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Zhang L, Li Z, Wu X, Li Y, Zeng Z. Sealing Pancreaticojejunostomy in Combination with Duct Parenchyma to Mucosa Seromuscular One-Layer Anastomosis: A Novel Technique to Prevent Pancreatic Fistula after Pancreaticoduodenectomy. J Am Coll Surg 2015; 220:e71-7. [DOI: 10.1016/j.jamcollsurg.2014.12.047] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 12/07/2014] [Accepted: 12/08/2014] [Indexed: 12/15/2022]
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Karavias DD, Karavias DD, Chaveles IG, Kakkos SK, Katsiakis NA, Maroulis IC. "True" duct-to-mucosa pancreaticojejunostomy, with secure eversion of the enteric mucosa, in Whipple operation. J Gastrointest Surg 2015; 19:498-505. [PMID: 25472029 DOI: 10.1007/s11605-014-2709-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 11/17/2014] [Indexed: 01/31/2023]
Abstract
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.
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Liu FB, Chen JM, Geng W, Xie SX, Zhao YJ, Yu LQ, Geng XP. Pancreaticogastrostomy is associated with significantly less pancreatic fistula than pancreaticojejunostomy reconstruction after pancreaticoduodenectomy: a meta-analysis of seven randomized controlled trials. HPB (Oxford) 2015; 17:123-30. [PMID: 24888576 PMCID: PMC4299386 DOI: 10.1111/hpb.12279] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 04/22/2014] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Fu-Bao Liu
- Department of Surgery, First Affiliated Hospital of Anhui Medical UniversityHefei, China
| | - Jiang-Ming Chen
- Department of Surgery, Second Affiliated Hospital of Anhui Medical UniversityHefei, China
| | - Wei Geng
- Department of Surgery, First Affiliated Hospital of Anhui Medical UniversityHefei, China
| | - Sheng-Xue Xie
- Department of Surgery, Second Affiliated Hospital of Anhui Medical UniversityHefei, China
| | - Yi-Jun Zhao
- Department of Surgery, First Affiliated Hospital of Anhui Medical UniversityHefei, China
| | - Li-Quan Yu
- Department of Surgery, Second Affiliated Hospital of Anhui Medical UniversityHefei, China
| | - Xiao-Ping Geng
- Department of Surgery, Second Affiliated Hospital of Anhui Medical UniversityHefei, China,Correspondence, Xiao-Ping Geng, Department of Surgery, Second Affiliated Hospital of Anhui Medical University, Furong Road 678, Shushan District, Hefei, Anhui 230022, China. Tel: + 86 153 0560 9606. Fax: + 86 0551-63869400. E-mail:
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Li T, Luo LX, Zhang C, Wang GP, Chen ZT, Jiang ZC, Wang XY, Zhi XT. End-to-End Invaginated Pancreaticojejunostomy with Three Overlapping U-Sutures--A Safe and Simple Method of Pancreaticoenteric Anastomosis. J INVEST SURG 2014; 28:115-9. [PMID: 25437946 DOI: 10.3109/08941939.2014.982313] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
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.
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Affiliation(s)
- Tao Li
- 1Department of General Surgery, Qilu Hospital, Shandong University, Jinan, P.R. China
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Fontes PRO, Waechter FL, Nectoux M, Sampaio JA, Teixeira UF, Pereira-Lima L. Low mortality rate in 97 consecutive pancreaticoduodenectomies: the experience of a group. ARQUIVOS DE GASTROENTEROLOGIA 2014; 51:29-33. [PMID: 24760061 DOI: 10.1590/s0004-28032014000100007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Accepted: 11/04/2013] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- Paulo Roberto Ott Fontes
- Universidade Federal de Ciências de Saúde de Porto Alegre, UFCSPA ? Departamento de Clínica Cirúrgica, Porto Alegre, RS, Brasil
| | - Fábio Luiz Waechter
- Universidade Federal de Ciências de Saúde de Porto Alegre, UFCSPA ? Departamento de Clínica Cirúrgica, Porto Alegre, RS, Brasil
| | - Mauro Nectoux
- Universidade Federal de Ciências de Saúde de Porto Alegre, UFCSPA ? Departamento de Clínica Cirúrgica, Porto Alegre, RS, Brasil
| | - José Artur Sampaio
- Universidade Federal de Ciências de Saúde de Porto Alegre, UFCSPA ? Departamento de Clínica Cirúrgica, Porto Alegre, RS, Brasil
| | - Uirá Fernandes Teixeira
- Universidade Federal de Ciências de Saúde de Porto Alegre, UFCSPA ? Departamento de Clínica Cirúrgica, Porto Alegre, RS, Brasil
| | - Luiz Pereira-Lima
- Universidade Federal de Ciências de Saúde de Porto Alegre, UFCSPA ? Departamento de Clínica Cirúrgica, Porto Alegre, RS, Brasil
