying (P = 0.0572) was higher following PG.

CONCLUSIONS

The rate of PF could be significantly reduced with the use of RAP. One should be cautious about the indication for PG, since it is associated with a higher rate of intraluminal hemorrhage and delayed gastric emptying. There are no long-term results on PG with respect to its durability and function. A general recommendation for its use cannot currently be made.

Does the type of pancreaticojejunostomy after Whipple alter the leak rate?

Despite the overwhelming limitations that plague the literature surrounding the optimal method of reestablishing pancreatico-enteric continuity following a Whipple operation, it is clear that all successful techniques conform to sound surgical principles. These principles include a water-tight and tension-free anastomosis, preservation of adequate blood supply for both organs involved in the anastomosis, and minimal trauma to the pancreas gland. Although surgeon experience, gland texture, and pancreatic duct size are clearly the dominate risk factors from a long list of variables associated with pancreatic leaks following pancreatoduodenectomy, these are nonmodifiable covariates. Although the plethora of current literature cannot provide a single definitive technical solution for restoring pancreatico-enteric continuity, a small number of well-designed RCTs support the use of transanastomotic external stenting for high-risk pancreatic glands and an end-to-side invaginated pancreaticojejunostomy. The truth remains that an individual surgeon's mastery of a specific anastomotic technique, in conjunction with a large personal experience, is likely to be the best predictor of a low pancreas leak rate following pancreatoduodenectomy.

A standardized technique for safe pancreaticojejunostomy: Pair-Watch suturing technique

AIM: To prevent pancreatic leakage after pancreaticojejunostomy, we designed a new standardized technique that we term the “Pair-Watch suturing technique”.

METHODS: Before anastomosis, we imagine the faces of a pair of watches on the jejunal hole and pancreatic duct. The first stitch was put between 9 o’clock of the pancreatic side and 3 o’clock of the jejunal side, and a total of 7 stitches were put on the posterior wall, followed by the 5 stitches on the anterior wall. Using this technique, twelve stitches can be sutured on the first layer anastomosis regardless of the caliber of the pancreatic duct. In all cases the amylase activity of the drain were measured. A postoperative pancreatic fistula was diagnosed using postoperative pancreatic fistula grading.

RESULTS: From March 2007 to July 2008, 29 consecutive cases underwent pancreaticojejunostomy using this technique. Pathologic examination results showed pancreatic carcinoma (n = 14), intraductal papillary-mucinous neoplasm (n = 10), intraductal papillary-mucinous carcinoma (n = 1), carcinoma of ampulla of Vater (n=1), carcinoma of extrahepatic bile duct (n = 1), metastasis of renal cell carcinoma (n = 1), and duodenal carcinoma (n = 1). Pancreaticojejunal anastomoses using this technique were all watertight during the surgical procedure. The mean diameter of main pancreatic duct was 3.4 mm (range 2-7 mm). Three patients were recognized as having an amylase level greater than 3 times the serum amylase level, but all of them were diagnosed as grade A postoperative pancreatic fistula grading and required no treatment. None of the cases developed complications such as hemorrhage, abdominal abscess, and pulmonary infection. There was no postoperative mortality.

CONCLUSION: Our technique is less complicated than other methods and very secure, providing reliable anastomosis for any size of pancreatic duct.

Impact of postoperative pancreatic fistula on surgical outcome--the need for a classification-driven risk management

BACKGROUND

The International Study Group of Pancreatic Fistula (ISGPF) classification allows comparison of incidence and severity of postoperative pancreatic fistula (POPF). Its post hoc character, however, does not provide a guideline for the treatment of POPF in individual patient. We therefore studied the association of POPF type A-C on secondary surgical morbidity and mortality in patients undergoing pancreatic resection.

PATIENTS AND METHODS

Between 3/2001-12/2007, 483 patients underwent pancreatic resections. POPF were classified according to the ISGPF classification. All patient data were entered in a clinical data management system prospectively.

RESULTS

Patients who developed POPF had significantly more vascular but not other surgical complications than patients without POPF. Patients with POPF A had no vascular or surgical complications. Twenty one of the 29 patients with POPF C had surgical complications (17 vascular complications). Mortality attributed to surgical complications after POPF C was 5/29. A soft pancreatic consistency (OR 8.5; p < 0.008) and a high drain lipase activity on postoperative day 3 (OR 4.4; p = 0,065) were predictors for the development of POPF C.