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Schoellhammer HF, Fong Y, Gagandeep S. Techniques for prevention of pancreatic leak after pancreatectomy. Hepatobiliary Surg Nutr 2014; 3:276-87. [PMID: 25392839 PMCID: PMC4207840 DOI: 10.3978/j.issn.2304-3881.2014.08.08] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 08/21/2014] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Hans F Schoellhammer
- Division of Surgical Oncology, Department of Surgery; City of Hope National Medical Center, Duarte, CA, USA
| | - Yuman Fong
- Division of Surgical Oncology, Department of Surgery; City of Hope National Medical Center, Duarte, CA, USA
| | - Singh Gagandeep
- Division of Surgical Oncology, Department of Surgery; City of Hope National Medical Center, Duarte, CA, USA
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El Nakeeb A, Hamdy E, Sultan AM, Salah T, Askr W, Ezzat H, Said M, Zeied MA, Abdallah T. Isolated Roux loop pancreaticojejunostomy versus pancreaticogastrostomy after pancreaticoduodenectomy: a prospective randomized study. HPB (Oxford) 2014; 16:713-22. [PMID: 24467711 PMCID: PMC4113253 DOI: 10.1111/hpb.12210] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 11/20/2013] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Ayman El Nakeeb
- Gastroenterology Surgical Centre, Mansoura University, Mansoura, Egypt
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Modified Blumgart anastomosis for pancreaticojejunostomy: technical improvement in matched historical control study. J Gastrointest Surg 2014; 18:1108-15. [PMID: 24733259 DOI: 10.1007/s11605-014-2523-3] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Accepted: 03/31/2014] [Indexed: 01/31/2023]
Abstract
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.
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Zhou Y, Zhang X, Wu L, Ye F, Su X, Li B. Evidence-based value of prophylactic intraperitoneal drainage following pancreatic resection: a meta-analysis. Pancreatology 2014; 14:302-7. [PMID: 25062881 DOI: 10.1016/j.pan.2014.04.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 04/07/2014] [Accepted: 04/08/2014] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Yanming Zhou
- Department of Hepatobiliary & Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Oncologic Center of Xiamen, 55 Zhenhai Road, Xiamen 361003, FJ, China.
| | - Xiaofeng Zhang
- Department of Hepatobiliary & Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Oncologic Center of Xiamen, 55 Zhenhai Road, Xiamen 361003, FJ, China
| | - Lupeng Wu
- Department of Hepatobiliary & Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Oncologic Center of Xiamen, 55 Zhenhai Road, Xiamen 361003, FJ, China
| | - Feng Ye
- Department of Hepatobiliary & Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Oncologic Center of Xiamen, 55 Zhenhai Road, Xiamen 361003, FJ, China
| | - Xu Su
- Department of Hepatobiliary & Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Oncologic Center of Xiamen, 55 Zhenhai Road, Xiamen 361003, FJ, China
| | - Bin Li
- Department of Hepatobiliary & Pancreatovascular Surgery, First Affiliated Hospital of Xiamen University, Oncologic Center of Xiamen, 55 Zhenhai Road, Xiamen 361003, FJ, China
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Krishna A, Bansal VK, Kumar S, Sridhar P, Kapoor S, Misra MC, Garg P. Preventing Delayed Gastric Emptying After Whipple's Procedure-Isolated Roux Loop Reconstruction With Pancreaticogastrostomy. Indian J Surg 2013; 77:703-7. [PMID: 26730093 DOI: 10.1007/s12262-013-0992-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 10/07/2013] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Asuri Krishna
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India
| | - Virinder Kumar Bansal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India
| | - Subodh Kumar
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India
| | - P Sridhar
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India
| | - Sameer Kapoor
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India
| | - Mahesh C Misra
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India
| | - Pramod Garg
- Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India
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Middle-preserving pancreatectomy with reversed pancreaticogastrostomy: report of a case. Surg Today 2013; 44:1584-7. [PMID: 24062087 DOI: 10.1007/s00595-013-0692-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2012] [Accepted: 03/04/2013] [Indexed: 10/26/2022]
Abstract
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.
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Su AP, Zhang Y, Ke NW, Lu HM, Tian BL, Hu WM, Zhang ZD. Triple-layer duct-to-mucosa pancreaticojejunostomy with resection of jejunal serosa decreased pancreatic fistula after pancreaticoduodenectomy. J Surg Res 2013; 186:184-91. [PMID: 24095023 DOI: 10.1016/j.jss.2013.08.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2013] [Revised: 08/24/2013] [Accepted: 08/28/2013] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- An-Ping Su
- Department of Hepatobiliopancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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Aikawa M, Miyazawa M, Okamoto K, Okada K, Akimoto N, Yamaguchi S, Koyama I, Taguchi T, Ikada Y. Novel pancreatoenteric reconstruction using a bioabsorbable polymer sheet and biocompatible bond. J Surg Res 2013; 183:1-7. [DOI: 10.1016/j.jss.2012.11.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Revised: 11/23/2012] [Accepted: 11/28/2012] [Indexed: 10/27/2022]
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Zhu F, Wang M, Wang X, Tian R, Shi C, Xu M, Shen M, Han J, Luo N, Qin R. Modified technique of pancreaticogastrostomy for soft pancreas with two continuous hemstitch sutures: a single-center prospective study. J Gastrointest Surg 2013; 17:1306-11. [PMID: 23508688 PMCID: PMC3674402 DOI: 10.1007/s11605-013-2183-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 03/05/2013] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Feng Zhu
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan City, Hubei Province 430030 People’s Republic of China
| | - Min Wang
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan City, Hubei Province 430030 People’s Republic of China
| | - Xin Wang
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan City, Hubei Province 430030 People’s Republic of China
| | - Rui Tian
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan City, Hubei Province 430030 People’s Republic of China
| | - Chengjian Shi
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan City, Hubei Province 430030 People’s Republic of China
| | - Meng Xu
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan City, Hubei Province 430030 People’s Republic of China
| | - Ming Shen
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan City, Hubei Province 430030 People’s Republic of China
| | - Juan Han
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan City, Hubei Province 430030 People’s Republic of China
| | - Ninanian Luo
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan City, Hubei Province 430030 People’s Republic of China
| | - Renyi Qin
- Department of Biliary-Pancreatic Surgery, Affiliated Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan City, Hubei Province 430030 People’s Republic of China
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Wang M, Zhu F, Wang X, Tian R, Shi C, Shen M, Xu M, Han J, Luo N, Qin R. A Modified Technique of End-to-End Pancreaticojejunostomy With Transpancreatic Interlocking Mattress Sutures. J Surg Oncol 2013; 107:783-788. [DOI: 10.1002/jso.23319] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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66
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der Wilt AA, Coolsen MME, Hingh IHJT, Wilt GJ, Groenewoud H, Dejong CHC, Dam RM. To drain or not to drain: a cumulative meta-analysis of the use of routine abdominal drains after pancreatic resection. HPB (Oxford) 2013; 15:337-44. [PMID: 23557407 PMCID: PMC3633034 DOI: 10.1111/j.1477-2574.2012.00609.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 09/26/2012] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Aart A der Wilt
- Department of Surgery, Maastricht University Medical CentreMaastricht, the Netherlands
| | - Mariëlle M E Coolsen
- Department of Surgery, Maastricht University Medical CentreMaastricht, the Netherlands
| | - Ignace H J T Hingh
- Department of Surgery, Catharina Hospital EindhovenEindhoven, the Netherlands
| | - Gert Jan Wilt
- Department of Epidemiology, Biostatistics and Health Technology Assessment, Radboud University Medical CentreNijmegen, the Netherlands
| | - Hans Groenewoud
- Department of Epidemiology, Biostatistics and Health Technology Assessment, Radboud University Medical CentreNijmegen, the Netherlands
| | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical CentreMaastricht, the Netherlands
| | - Ronald M Dam
- Department of Surgery, Maastricht University Medical CentreMaastricht, the Netherlands
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Ke S, Ding XM, Gao J, Zhao AM, Deng GY, Ma RL, Xin ZH, Ning CM, Sun WB. A prospective, randomized trial of Roux-en-Y reconstruction with isolated pancreatic drainage versus conventional loop reconstruction after pancreaticoduodenectomy. Surgery 2013; 153:743-52. [PMID: 23601899 DOI: 10.1016/j.surg.2013.02.008] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 02/05/2013] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Shan Ke
- Department of Hepatobiliary Surgery, Beijing Chao-yang Hospital Affiliated to Capital Medical University, Beijing, China
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68
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Corcione F, Pirozzi F, Cuccurullo D, Piccolboni D, Caracino V, Galante F, Cusano D, Sciuto A. Laparoscopic pancreaticoduodenectomy: experience of 22 cases. Surg Endosc 2013; 27:2131-6. [PMID: 23355144 DOI: 10.1007/s00464-012-2728-z] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 12/01/2012] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Francesco Corcione
- Department of Laparoscopic and Robotic Surgery, Azienda Ospedaliera dei Colli-Monaldi Hospital, Via Leonardo Bianchi, 80131, Naples, Italy.