DISCUSSION

POPF C is associated with vascular complications like erosion bleeding and other surgical complications like delayed gastric emptying or pleural effusions. A soft pancreatic consistency and a high drain lipase activity on postoperative day 3 are early predictors for the development of POPF C.

Modified pancreaticogastrostomy for digestive tract reconstruction after pancreatoduodenectomy

AIM: To investigate the safety and efficacy of modified pancreaticogastrostomy (PG) for digestive tract reconstruction after pancreaticoduodenectomy (PD).

METHODS: A total of 44 patients who underwent modified PG after PD at our hospital from March 2006 to July 2009 were retrospectively analyzed.

RESULTS: The mean operation time was 260 min (range: 200-420 min). The mean blood loss was 260 mL (range: 150-1600 mL). No mortality occurred postoperatively. The postoperative pancreatic leakage occurred in 2 patients (4.55%, 2/44), both of which were cured by conservative management. Delayed gastric emptying occurred in 5 patients (11.36%, 5/44). The bleeding of the pancreatic stump occurred in 1 patient (2.27%, 1/44). No surgical wound infection or abdominal infection occurred. The mean postoperative length of stay (LOS) was 15 days (range: 13-27 days). The postoperative follow-up, which lasted from 3 months to 3 years, was carried out in all patients, and no long-term complications were found.

CONCLUSION: Modified PG after PD is a safe and easy procedure for digestive tract reconstruction.

Pancreatic leakage after pancreaticoduodenectomy: the impact of the isolated jejunal loop length and anastomotic technique of the pancreatic stump

OBJECTIVES

To evaluate the impact of the length of the isolated jejunal loop and the type of pancreaticojejunostomy on pancreatic leakage after pancreaticoduodenectomy.

METHODS

One hundred thirty-two consecutive patients who underwent a pancreaticoduodenectomy were studied according to the length of the isolated jejunal loop (short loop, 20-25 cm vs long loop, 40-50 cm) and the type of pancreaticojejunostomy (invagination vs duct to mucosa).

RESULTS

The use of the long isolated jejunal loop was associated with a significantly lower pancreatic leakage rate compared with the use of a short isolated jejunal loop (4.34% vs 14.2%, P < 0.05). In addition, the use of duct-to-mucosa technique was associated with significantly lower incidence of postoperative pancreatic fistula compared with the invagination technique (4.2% vs 14.5%, P < 0.05). Finally, patients with a short isolated jejunal loop compared with patients with a long loop had increased morbidity (50.7% vs 27.5%, P < 0.05) and prolonged hospital stay (16.3 +/- 1.9 days vs 10.2 +/- 2.3 days, P < 0.05). Overall mortality rate was 1.5%.

CONCLUSIONS

The use of a long isolated jejunal loop and a duct-to-mucosa pancreaticojejunostomy is associated with decreased pancreatic leakage rate after pancreaticoduodenectomy.

Blumgart anastomosis for pancreaticojejunostomy minimizes severe complications after pancreatic head resection

BACKGROUND

Leakage from the pancreaticojejunostomy is the major cause of septic complications after partial pancreaticoduodenectomy. This study evaluated a new transpancreatic U-suture technique (Blumgart anastomosis, BA), which aims to avoid shear forces during knot-tying.

METHODS

Using a before-after study design, BA was compared with a modified Cattell-Warren anastomosis (CWA). Two patient cohorts (CWA, 90; BA, 92), which were similar with respect to primary diagnosis, age, sex and American Society of Anesthesiologists score, were compared retrospectively. Dependent variables were surgical and overall morbidity and mortality after partial pancreaticoduodenectomy.

RESULTS

Duration of operation (354 versus 328 min for CWA versus BA; P = 0.002), pancreatic leakage rate (13 versus 4 per cent; P = 0.032), postoperative haemorrhage (11 versus 3 per cent; P = 0.040), total surgical complications (31 versus 15 per cent; P = 0.011), general complications (36 versus 17 per cent; P = 0.005) and length of intensive care unit stay (median 5.4 versus 2.8 days; P = 0.015) were significantly reduced after BA. These effects were not related merely to an improvement over time.

CONCLUSION

BA appears to be a fast, simple and safe technique for pancreaticojejunostomy. It might reduce leakage rates and surgical complications after partial pancreaticoduodenectomy.