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Options and limitations in applying the fistula classification by the International Study Group for Pancreatic Fistula. Ann Surg 2012; 256:130-8. [PMID: 22504279 DOI: 10.1097/sla.0b013e31824f24e4] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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70
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Evaluation of the International Study Group of Pancreatic Surgery definition of post-pancreatectomy hemorrhage in a high-volume center. Surgery 2012; 151:612-20. [DOI: 10.1016/j.surg.2011.09.039] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Accepted: 09/22/2011] [Indexed: 01/04/2023]
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71
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Stented pancreaticojejunostomy (with video). JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2011; 19:116-24. [DOI: 10.1007/s00534-011-0472-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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72
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A modified technique of pancreaticojejunostomy after pancreatoduodenectomy: a preliminary experience. Updates Surg 2011; 63:287-91. [DOI: 10.1007/s13304-011-0120-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2011] [Accepted: 05/25/2011] [Indexed: 12/29/2022]
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73
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Hong TH, Youn YC, You YK, Kim DG. An easy and secure pancreaticogastrostomy after pancreaticoduodenectomy: transpancreatic suture with a buttress method through an anterior gastrotomy. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2011; 81:332-8. [PMID: 22148126 PMCID: PMC3229002 DOI: 10.4174/jkss.2011.81.5.332] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Revised: 07/04/2011] [Accepted: 07/28/2011] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Tae Ho Hong
- Division of Hepatobiliary-Pancreas Surgery, Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea School of Medicine, Seoul, Korea
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74
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Eckardt AJ, Klein F, Adler A, Veltzke-Schlieker W, Warnick P, Bahra M, Wiedenmann B, Neuhaus P, Neumann K, Glanemann M. Management and outcomes of haemorrhage after pancreatogastrostomy versus pancreatojejunostomy. Br J Surg 2011; 98:1599-607. [DOI: 10.1002/bjs.7623] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2011] [Indexed: 12/11/2022]
Abstract
Abstract
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.
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Affiliation(s)
- A J Eckardt
- Department of Gastroenterology and Hepatology, Deutsche Klinik für Diagnostik, Wiesbaden, Germany
| | - F Klein
- Department of Gastroenterology and Hepatology, Central Interdisciplinary Endoscopy, Campus Virchow, Germany
| | - A Adler
- Department of General, Visceral and Transplantation Surgery, Charité, Campus Virchow, Germany
| | - W Veltzke-Schlieker
- Department of General, Visceral and Transplantation Surgery, Charité, Campus Virchow, Germany
| | - P Warnick
- Department of Gastroenterology and Hepatology, Deutsche Klinik für Diagnostik, Wiesbaden, Germany
| | - M Bahra
- Department of Gastroenterology and Hepatology, Deutsche Klinik für Diagnostik, Wiesbaden, Germany
| | - B Wiedenmann
- Department of General, Visceral and Transplantation Surgery, Charité, Campus Virchow, Germany
| | - P Neuhaus
- Department of Gastroenterology and Hepatology, Central Interdisciplinary Endoscopy, Campus Virchow, Germany
| | - K Neumann
- Department of Biomathematics, Statistics, Charité, Campus Mitte, Berlin, Germany
| | - M Glanemann
- Department of Gastroenterology and Hepatology, Central Interdisciplinary Endoscopy, Campus Virchow, Germany
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Zhou Y, Yang C, Wang S, Chen J, Li B. Does external pancreatic duct stent decrease pancreatic fistula rate after pancreatic resection?: a meta-analysis. Pancreatology 2011; 11:362-70. [PMID: 21876365 DOI: 10.1159/000330222] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2011] [Accepted: 06/08/2011] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Yanming Zhou
- Department of Hepato-Biliary-Pancreato-Vascular Surgery, First Affiliated Hospital of Xiamen University, China
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76
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The effect of somatostatin and its analogs in the prevention of pancreatic fistula after elective pancreatic surgery. Eur Surg 2011. [DOI: 10.1007/s10353-011-0612-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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77
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Lemmens VEPP, Bosscha K, van der Schelling G, Brenninkmeijer S, Coebergh JWW, de Hingh IHJT. Improving outcome for patients with pancreatic cancer through centralization. Br J Surg 2011; 98:1455-62. [PMID: 21717423 DOI: 10.1002/bjs.7581] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2011] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- V E P P Lemmens
- Eindhoven Cancer Registry, Comprehensive Cancer Centre South (IKZ), Eindhoven, The Netherlands.
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78
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Jiang C, Wang M, Xu Q, Wu X, Yu D, Ding Y. A modified technique for end-to-side pancreaticojejunostomy by purse-string suture. J Surg Oncol 2011; 104:852-6. [PMID: 21713776 DOI: 10.1002/jso.21978] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2010] [Accepted: 04/22/2011] [Indexed: 12/24/2022]
Affiliation(s)
- Chunping Jiang
- Department of Hepatobiliary Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical College, Nanjing, China
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79
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Systematic review of delayed postoperative hemorrhage after pancreatic resection. J Gastrointest Surg 2011; 15:1055-62. [PMID: 21267670 DOI: 10.1007/s11605-011-1427-8] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2010] [Accepted: 01/11/2011] [Indexed: 01/31/2023]
Abstract
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.
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Niedergethmann M, Dusch N, Widyaningsih R, Weiss C, Kienle P, Post S. Risk-adapted anastomosis for partial pancreaticoduodenectomy reduces the risk of pancreatic fistula: a pilot study. World J Surg 2011; 34:1579-86. [PMID: 20333381 DOI: 10.1007/s00268-010-0521-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Marco Niedergethmann
- Department of Surgery, Faculty of Medicine Mannheim, University Medical Center Mannheim, University of Heidelberg, 68135, Mannheim, Germany.
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Ball CG, Howard TJ. Does the type of pancreaticojejunostomy after Whipple alter the leak rate? Adv Surg 2010; 44:131-48. [PMID: 20919519 DOI: 10.1016/j.yasu.2010.05.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Chad G Ball
- Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Indianapolis 46202, USA
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Azumi Y, Isaji S, Kato H, Nobuoka Y, Kuriyama N, Kishiwada M, Hamada T, Mizuno S, Usui M, Sakurai H, Tabata M. A standardized technique for safe pancreaticojejunostomy: Pair-Watch suturing technique. World J Gastrointest Surg 2010; 2:260-4. [PMID: 21160885 PMCID: PMC2999251 DOI: 10.4240/wjgs.v2.i8.260] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Revised: 07/18/2010] [Accepted: 07/26/2010] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Yoshinori Azumi
- Yoshinori Azumi, Shuji Isaji, Hiroyuki Kato, Yuu Nobuoka, Naohisa Kuriyama, Masashi Kishiwada, Takashi Hamada, Shugo Mizuno, Masanobu Usui, Hiroyuki Sakurai, Masami Tabata, Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
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Impact of postoperative pancreatic fistula on surgical outcome--the need for a classification-driven risk management. J Gastrointest Surg 2010; 14:711-8. [PMID: 20094814 DOI: 10.1007/s11605-009-1147-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Accepted: 12/16/2009] [Indexed: 01/31/2023]
Abstract
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.
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Wu XG, Zhang QL, Li Y, Lin GH. Modified pancreaticogastrostomy for digestive tract reconstruction after pancreatoduodenectomy. Shijie Huaren Xiaohua Zazhi 2009; 17:3259-3262. [DOI: 10.11569/wcjd.v17.i31.3259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Pancreatic leakage after pancreaticoduodenectomy: the impact of the isolated jejunal loop length and anastomotic technique of the pancreatic stump. Pancreas 2009; 38:e177-82. [PMID: 19730152 DOI: 10.1097/mpa.0b013e3181b57705] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Kleespies A, Rentsch M, Seeliger H, Albertsmeier M, Jauch KW, Bruns CJ. Blumgart anastomosis for pancreaticojejunostomy minimizes severe complications after pancreatic head resection. Br J Surg 2009; 96:741-50. [PMID: 19526614 DOI: 10.1002/bjs.6634] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- A Kleespies
- Department of Surgery, Klinikum Grosshadern, University of Munich, Marchioninistrasse 15, 81377 Munich, Germany.
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The pancreatic anastomosis: the danger of a leak, which anastomotic technique is better? J Gastrointest Surg 2009; 13:1182-3. [PMID: 19333663 DOI: 10.1007/s11605-009-0865-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2009] [Accepted: 03/06/2009] [Indexed: 01/31/2023]
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Standop J, Schäfer N, Overhaus M, Schmitz V, Ladwein L, Hirner A, Kalff JC. Endoscopic management of anastomotic hemorrhage from pancreatogastrostomy. Surg Endosc 2008; 23:2005-10. [DOI: 10.1007/s00464-008-0235-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2008] [Revised: 08/26/2008] [Accepted: 10/07/2008] [Indexed: 12/19/2022]
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